1.Medicare fraud, waste, and
abuse prevention solution
(a)
(1)The Secretary of Health and Human Services (in this
section referred to as the Secretary) shall develop and implement
a fraud, waste, and abuse comprehensive pre-payment review prevention system
(in this section referred to as the Prevention System) for
reviewing claims for reimbursement under the Medicare Program under title XVIII
of the Social Security Act (in this section referred to as the Medicare
Program).
(2)The
Secretary shall carry out the Prevention System acting through the Center for
Program Integrity of the Centers for Medicare & Medicaid Services.
(b)Selection of
claims across all provider typesThe Prevention System shall cover all types
of providers of services and suppliers under the Medicare Program, but may be
limited to a subset of claim segments.
(c)To the extent practicable, the Prevention System,
shall—
(1)be
holistic;
(2)be able to view
and analyze all provider of services, supplier, and patient activities from
multiple providers of services and suppliers under the Medicare Program;
(3)be able to be
integrated into the health care claims flow in existence as of the date of the
enactment of this Act with minimal effort, time, and cost;
(4)be designed to use
technologies, including predictive modeling, that can utilize integrated near
real-time transaction risk scoring and referral strategy capabilities to
identify transactions, patterns, anomalies, and linkages that are statistically
unusual or suspicious and can undertake analysis before payment is made and
that prioritizes unusual or suspicious claims in terms of likelihood of
potential fraud, waste, or abuse to more efficiently utilize investigative
resources;
(5)be designed to—
(A)allow for ease of
integration into multiple points along the claims flow under the Medicare
Program (pre-adjudication and post-adjudication of such claims) in order to
demonstratively show that the system ranks the likelihood of high-risk behavior
patterns and of fraud, waste, or abuse; and
(B)utilize
experimental design methodology to monitor and measure the performance between
the control treatments (which shall be the methods and assessments used as of
the day before the date of the enactment of this Act to address fraud, waste,
and abuse under the Medicare Program) and test treatments (which shall be the
Prevention System identification of such fraud, waste, and abuse and actions
taken pursuant to such system to address such fraud, waste, and abuse);
and
(6)be provided through competitively bid
contracts using the Federal Acquisition Regulations.
(d)
(1)Scoring and near
real-time analysis
(A)The Prevention System shall identify high-risk Medicare
claims by scoring all such claims in near real-time, prior to the Centers for
Medicare & Medicaid Services making payment on such claims under the
Medicare Program.
(B)The scores under
subparagraph (A) shall be communicated to
the fraud management system under
subsection (f).
(C)Under the Prevention System, the near real-time analysis
of Medicare claims data shall be conducted in a manner that ensures—
(i)prompt
identification of fraud, waste, and abuse; and
(ii)prompt payment of
legitimate claims.
(2)The Prevention System shall involve the implementation
of a statistically sound, empirically derived predictive modeling technology
that is designed to prevent fraud, waste, and abuse (by identifying such fraud,
waste, and abuse before payment is made under the Medicare Program on related
claims). The Prevention System shall use a predictive model to identify fraud,
waste, and abuse that is—
(A)based on
historical transaction data, from across all markets and regions available, to
build and continuously re-develop scoring models that are capable of
incorporating external data and external models from other sources into the
predictive model; and
(B)regularly updated,
through the feedback loop under
subsection (g), to provide information and
incorporate data on reimbursement claims that is collected through the
Prevention System, including information gathered through the investigation of
claims for reimbursement under the Medicare Program that the system identifies
as being potentially fraudulent, wasteful, or abusive.
(3)Protections for
patients and providersThe identification of an unusual or
suspect Medicare claim by the Prevention System shall—
(A)not result in the
denial of items or services to an individual under the Medicare Program until
such claim is further reviewed by the Secretary; and
(B)not result in a
failure to comply with prompt payment requirements under applicable law.
(4)Any data collected, stored, or reviewed under the
Prevention System shall be treated in a manner that is in accordance with the
regulations promulgated under section 264(c) of the Health Insurance
Portability and Accountability Act of 1996 (42 U.S.C. 1320d–2 note) and any
other applicable law.
(e)
(1)The Prevention System shall be a high volume, rapid, near
real-time information technology solution, which includes data pooling and
scoring capabilities to quickly and accurately capture and evaluate
data.
(2)The Prevention System shall, for purposes of preventing
fraud, waste, and abuse under the Medicare Program—
(A)use data from
claims for reimbursement under the Medicare Program contained in existing files
of Medicare claims data, including the Common Working File of the Centers for
Medicare & Medicaid Services; and
(B)to the extent
practicable, pool data from all available Government sources (including the
Death Master File of the Social Security Administration).
(3)The Prevention System shall be stored in an industry
standard secure data environment that complies with applicable Federal privacy
laws for use in building Medicare fraud, waste, and abuse prevention predictive
models that have a comprehensive view of provider and supplier activity across
all markets, geographic areas, and provider and supplier types.
(f)
(1)The Prevention System shall utilize a fraud management
system containing workflow management and workstation tools to provide the
ability to systematically present score, reason codes, and treatment actions
for high-risk scored transactions, as determined under subsection (d).
(2)The fraud management system under paragraph (1) shall
ensure that analysts who review Medicare claims have the capability to access,
review, and research claims efficiently, as well as decline or approve payments
on claims in an automated manner.
(g)
(1)The Prevention System shall utilize a feedback loop to
gain access to outcome information on adjudicated Medicare claims so future
system enhancements can utilize previous experience.
(2)The
purpose of the feedback loop under
paragraph (1) is to—
(A)enable the
Secretary to measure—
(i)the
actual amount of fraud, waste, and abuse under the Medicare Program; and
(ii)any
savings to the Medicare Program resulting from implementation of the Prevention
System; and
(B)provide necessary
data to develop future, enhanced models for use in the Prevention
System.
(3)Analysis of
final claims statusThe feedback loop under
paragraph (1) shall analyze data from all
carriers to provide post-payment information about the eventual status of a
Medicare claim as Normal
, Fraud
,
Waste
, Abuse
, or Education
required
.
(h)Claims review
prior to payment
(1)Subject to paragraph (2), if a claim for reimbursement
under the Medicare Program is selected for review under the Prevention System,
the Secretary shall not make a payment on such claim until such claim has been
reviewed under the system. In order to carry out this paragraph, the Secretary
shall ensure that appropriate controls and technology are in place to assess
and measure the effectiveness of the Prevention System, predictive models used
under such system, and the overall strategy for Medicare claims review.
(2)
(A)The review of a claim under the Prevention System shall
occur in a timely manner.
(B)Application of
prompt payment requirementsThe limitation on payment under
paragraph (1) shall not interfere with the prompt payment of a Medicare claim
in accordance with applicable law.
(3)If automated
technology presents a score, reason code, or treatment action for a claim that
is scored as “high-risk,” the Prevention System shall provide for manual review
of medical records related to such claim by both clinical and fraud
investigators to ensure accuracy and mitigate false positive events.
(4)The Secretary may use
self-audit practices by providers and suppliers under the Prevention System in
a manner such that once high-risk claims are identified through the predictive
modeling, providers and suppliers are offered the opportunity to adjust or
withdraw their claims.
(5)Denial of
payment for fraudulent claimsUnder the Prevention System, if
automated technology of a claim under paragraph (3) and manual review under
paragraph (4) confirm fraud has occurred, the Secretary may deny payment of
such claim.
(i)
(1)Not later than 2 years after the implementation of the
Prevention System, the Secretary, through the Office of the Inspector General
of the Department of Health and Human Services, shall submit to Congress a
report on the implementation of such system.
(2)The
report submitted under paragraph (1) may contain—
(A)a detailed assessment of the Prevention
System’s success in identifying fraud, waste, and abuse;
(B)the costs of
operating the Prevention System; and
(C)an analysis of the
overall return on investment for the Prevention System.
(j)Authorization of
appropriationsThere are authorized to be appropriated to carry
out this section such sums as may be necessary.
(k)If the Secretary determines that the
Prevention System results in savings to the Medicare Program, the Secretary
shall expand the project throughout Federal health programs, including the
Medicaid Program under title XIX of the Social Security Act and the Children’s
Health Insurance Program under title XXI of such Act.