1.Short title; table of
contents
(a)This Act may be cited
as the Fighting Fraud and Abuse to
Save Taxpayers' Dollars Act
or the
FAST Act
.
(b)The table of
contents of this Act is as follows:
Sec. 1. Short title; table of contents.
Sec. 2. Findings.
Sec. 3. Tracking excluded providers across State
lines.
Sec. 4. Access for private sector and governmental
entities.
Sec. 5. Liability of Medicare administrative contractors for
claims submitted by excluded providers.
Sec. 6. Limiting the discharge of debts in bankruptcy
proceedings in cases where a health care provider or a supplier engages in
fraudulent activity.
Sec. 7. Prevention of waste, fraud, and abuse in the Medicaid
and CHIP programs.
Sec. 8. Illegal distribution of a Medicare, Medicaid, or CHIP
beneficiary identification or billing privileges.
Sec. 9. Pilot program for the use of universal product numbers
on claim forms for reimbursement under the Medicare program.
Sec. 10. Prohibition of inclusion of social security account
numbers on Medicare cards.
Sec. 11. Implementation.
2.Congress makes the following
findings:
(1)The Medicare
program loses an estimated $60,000,000,000 annually to wasted and fraudulent
payments.
(2)The Medicaid
program also suffers from rampant fraud. As the Office of the Inspector General
of the Department of Health and Human Services noted in 2009, in an analysis of
the only source of nationwide Medicaid claims and beneficiary eligibility
information, the Medicaid Statistical Information System, the Federal
Government does not have timely, accurate, or comprehensive information
for fraud, waste, and abuse detection
in the Medicaid program.
(3)Absent
comprehensive estimates, the Medicaid program's improper payment rate may be
the most objective measure of taxpayer dollars lost to fraud. The national
average improper payment rate ranges between 8.7 percent and 10.5 percent, but
many States have much higher improper payment rates.
(4)The new Federal
health reform law substantially expands the Medicaid program, significantly
changes the Medicare program, creates new mandates and regulations, and will
send hundreds of billions of dollars to insurance companies.
(5)It is the duty of
public officials and public servants in Congress and the Administration to
protect the American public’s taxpayer dollars. Congress and the Administration
must continue to aggressively combat waste, fraud, and abuse in public health
care programs.
(6)The Inspector
General of the Department of Health and Human Services has stated that
swift and effective detection of and response to waste, fraud, and abuse
remain an essential program integrity strategy
. Furthermore, the
Inspector General noted that effective use of Medicare and Medicaid data
is critical to the success of the Government’s efforts to reduce waste, fraud,
and abuse
.
(7)The loss of
taxpayer dollars due to waste and fraud under the Medicare and Medicaid
programs not only threatens the financial viability of those programs, it
erodes the public trust. American taxpayers should not be expected to tolerate
rampant waste, fraud, and abuse in publicly funded health care programs.
(8)Congress supports
the commitment of the Office of the Inspector General of the Department of
Health and Human Services to enhancing existing data analysis and mining
capabilities and employing advanced techniques such as predictive analytics and
social network analysis, to counter new and existing fraud
schemes
.
(9)Congress supports
the use of predictive modeling and other smart technologies that can transform
the current pay and chase
payment cultures under the Medicare
and Medicaid programs and prevent taxpayer dollars from being lost to waste,
fraud, and abuse.
3.Tracking
excluded providers across State lines
(a)In order to ensure that providers of services and
suppliers that have operated in one State and are excluded from participation
in the Medicare program are unable to begin operation and participation in
other Federal health care programs in another State, the Secretary shall
provide for increased coordination between the following:
(1)The Administrator
of the Centers for Medicare & Medicaid Services.
(2)Regional offices
of the Centers for Medicare & Medicaid Services.
(3)Medicare
administrative contractors, fiscal intermediaries, and carriers.
(4)State health
agencies, State plans under title XIX of the Social Security Act (42 U.S.C.
1396 et seq.), State plans under title XXI of such Act (42 U.S.C. 1397aa et
seq.), and entities that contract with such agencies and plans, as directed by
the Secretary.
(5)The Federation of
State Medical Boards.
(b)Improved
Information Systems
(1)The Secretary shall improve information systems to allow
greater integration between databases under the Medicare program so
that—
(A)Medicare
administrative contractors, fiscal intermediaries, and carriers have immediate
access to information identifying providers and suppliers excluded from
participation in the Medicare program, the Medicaid program under title XIX of
the Social Security Act, the State Children's Health Insurance Program under
title XXI of such Act, and other Federal health care programs; and
(B)such information
can be shared on a real-time basis, in accordance with protocols established
under subsection (g)(2)—
(i)across Federal
health care programs and agencies, including between the Department of Health
and Human Services, the Social Security Administration, the Department of
Veterans Affairs, the Department of Defense, the Department of Justice, and the
Office of Personnel Management; and
(ii)with State
health agencies, State plans under title XIX of the Social Security Act (42
U.S.C. 1396 et seq.), State child health plans under title XXI of such Act (42
U.S.C. 1397aa et seq.), and entities that contract with such agencies and
plans, as directed by the Secretary.
(2)Sharing of
information in addition to HEAT effortsThe information shared
under paragraph (1) shall be in addition to, and shall not replace, activities
of the Health Care Fraud Prevention and Enforcement Action Team (HEAT)
established by the Attorney General and the Department of Health and Human
Services.
(3)In implementing this subsection, the Secretary shall
provide for the maximum appropriate coordination with the process established
under section 6401(b)(2) of the Patient Protection and Affordable Care Act
(Public Law 111–148).
(c)One
PI
Database for Medicare, Medicaid, and CHIP
(1)The Secretary shall—
(A)continue to
upload Medicare claims, provider, and beneficiary data into the Integrated Data
Repository under section 1128J(a)(1) of the Social Security Act, as added by
section 6402(a) of the Patient Protection and Affordable Care Act until such
time as the Secretary determines that the Integrated Data Repository is
completed; and
(B)fully implement
the waste, fraud, and abuse detection solution of the Centers for Medicare
& Medicaid Services, called the One PI project
(in this
subsection referred to as the project
) by not later than January
1, 2013.
(2)The
Secretary, in consultation with Inspector General of the Department of Health
and Human Services, may allow stakeholders who combat, or could assist in
combating, waste, fraud, and abuse under Federal health care programs to have
access to the One PI system established under the project. Such stakeholders
may include the Director of the Federal Bureau of Investigation, the
Comptroller General of the United States, Medicare administrative contractors,
fiscal intermediaries, and carriers.
(d)Federal and
state agency access to national practitioner data bankFor
purposes of enhancing data sharing in order to identify programmatic weaknesses
and improving the timeliness of analysis and actions to prevent waste, fraud,
and abuse, relevant Federal and State agencies, including the Department of
Health and Human Services, the Department of Justice, State departments of
health, State Medicaid plans under title XIX of the Social Security Act, State
child health plans under title XXI of such Act, and State medicaid fraud
control units (as described in section 1903(q) of the Social Security Act (42
U.S.C. 1396b(q))), shall have real-time access to the National Practitioner
Data Bank, as directed by the Secretary. The Secretary may, in consultation
with the Inspector General of the Department of Health and Human Services, give
such real-time access to State attorneys general and State and local law
enforcement agencies.
(e)Access to
claims and payment databasesSection 1128J(a)(2) of the Social
Security Act, as added by section 6402(a) of the Patient Protection and
Affordable Care Act (Public Law 111–148) is amended—
(1)by striking
databases.—For purposes
and inserting
“databases.—
(A)Access for the
conduct of law enforcement and oversight activitiesFor
purposes
;
(2)in subparagraph
(A), as added by paragraph (1), by inserting , including the Integrated
Data Repository under paragraph (1)
before the period at the end;
and
(3)by adding at the
end the following new subparagraph:
(B)Access to
reduce waste, fraud, and abuseFor purposes of reducing waste,
fraud, and abuse, and to the extent consistent with applicable information,
privacy, security, and disclosure laws, including the regulations promulgated
under the Health Insurance Portability and Accountability Act of 1996 and
section 552a of title 5, United States Code, and subject to any information
systems security requirements under such laws or otherwise required by the
Secretary, the Secretary, in consultation with the Inspector General of the
Department of Health and Human Services, may allow State Medicaid fraud control
units and State and local law enforcement officials to have access to claims
and payment data of the Department of Health and Human Services and its
contractors related to titles XVIII, XIX, and XXI, including the Integrated
Data Repository under paragraph
(1).
.
(f)Ensuring data
is uploaded to the IDR on a daily basisSection 1128J(a)(1) of
the Social Security Act, as added by section 6402(a) of the Patient Protection
and Affordable Care Act (Public Law 111–148) is amended by adding at the end
the following new subparagraph:
(C)Uploading of
Medicare claims data on a daily basisAll Medicare claims data
shall be uploaded into the Integrated Data Repository on a daily
basis.
.
(g)
(1)The Secretary shall ensure that any data provided to an
entity or individual under the provisions of or amendments made by this section
is provided to such entity or individual on a real-time basis, in accordance
with protocols established by the Secretary under paragraph (2). The Secretary
shall consult with the Inspector General of the Department of Health and Human
Services prior to implementing this subsection.
(2)
(A)The Secretary shall establish protocols to ensure the
secure transfer and storage of any data provided to another entity or
individual under the provisions of or amendments made by this section.
(B)Consideration
of HHS OIG recommendationsIn establishing protocols under
subparagraph (A), the Secretary shall take into account recommendations
submitted to the Secretary by the Inspector General of the Department of Health
and Human Services with respect to the secure transfer and storage of such
data.
(h)GAO study and
report on use of Federation of State Medical Boards To strengthen enrollment
integrity processes
(1)The
Comptroller General of the United States shall, in consultation with the
Federation of State Medical Boards, conduct a study on whether and, if so, to
what degree, such Federation may be useful to the Secretary in further
strengthening the integrity of processes for enrolling providers of services
and suppliers under Federal health care programs.
(2)Not
later than 1 year after the date of enactment of this Act, the Comptroller
General of the United States shall submit to Congress a report containing the
results of the study conducted under paragraph (1), together with
recommendations for such legislation and administrative action as the
Comptroller General determines appropriate.
(i)In this section:
(1)The
term Administrator means the Administrator of the Centers for
Medicare & Medicaid Services.
(2)The
term CHIP means the State Children's Health Insurance Program
under title XXI of the Social Security Act (42 U.S.C. 1397aa et seq.).
(3)Federal health
care programThe term Federal health care program
has the meaning given such term in section 1128B(f) of the Social Security Act
(42 U.S.C. 1320a–7b(f)).
(4)The term HHS OIG means the Inspector General of
the Department of Health and Human Services.
(5)Medicare
administrative contractors, fiscal intermediaries, and
carriersThe term Medicare administrative contractors,
fiscal intermediaries, and carriers includes zone program integrity
contractors, program safeguard or integrity contractors, recovery audit
contractors under section 1893(h) of the Social Security Act (42 U.S.C.
1395ddd(h)), and special investigative units at Medicare contractors (as
defined in section 1889(g) of the Social Security Act (42 U.S.C.
1395zz(g))).
(6)The term Medicare program means the program
under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.).
(7)The term provider of services has the
meaning given such term in section 1861(u) of the Social Security Act (42
U.S.C. 1395x(u)).
(8)The
term Secretary means the Secretary of Health and Human
Services.
(9)The
term State includes the District of Columbia, the Commonwealth of
Puerto Rico, the Virgin Islands, Guam, and American Samoa.
(10)The
term supplier has the meaning given such term in section 1861(d)
of the Social Security Act (42 U.S.C. 1395x(d)).
4.Access for
private sector and governmental entities
(a)Title XI of the Social Security Act (42 U.S.C. 1301 et
seq.), as amended by section 6402(a) of the Patient Protection and Affordable
Care Act (Public Law 111–148), is amended by inserting after section 1128J the
following new section:
1128K.Expanded access to the national practitioner data
bank(a)
(1)The information in
the National Practitioner Data Bank established pursuant to the Health Care
Quality Improvement Act of 1986 (42 U.S.C. 11101 et seq.) may be available on a
real-time basis, in accordance with protocols established by the Secretary
under subsection (b), to—
(A)Federal and State
government agencies and health plans, commercial health plans, and any health
care provider, supplier, or practitioner entering an employment or contractual
relationship with an individual or entity who has been subject to a final
adverse action in the past 10 years, where the contract involves the furnishing
of items or services reimbursed by 1 or more Federal health care programs
(regardless of whether the individual or entity is paid by the programs
directly, or whether the items or services are reimbursed directly or
indirectly through the claims of a direct provider); and
(B)utilization and
quality control peer review organizations and accreditation entities as defined
by the Secretary, including but not limited to organizations described in part
B of this title and in section 1154(a)(4)(C).
(2)No effect on
access under other applicable law; appropriate
coordinationNothing in this section shall affect the
availability of information in the National Practitioner Data Bank under other
applicable law, including the availability of such information to entities or
individuals under part B of the Health Care Quality Improvement Act of 1986 (42
U.S.C. 11131 et seq.). In implementing this section, the Secretary shall
provide for the maximum appropriate coordination with such part.
(b)The
Secretary shall establish protocols to ensure the secure transfer and storage
of data made available under this section. In establishing such protocols the
Secretary shall take into account recommendations submitted to the Secretary by
the Inspector General of the Department of Health and Human Services and the
National Association of Insurance Commissioners with respect to the secure
transfer and storage of such data, the establishment or approval of a fee
structure under subsection (c), and the establishment of user access
protocols.
(c)
(1)
(A)Subject
to paragraph (2), the Secretary may establish or approve reasonable fees for
the disclosure of information under this section, including with respect to
requests by Federal agencies or other entities, such as fiscal intermediaries
and carriers, acting under contract on behalf of such agencies.
(B)Establishment
or approval of fee amountsIn establishing or approving the
amount of such fees, the Secretary shall ensure that the total amount of the
fees to be collected is equal to the total costs of processing the requests for
disclosure and of providing such information. Such fees shall be available to
the Secretary to cover such costs.
(C)The Secretary may allow for-profit entities to receive
data under this section for a fee that is comparable to the fee charged to a
Federal agency or other entity under subparagraph (A) with respect to a similar
request.
(2)Free access to
certain data
(A)Not later than 1 year after the date of enactment of the
Fighting Fraud and Abuse to Save Taxpayers'
Dollars Act, for purposes of identifying additional strategies
and tools to combat waste, fraud, and abuse, the Secretary—
(i)establish
protocols to ensure the secure transmission of data under this section;
and
(ii)may ensure
nonprofit academic, policy, and research institutions have access to data from
the National Practitioner Data Bank.
(B)Data shall be provided under subparagraph (A)(ii) free of
charge to academic, policy, and research institutions.
(C)Any
academic, policy, or research institution that is provided data under
subparagraph (A)(ii) shall, as a condition of receiving such data, be required
to share with the Secretary any findings using such data to combat waste,
fraud, and abuse (in a form and manner of the academic, policy, or research
institution's choosing).
(d)Establishment
of appeals process
(1)The Secretary shall establish a transparent and
responsive appeals process under which a provider of services or supplier may
have their name removed from the National Practitioner Data Bank. Under such
process, appeals shall be conducted in a timely manner (not more than 90 days
after the earlier of the date of the listing in the National Practitioner Data
Bank or the issuance of any penalty involved) in order to minimize the time
that providers of services or suppliers who successfully appeal are excluded
from participation under the programs under titles XVIII and XIX.
(2)The
Secretary shall consult with major colleges of medical practice in the United
States, commercial health plans, the Inspector General of the Department of
Health and Human Services, the National Association of Insurance Commissioners,
and the Federation of State Medical Boards in establishing the appeals process
under paragraph (1).
(e)In
this section:
(1)The term commercial health plan
means
health insurance coverage (as defined in section 2791 of the Public Health
Service Act and including group health plans).
(2)The term final adverse action means one or
more of the following actions:
(A)A
Medicare-imposed revocation of any Medicare billing privileges.
(B)Suspension or
revocation of a license to provide health care by any State licensing
authority.
(C)A conviction of a
Federal or State felony offense within the last 10 years preceding enrollment,
revalidation, or re-enrollment.
(D)An exclusion or
debarment from participation in a Federal or State health care
program.
.
(b)Criminal
Penalty for Misuse of Information disclosedSection 1128B(b) of
the Social Security Act (42 U.S.C. 1320a–7b(b)) is amended by adding at the end
the following:
(4)Whoever knowingly
uses information disclosed from the National Practitioner Data Bank under
section 1128K for a purpose other than those authorized under that section
shall be imprisoned for not more than 3 years or fined under title 18, United
States Code, or
both.
.
(c)The amendments made by this section shall take effect on the
date of enactment of this Act.
5.Liability of
Medicare administrative contractors for claims submitted by excluded
providers
(a)Reimbursement
to the Secretary for Amounts Paid to Excluded ProvidersSection
1874A(b) of the Social Security Act (42 U.S.C. 1395kk(b)) is amended by adding
at the end the following new paragraph:
(6)Reimbursements
to Secretary for amounts paid to excluded providers
(A)
(i)Except as provided in clause (ii), the Secretary shall
not enter into a contract with a Medicare administrative contractor under this
section unless the contractor agrees to reimburse the Secretary for any amounts
paid by the contractor for with respect to any item or service (other than an
emergency item or service, not including items or services furnished in an
emergency room of a hospital) which is furnished—
(I)by an individual
or entity during the period when such individual or entity is excluded pursuant
to section 1128, 1128A, 1156 or 1842(j)(2) from participation in the program
under this title; or
(II)at the medical
direction or on the prescription of a physician during the period when he is
excluded pursuant to section 1128, 1128A, 1156 or 1842(j)(2) from participation
in the program under this title and when the person furnishing such item or
service knew or had reason to know of the exclusion (after a reasonable time
period after reasonable notice has been furnished to the person).
(ii)Where
a Medicare administrative contractor pays a claim for payment for items or
services furnished by an individual or entity excluded from participation in
the programs under this title, pursuant to section 1128, 1128A, 1156, or l866,
and such Medicare administrative contractor did not know or have reason to know
that such individual or entity was so excluded, then, to the extent permitted
by this title, and notwithstanding such exclusion, the contractor shall not be
required to reimburse the Secretary under clause (i) for any amounts paid with
respect to such items or services. In each such case the Secretary shall notify
the contractor of the exclusion of the individual or entity furnishing the
items or services. A Medicare administrative contractor shall not make payment
for items or services furnished by an excluded individual or entity to a
beneficiary after a reasonable time (as determined by the Secretary in
regulations) after the Secretary has notified the contractor of the exclusion
of that individual or entity.
(B)Requirement to
review claimsA Medicare administrative contractor shall review
claims submitted to the contractor for payment for services under this title in
order to ensure that such services were not furnished by an individual or
entity during any period for which the individual or entity is excluded from
such participation (as described in subparagraph
(A)).
.
(b)Report on
effectiveness and development of scorecard and measurable performance metrics
for medicare contractors
(1)
(A)Not later than 12 months after the date of enactment of
this Act, the Secretary of Health and Human Services shall submit to Congress a
report on the overall effectiveness and potential of Medicare
contractors.
(B)The report submitted under subparagraph (A) shall include
the Secretary's recommendations for the development of measurable performance
metrics and a scorecard for Medicare contractors (or, in the case of Medicare
administrative contractors, updated and revised measurable performance metrics
and a revised scorecard), together with recommendations for such legislation
and administrative action as the Secretary determines appropriate
(2)The
Secretary shall consult with Medicare contractors, the Inspector General of the
Department of Health and Human Services, private sector waste, fraud, and abuse
experts, and entities with experience combating and preventing waste, fraud,
and abuse, including through the review of Medicare claims, in preparing the
report submitted under paragraph (1).
(3)Medicare
contractors definedIn this subsection, the term Medicare
contractor means any of the following:
(A)A Medicare
administrative contractor under section 1874A of the Social Security
Act.
(B)A Medicare
Program Safeguard Contractor.
(C)A Zone Program
Integrity Contractor.
(D)A Medicare Drug
Integrity Contractor.
(c)
(1)The amendments made by subsection (a) shall apply to
claims for reimbursement submitted on or after the date of enactment of this
Act.
(2)The Secretary of Health and Human Services shall
take such steps as may be necessary to modify contracts entered into, renewed,
or extended prior to the date of enactment of this Act to conform such
contracts to the provisions of and amendments made by this section.
6.Limiting the
discharge of debts in bankruptcy proceedings in cases where a health care
provider or a supplier engages in fraudulent activity
(a)
(1)Section 1128A(a) of the Social Security Act (42 U.S.C.
1320a–7a(a)) is amended by adding at the end the following:
Notwithstanding any other provision of law, amounts made payable under
this section are not dischargeable under section 727, 944, 1141, 1228, or 1328
of title 11, United States Code, or any other provision of such
title.
.
(2)Recovery of
overpayment to providers of services under part ASection 1815(d)
of the Social Security Act (42 U.S.C. 1395g(d)) is amended—
(A)by inserting
(1)
after (d)
; and
(B)by adding at the
end the following:
(2)Notwithstanding
any other provision of law, amounts due to the Secretary under this section are
not dischargeable under section 727, 944, 1141, 1228, or 1328 of title 11,
United States Code, or any other provision of such title if the overpayment was
the result of fraudulent activity, as may be defined by the
Secretary.
.
(3)Recovery of
overpayment of benefits under part BSection 1833(j) of the
Social Security Act (42 U.S.C. 1395l(j)) is amended—
(A)by inserting
(1)
after (j)
; and
(B)by adding at the
end the following:
(2)Notwithstanding
any other provision of law, amounts due to the Secretary under this section are
not dischargeable under section 727, 944, 1141, 1228, or 1328 of title 11,
United States Code, or any other provision of such title if the overpayment was
the result of fraudulent activity, as may be defined by the
Secretary.
.
(4)Collection of
past-due obligations arising from breach of scholarship and loan
contractSection 1892(a) of the Social Security Act (42 U.S.C.
1395ccc(a)) is amended by adding at the end the following:
(5)Notwithstanding
any other provision of law, amounts due to the Secretary under this section are
not dischargeable under section 727, 944, 1141, 1228, or 1328 of title 11,
United States Code, or any other provision of such
title.
.
(b)The amendments made by subsection (a) shall apply to
bankruptcy petitions filed after the date of enactment of this Act.
7.Prevention of
waste, fraud, and abuse in the Medicaid and CHIP programs
(a)Detection of
fraudulent identification numbers within the Medicaid and CHIP
programs
(1)Section
1903(i) of the Social Security Act (42 U.S.C. 1396b(i)), as amended by section
2001(a)(2)(B) of the Patient Protection and Affordable Care Act (Public Law
111–148), is amended—
(A)in paragraph
(25), by striking or
at the end;
(B)in paragraph
(26), by striking the period and inserting ; or
; and
(C)by adding at the
end the following new paragraph:
(27)with respect to
amounts expended for an item or service for which medical assistance is
provided under the State plan or under a waiver of such plan unless the claim
for payment for such item or service contains—
(A)a valid
beneficiary identification number that, for purposes of the individual who
received such item or service, has been determined by the State agency to
correspond to an individual who is eligible to receive benefits under the State
plan or waiver; and
(B)a valid National
Provider Identifier that, for purposes of the provider that furnished such item
or service, has been determined by the State agency to correspond to a
participating provider that is eligible to receive payment for furnishing such
item or service under the State plan or
waiver.
.
(2)Section
2107(e)(1)(I) of the Social Security Act (42 U.S.C. 1397gg(e)(1)(I)) is amended
by striking and (17)
and inserting (17), and
(27)
.
(b)Screening
requirements for managed care entities
(1)Section 1902 of the Social Security Act (42 U.S.C. 1396a)
is amended—
(A)by redesignating
the second subsection (ii), as added by section 6401(b)(1)(B) of the Patient
Protection and Affordable Care Act, as subsection (kk) of such section;
and
(B)in subsection
(kk), as so redesignated—
(i)by
redesignating paragraph (8) as paragraph (9); and
(ii)by
inserting after paragraph (7) the following new paragraph:
(8)The State establishes procedures to ensure that any
managed care entity (as defined in section 1932(a)(1)(B)) under contract with
the State complies with all applicable requirements under this
subsection.
.
(2)Medicaid
managed care organizationsSection 1903(m)(2)(A) of the Social
Security Act (42 U.S.C. 1396b(m)(2)(A)) is amended—
(A)in clause (xii),
by striking and
at the end;
(B)in clause (xiii),
by striking the period and inserting ; and
; and
(C)by adding at the
end the following new clause:
(xiv)such contract
requires that the entity comply with any applicable screening, oversight, and
reporting requirements under section
1902(kk).
.
(3)Section 1932(d) of the Social Security Act (42 U.S.C.
1396u–2(d)) is amended by adding at the end the following new paragraph:
(5)Compliance with
screening, oversight, and reporting requirementsA managed care
entity shall comply with any applicable screening, oversight, and reporting
requirements under section
1902(kk).
.
(c)Clause (i) of section 1866(j)(2)(B) of the Social
Security Act (42 U.S.C. 1395cc(j)(2)(B)) is amended to read as follows:
(i)shall
include—
(I)a licensure
check, which may include such checks across States; and
(II)for purposes of
the Medicaid program under title XIX—
- (aa)database checks
(including such checks across States), which shall include—
(AA)the Medicaid
Statistical Information System (as described in section 1903(r)(1)(F));
and
(BB)any relevant
medical databases that are maintained by the State agencies, as determined by
the Secretary in consultation with the directors of the State agencies;
and
- (bb)coordination of
excluded provider lists between the Secretary and the State agency, including
exchanges of data regarding excluding providers between Federal and State
databases;
and
.
(d)Section 1902 of the Social Security Act (42 U.S.C.
1396a), as amended by subsection (b)(1), is further amended—
(1)in subsection
(a)—
(A)in paragraph
(23), by striking subsection (ii)(4)
and inserting
subsection (kk)(4)
; and
(B)in paragraph
(77), by striking subsection (ii)
and inserting
subsection (kk)
; and
(2)in subsection
(kk), by striking section 1886
each place it appears and
inserting section 1866
.
8.Illegal
distribution of a Medicare, Medicaid, or CHIP beneficiary identification or
billing privilegesSection
1128B(b) of the Social Security Act (42 U.S.C. 1320a–7b(b)), as amended by
section 4(b), is amended by adding at the end the following:
(5)Whoever
knowingly, intentionally, and with the intent to defraud purchases, sells or
distributes, or arranges for the purchase, sale, or distribution of a Medicare,
Medicaid, or CHIP beneficiary identification number or billing privileges under
title XVIII, title XIX, or title XXI shall be imprisoned for not more than 10
years or fined not more than $500,000 ($1,000,000 in the case of a
corporation), or
both.
.
9.Pilot program
for the use of universal product numbers on claim forms for reimbursement under
the Medicare program
(a)
(1)Not later than January 1, 2013, the Secretary shall
establish a pilot program under which claims for reimbursement under the
Medicare program for UPN covered items contain the universal product number of
the UPN covered item.
(2)The
pilot program under this section shall be conducted for a 2-year period.
(3)Consideration
of GAO recommendationsThe Secretary shall take into account the
recommendations of the Comptroller General of the United States in establishing
the pilot program under this section.
(b)Development and
implementation of procedures
(1)Information
included in UPNThe Secretary, in consultation with manufacturers
and entities with appropriate expertise, shall determine the relevant
descriptive information appropriate for inclusion in a universal product number
for a UPN covered item under the pilot program.
(2)The Secretary, in consultation with interested parties
(which shall, at a minimum, include the Inspector General of the Department of
Health and Human Services and private sector and health industry experts),
shall use information obtained under the pilot program through the use of
universal product numbers on claims for reimbursement under the Medicare
program to periodically review the UPN covered items billed under the Health
Care Financing Administration Common Procedure Coding System and adjust such
coding system to ensure that functionally equivalent UPN covered items are
billed and reimbursed under the same codes.
(c)GAO reports to
congress on effectiveness of implementation of pilot program
(1)Not later than 6 months after the implementation of the
pilot program under this section, the Comptroller General of the United States
shall submit to Congress a report on the effectiveness of such
implementation.
(2)Not later than 18 months after the completion of the pilot
program under this section, the Comptroller General of the United States shall
submit to Congress a report on the effectiveness of the pilot program, together
with recommendations regarding the use of universal product numbers and the use
of data obtained from the use of such numbers, and recommendations for such
legislation and administrative action as the Comptroller General determines
appropriate.
(d)The Secretary shall use amounts available in
the Centers for Medicare & Medicaid Services Program Management Account or
in the Health Care Fraud and Abuse Control Account under section 1817(k) of the
Social Security Act (42 U.S.C. 1395i(k)) to carry out the pilot program under
this section.
(e)In
this section:
(1)The term Medicare program means the program
under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.).
(2)The
term Secretary means the Secretary of Health and Human
Services.
(3)The term universal product number
means a number that is—
(A)affixed by the
manufacturer to each individual UPN covered item that uniquely identifies the
item at each packaging level; and
(B)based on
commercially acceptable identification standards such as, but not limited to,
standards established by the Uniform Code Council—International Article
Numbering System or the Health Industry Business Communication Council.
(4)
(A)Except as provided in subparagraph (B), the term
UPN covered item means—
(i)a
covered item as that term is defined in section 1834(a)(13) of the Social
Security Act (42 U.S.C. 1395m(a)(13));
(ii)an
item described in paragraph (8) or (9) of section 1861(s) of such Act (42
U.S.C. 1395x);
(iii)an item
described in paragraph (5) of such section 1861(s); and
(iv)any other item
for which payment is made under this title that the Secretary determines to be
appropriate.
(B)The
term UPN covered item does not include a customized item for which
payment is made under this title.
10.Prohibition of
inclusion of social security account numbers on Medicare cards
(a)Section 205(c)(2)(C) of the Social Security Act (42
U.S.C. 405(c)(2)(C)), as amended by section 1414(a)(2) of the Patient
Protection and Affordable Care Act (Public Law 111–148), is amended by adding
at the end the following new clause:
(xi)The Secretary of Health and Human
Services, in consultation with the Commissioner of Social Security, shall
establish cost-effective procedures to ensure that a social security account
number (or any derivative thereof) is not displayed, coded, or embedded on the
Medicare card issued to an individual who is entitled to benefits under part A
of title XVIII or enrolled under part B of title XVIII and that any other
identifier displayed on such card is easily identifiable as not being the
social security account number (or a derivative
thereof).
.
(b)
(1)The amendment made by subsection (a) shall apply with
respect to Medicare cards issued on and after an effective date specified by
the Secretary of Health and Human Services, but in no case shall such effective
date be later than the date that is 24 months after the date adequate funding
is provided pursuant to subsection (d)(2).
(2)Subject
to subsection (d)(2), in the case of individuals who have been issued such
cards before such date, the Secretary of Health and Human Services—
(A)shall provide for
the reissuance for such individuals of such a card that complies with such
amendment not later than 3 years after the effective date specified under
paragraph (1); and
(B)may permit such
individuals to apply for the reissuance of such a card that complies with such
amendment before the date of reissuance otherwise provided under subparagraph
(A) in such exceptional circumstances as the Secretary may specify.
(c)Subject to subsection (d)(2), the Secretary of Health and
Human Services, in consultation with the Commissioner of Social Security, shall
conduct an outreach program to Medicare beneficiaries and providers about the
new Medicare card provided under this section.
(d)Report to
Congress and limitations on effective date
(1)Not
later than 90 days after the date of the enactment of this Act, the Secretary
of Health and Human Services, acting through the Administrator of the Centers
for Medicare & Medicaid Services and in consultation with the Commissioner
of Social Security, shall submit to Congress a report that includes detailed
options regarding the implementation of this section, including line-item
estimates of and justifications for the costs associated with such options and
estimates of timeframes for each stage of implementation. In recommending such
options, the Secretary shall take into consideration, among other factors,
cost-effectiveness and beneficiary outreach and education.
(2)Limitation;
modification of deadlinesWith respect to the amendment made by
subsection (a), and the requirements of subsections (b) and (c)—
(A)such amendment and
requirements shall not apply until adequate funding is transferred pursuant to
section 11(b) to implement the provisions of this section, as determined by
Congress; and
(B)any deadlines
otherwise established under this section for such amendment and requirements
are contingent upon the receipt of adequate funding (as determined in
subparagraph (A)) for such implementation.
The previous
sentence shall not affect the timely submission of the report required under
paragraph (1).11.
(a)Empowering the
HHS OIG and GAOExcept as otherwise provided, to the extent
practicable, the Secretary of Health and Human Services (in this section
referred to as the Secretary
) shall—
(1)carry out the
provisions of and amendments made by this Act in consultation with the
Inspector General of the Department of Health and Human Services; and
(2)take into
consideration the findings and recommendations of the Comptroller General of
the United States in carrying out such provisions and amendments.
(b)The Secretary shall provide for the
transfer, from the Health Care Fraud and Abuse Control Account under section
1817(k) of the Social Security Act (42 U.S.C. 1395i(k)), to the Centers for
Medicare & Medicaid Services Program Management Account, of such sums,
provided such sums are fully offset, as the Secretary determines are for
necessary administrative expenses associated with carrying out the provisions
of and amendments made by this Act (other than section 9). Amounts transferred
under the preceding sentence shall remain available until expended.
(c)Any
reduction in outlays under the Medicare program under title XVIII of the Social
Security Act under the provisions of, and amendments made by, this Act may only
be utilized to offset outlays under part A of such title.