[Congressional Bills 114th Congress]
[From the U.S. Government Publishing Office]
[S. 2368 Placed on Calendar Senate (PCS)]

<DOC>





                                                       Calendar No. 317
114th CONGRESS
  1st Session
                                S. 2368

                          [Report No. 114-177]

    To amend title XVIII of the Social Security Act to improve the 
  efficiency of the Medicare appeals process, and for other purposes.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                            December 8, 2015

   Mr. Hatch, from the Committee on Finance, reported the following 
     original bill; which was read twice and placed on the calendar

_______________________________________________________________________

                                 A BILL


 
    To amend title XVIII of the Social Security Act to improve the 
  efficiency of the Medicare appeals process, and for other purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Audit & Appeals 
Fairness, Integrity, and Reforms in Medicare Act of 2015'' or the 
``AFIRM Act''.
    (b) Table of Contents.--The table of contents for this Act is as 
follows:

Sec. 1. Short title; table of contents.
Sec. 2. Increased resources for the Office of Medicare Hearings and 
                            Appeals and the Departmental Appeals Board.
Sec. 3. Establishment of Medicare magistrate review and revision of 
                            amount in controversy thresholds.
Sec. 4. Remanding appeals to the redetermination level with the 
                            introduction of new evidence.
Sec. 5. Expedited access to appeals.
Sec. 6. Authority to use sampling and extrapolation methodologies and 
                            to consolidate appeals for administrative 
                            efficiency.
Sec. 7. Identification and referral of fraud.
Sec. 8. Study to assess hearing participation.
Sec. 9. Improvements to the Office of Medicare Hearings and Appeals.
Sec. 10. Review program improvements.
Sec. 11. Creation of Medicare Provider and Supplier Ombudsman for 
                            Reviews and Appeals.
Sec. 12. Limiting the audit and recovery period for patient status 
                            reviews.
Sec. 13. Incentives and disincentives for Medicare contractors, 
                            providers, and suppliers.

SEC. 2. INCREASED RESOURCES FOR THE OFFICE OF MEDICARE HEARINGS AND 
              APPEALS AND THE DEPARTMENTAL APPEALS BOARD.

    (a) In General.--For fiscal year 2016 and for each fiscal year 
thereafter, for purposes of conducting reviews, hearings, and appeals 
under title XVIII of the Social Security Act, the Secretary of Health 
and Human Services shall provide for the transfer from the Federal 
Hospital Insurance Trust Fund under section 1817 of such Act (42 U.S.C. 
1395i) and the Federal Supplementary Insurance Trust Fund under section 
1841 of such Act (42 U.S.C. 1395t), in such proportion as the Secretary 
may determine, of--
            (1) $125,000,000 to the Office of Medicare Hearings and 
        Appeals; and
            (2) $2,000,000 to the Departmental Appeals Board of the 
        Department of Health and Human Services.
Amounts transferred under the preceding sentence shall be in addition 
to any other amounts that may be available for such purposes and shall 
remain available until expended.
    (b) GAO Study and Report.--
            (1) Study.--The Comptroller General of the United States 
        shall conduct a study of the use of the amount made available 
        to the Office of Medicare Hearings and Appeals under subsection 
        (a) to determine whether the availability of such amounts led 
        to any improvements in the Medicare appeals program, such as an 
        increased number of appeals processed or a decrease in the time 
        required to process an appeal.
            (2) Report.--Not later than December 31, 2018, the 
        Comptroller General of the United States shall submit a report 
        to Congress on the study required under paragraph (1), together 
        with recommendations for such legislative and administrative 
        actions as the Comptroller General determines appropriate.

SEC. 3. ESTABLISHMENT OF MEDICARE MAGISTRATE REVIEW AND REVISION OF 
              AMOUNT IN CONTROVERSY THRESHOLDS.

    (a) Establishment of Medicare Magistrate Program.--
            (1) In general.--Section 1869(b) of the Social Security Act 
        (42 U.S.C. 1395ff(b)) is amended by adding at the end the 
        following new paragraph:
            ``(4) Conduct of reviews by medicare magistrates.--
                    ``(A) In general.--The Secretary shall establish 
                within the Office of Medicare Hearings and Appeals 
                decision-making officials to be known as Medicare 
                magistrates.
                    ``(B) Medicare magistrate defined.--For purposes of 
                this section, the term `Medicare magistrate' means an 
                attorney who is licensed by a State, has expertise in 
                this title (including regulations and policies 
                promulgated thereunder), meets such other 
                qualifications as the Secretary shall require, and who 
                performs reviews and renders decisions in appeals 
                described in paragraph (1)(E)(i)(II).
                    ``(C) Requirements for reviews conducted by 
                magistrates.--The provisions of this subsection and 
                subsection (d) that govern hearings and decisions by 
                administrative law judges (including provisions related 
                to reviews of decisions by administrative law judges by 
                the Departmental Appeals Board of the Department of 
                Health and Human Services) shall apply to reviews and 
                decisions by Medicare magistrates in the same manner 
                and to the same extent as such provisions apply to 
                hearings and decisions by an administrative law judge. 
                The Secretary may establish by regulation such other 
                requirements and procedures as may be necessary so that 
                reviews by Medicare magistrates are resolved fairly, 
                efficiently, and expeditiously.''.
            (2) Conforming amendment.--Section 1869(b)(1)(A) of the 
        Social Security Act (42 U.S.C. 1395ff(b)(1)(A)) is amended by 
        inserting ``and paragraph (4)'' after ``subject to 
        subparagraphs (D) and (E)''.
    (b) Amount in Controversy Thresholds.--
            (1) In general.--Section 1869(b)(1)(E) of the Social 
        Security Act (42 U.S.C. 1395ff(b)(1)(E)) is amended--
                    (A) by striking clause (i) and inserting the 
                following:
                            ``(i) In general.--Except as otherwise 
                        provided in this section, subject to clause 
                        (iii)--
                                    ``(I) a review by a Medicare 
                                magistrate under paragraph (4), or a 
                                hearing by an administrative law judge 
                                under this subsection or subsection 
                                (d), shall not be available to an 
                                individual if the amount in controversy 
                                is less than $150;
                                    ``(II) a review by a Medicare 
                                magistrate under paragraph (4) shall be 
                                available to an individual if the 
                                amount in controversy is equal to or 
                                greater than the amount specified in 
                                subclause (I) but less than the amount 
                                specified in subclause (III); and
                                    ``(III) a hearing by an 
                                administrative law judge shall be 
                                available to an individual under this 
                                subsection or subsection (d) if the 
                                amount in controversy is equal to or 
                                greater than $1,500.'';
                    (B) in clause (iii)--
                            (i) by striking ``For requests for 
                        hearings'' and inserting ``For requests for 
                        Medicare magistrate reviews, hearings,'';
                            (ii) by striking ``2004'' and inserting 
                        ``2017''; and
                            (iii) by striking ``2003'' and inserting 
                        ``2016''; and
                    (C) by adding at the end the following new clause:
                            ``(iv) Judicial review.--Judicial review 
                        shall not be available to an individual under 
                        this section if the amount in controversy is 
                        less than the amount specified in clause 
                        (i)(III).''.
            (2) Conforming amendments.--
                    (A) Section 1155 of the Social Security Act (42 
                U.S.C. 1320c-4) is amended--
                            (i) in the second sentence, by striking 
                        ``$200 or more'' and inserting ``equal to or 
                        greater than the amount specified in section 
                        1869(b)(1)(E)(i)(III)'';
                            (ii) in the fourth sentence, by striking 
                        ``$2,000 or more'' and inserting ``equal to or 
                        greater than the amount specified in section 
                        1869(b)(1)(E)(i)(III)''; and
                            (iii) by adding at the end the following 
                        new sentences: ``Where the amount in 
                        controversy is equal to or greater than the 
                        amount specified in subclause (I) of section 
                        1869(b)(1)(E)(i) but less than the amount 
                        specified in subclause (III) of such section, 
                        such beneficiary shall be entitled to a review 
                        by a Medicare magistrate in accordance with 
                        procedures established by the Secretary 
                        pursuant to section 1869. The provisions of 
                        section 1869(b)(1)(E)(iii) shall apply with 
                        respect to the dollar amounts referred to in 
                        this section in the same manner as they apply 
                        to the dollar amounts specified in section 
                        1869(b)(1)(E)(i).''.
                    (B) Section 1852(g)(5) of the Social Security Act 
                (42 U.S.C. 1395w-22(g)(5)) is amended--
                            (i) in the first sentence, by striking 
                        ``$100 or more'' and inserting ``equal to or 
                        greater than the amount specified in section 
                        1869(b)(1)(E)(i)(III)'';
                            (ii) in the second sentence, by striking 
                        ``$1,000 or more'' and inserting ``equal to or 
                        greater than the amount specified in section 
                        1869(b)(1)(E)(i)(III)'';
                            (iii) by inserting after the second 
                        sentence the following new sentence: ``If the 
                        amount in controversy is equal to or greater 
                        than the amount specified in subclause (I) of 
                        section 1869(b)(1)(E)(i) but less than the 
                        amount specified in subclause (III) of such 
                        section, such enrollee shall be entitled to 
                        review by a Medicare magistrate in accordance 
                        with procedures established by the Secretary 
                        pursuant to section 1869.''; and
                            (iv) in the last sentence, by striking 
                        ``the first 2 sentences of''.
                    (C) Section 1876(c)(5)(B) of the Social Security 
                Act (42 U.S.C. 1395mm(c)(5)(B)) is amended--
                            (i) in the first sentence, by striking 
                        ``$100 or more'' and inserting ``equal to or 
                        greater than the amount specified in section 
                        1869(b)(1)(E)(i)(III)'';
                            (ii) in the second sentence, by striking 
                        ``$1,000 or more'' and inserting ``equal to or 
                        greater than the amount specified in section 
                        1869(b)(1)(E)(i)(III)'';
                            (iii) by inserting after the second 
                        sentence the following new sentence: ``If the 
                        amount in controversy is equal to or greater 
                        than the amount specified in subclause (I) of 
                        section 1869(b)(1)(E)(i) but less than the 
                        amount specified in subclause (III) of such 
                        section, such member shall be entitled to 
                        review by a Medicare magistrate in accordance 
                        with procedures established by the Secretary 
                        pursuant to section 1869.''; and
                            (iv) in the last sentence, by striking 
                        ``the first 2 sentences of''.
    (c) Calculation of Amount in Controversy for the Aggregation of 
Claims.--Section 1869(b)(1)(E)(ii) of the Social Security Act (42 
U.S.C. 1395ff(b)(1)(E)(ii)) is amended--
            (1) by redesignating subclauses (I) and (II) as items (aa) 
        and (bb), respectively, and indenting appropriately;
            (2) in the matter preceding item (aa), as so redesignated, 
        by striking ``if the appeals involve'' and inserting the 
        following: ``if--
                                    ``(I) the appeals involve--'';
            (3) in item (bb), as so redesignated, by striking the 
        period at the end and inserting ``; and''; and
            (4) by adding at the end the following new subclause:
                                    ``(II) all claims that an 
                                individual seeks to aggregate are 
                                included in the same request for an 
                                aggregated appeal.''.
    (d) Effective Date.--The amendments made by this section shall take 
effect on January 1, 2017.

SEC. 4. REMANDING APPEALS TO THE REDETERMINATION LEVEL WITH THE 
              INTRODUCTION OF NEW EVIDENCE.

    (a) In General.--Section 1869(b)(3) of the Social Security Act (42 
U.S.C. 1395ff(b)(3)) is amended by striking ``A provider of services'' 
and all that follows through the period and inserting the following new 
subparagraphs:
                    ``(A) Remand upon submission of new evidence.--
                            ``(i) In general.--Except as provided in 
                        subparagraph (B), when a party to an appeal, 
                        other than an individual entitled to, or 
                        enrolled for, benefits under part A or enrolled 
                        under part B or the Centers for Medicare & 
                        Medicaid Services or its contractors, 
                        introduces new evidence into the administrative 
                        record at a reconsideration conducted by a 
                        qualified independent contractor under 
                        subsection (c) or at any subsequent, higher 
                        level of appeal, the appeal shall be remanded 
                        for a de novo redetermination under subsection 
                        (a)(3), and any prior decisions (other than the 
                        initial determination made by the Secretary 
                        pursuant to subsection (a)(1)) on this appeal 
                        shall be vacated.
                            ``(ii) Requirements.--For purposes of 
                        clause (i), except to the extent otherwise 
                        provided by the Secretary in regulations, the 
                        provisions that apply to redeterminations under 
                        subsection (a) and this subsection shall apply 
                        to redeterminations of appeals that are 
                        remanded.
                    ``(B) Exceptions.--The provisions of subparagraph 
                (A) shall not apply in instances where an adjudicator 
                determines that introduction of new evidence is 
                justified due to--
                            ``(i) an inadvertent omission or erroneous 
                        decision by a lower-level adjudicator to omit 
                        the evidence from the administrative record 
                        when that evidence was timely submitted to the 
                        lower-level adjudicator by a party to the 
                        appeal;
                            ``(ii) a decision by a lower-level 
                        adjudicator to issue an unfavorable decision 
                        based on new or different grounds than were 
                        previously adjudicated; or
                            ``(iii) such other circumstances for good 
                        cause as the Secretary may establish.
                    ``(C) No appeal.--A decision to remand an appeal 
                under this paragraph shall not be subject to appeal.''.
    (b) Effective Date.--The amendments made by this section shall take 
effect on January 1, 2017.

SEC. 5. EXPEDITED ACCESS TO APPEALS.

    (a) In General.--Section 1869(b)(1) of the Social Security Act (42 
U.S.C. 1395ff(b)(1)) is amended by adding at the end the following new 
subparagraph:
                    ``(H) Expedited access to appeals.--
                            ``(i) Decision on the record.--Not later 
                        than January 1, 2017, the Secretary shall 
                        establish by regulation and implement a process 
                        authorizing an administrative law judge 
                        reviewing a decision pursuant to this 
                        subsection or subsection (d) to issue a 
                        decision on the record in cases where, based on 
                        the evidence of record, there are no material 
                        issues of fact in dispute and the 
                        administrative law judge determines that there 
                        is a binding authority that controls the 
                        decision in the matter under review.
                            ``(ii) Expedited access to judicial review 
                        not requested by appellant.--The Secretary 
                        shall by regulation establish a process 
                        authorizing an administrative law judge 
                        reviewing a decision pursuant to this 
                        subsection or subsection (d) to certify the 
                        appeal for expedited access to judicial review 
                        where--
                                    ``(I) the appellant does not 
                                request expedited access to judicial 
                                review pursuant to paragraph (2);
                                    ``(II) there are no material issues 
                                of fact in dispute; and
                                    ``(III) neither the administrative 
                                law judge nor the Departmental Appeals 
                                Board has authority to decide the 
                                questions of law or regulation relevant 
                                to the matters in controversy.
                            ``(iii) Application of hearing rules to 
                        decisions on the record.--The provisions of 
                        subsection (d) that govern hearings by 
                        administrative law judges shall apply to a 
                        decision issued by an administrative law judge 
                        without a hearing pursuant to clause (i) in the 
                        same manner and to the same extent as such 
                        provisions apply to a hearing by an 
                        administrative law judge.
                            ``(iv) Effect of certification for judicial 
                        review.--Notwithstanding subsection (d)(2), a 
                        decision to certify an appeal pursuant to 
                        clause (ii) shall not be subject to further 
                        review by the Secretary and shall be deemed a 
                        final decision by the Secretary as provided in 
                        section 205(g) (as applied to this section) for 
                        purposes of determining an individual's 
                        entitlement to judicial review.''.
    (b) Conforming Amendments.--
            (1) Section 1155 of the Social Security Act (42 U.S.C. 
        1320c-4), as amended by section 3(b)(2)(A), is amended--
                    (A) in the second sentence, by striking ``Where'' 
                and inserting ``Subject to the succeeding sentences of 
                this section, where''; and
                    (B) by adding at the end the following new 
                sentence: ``The provisions of subparagraph (H) of 
                section 1869(b)(1) shall apply with respect to 
                decisions by an administrative law judge under this 
                section in the same manner as they apply to decisions 
                by an administrative law judge under such subparagraph 
                (H).''.
            (2) Section 1852(g)(5) of the Social Security Act (42 
        U.S.C. 1395w-22(g)(5)), as amended by section 3(b)(2)(B), is 
        amended--
                    (A) in the first sentence, by striking ``An 
                enrollee'' and inserting ``Subject to the succeeding 
                sentences of this paragraph, an enrollee''; and
                    (B) by adding at the end the following new 
                sentence: ``The provisions of subparagraph (H) of 
                section 1869(b)(1) shall apply with respect to 
                decisions by an administrative law judge under this 
                paragraph in the same manner as they apply to decisions 
                by an administrative law judge under such subparagraph 
                (H).''.
            (3) Section 1869(b)(1)(A) of the Social Security Act (42 
        U.S.C. 1395ff(b)(1)(A)), as amended by section 3(a)(2), is 
        amended by striking ``subparagraphs (D) and (E)'' and inserting 
        ``subparagraphs (D), (E), and (H)''.
            (4) Section 1876(c)(5)(B) of the Social Security Act (42 
        U.S.C. 1395mm(c)(5)(B)), as amended by section 3(b)(2)(C), is 
        amended--
                    (A) in the first sentence, by striking ``A member'' 
                and inserting ``Subject to the succeeding sentences of 
                this subparagraph, a member''; and
                    (B) by adding at the end the following new 
                sentence: ``The provisions of subparagraph (H) of 
                section 1869(b)(1) shall apply with respect to 
                decisions by an administrative law judge under this 
                subparagraph in the same manner as they apply to 
                decisions by an administrative law judge under such 
                subparagraph (H).''.
    (c) Effective Date.--The amendments made by subsections (a) and (b) 
shall take effect on the date of the enactment of this Act and shall 
apply to cases that are pending as of such date.

SEC. 6. AUTHORITY TO USE SAMPLING AND EXTRAPOLATION METHODOLOGIES AND 
              TO CONSOLIDATE APPEALS FOR ADMINISTRATIVE EFFICIENCY.

    (a) In General.--Section 1869 of the Social Security Act (42 U.S.C. 
1395ff) is amended by adding at the end the following new subsection:
    ``(j) Authorities To Promote Administrative Efficiencies.--
            ``(1) Authority to consolidate appeals.--
                    ``(A) In general.--Any individual or entity 
                conducting redeterminations, reconsiderations, reviews, 
                or hearings under subsection (a)(3), (b), (c), or (d) 
                (in this section, referred to as an `adjudicator') may 
                consolidate pending requests for review into a single 
                action, and may issue a single decision, or separate 
                decisions, with respect to such review requests--
                            ``(i) if such requests involve one or more 
                        common questions of fact or law for similar 
                        claims submitted by the same individual or 
                        entity;
                            ``(ii) if such requests involve claims that 
                        were included within a statistical sample 
                        during the initial determination or any 
                        previous level of appeal;
                            ``(iii) if the appellant requests 
                        aggregation of two or more claims under 
                        subsection (b)(1)(E)(ii); or
                            ``(iv) in any other case in which the 
                        adjudicator determines that consolidation would 
                        promote administrative efficiency, consistent 
                        with such standards as the Secretary shall 
                        establish by regulation.
                    ``(B) Deadlines.--The Secretary may establish the 
                applicable timeframe for requesting consolidations and 
                for issuing decisions on appeals that have been 
                consolidated.
            ``(2) Requirements for claims that were included in an 
        extrapolated overpayment or previously consolidated.--An 
        individual or entity requesting a redetermination, 
        reconsideration, review or hearing under subsection (a)(3), 
        (b), (c), or (d) with respect to two or more claims that were 
        included in an extrapolated overpayment, or claims that were 
        consolidated into a single appeal at a lower-level adjudication 
        under this section, must submit a single request for review or 
        hearing with respect to such claims in order to be entitled to 
        a review or hearing.
            ``(3) Authority to use statistical sampling and 
        extrapolation methodologies in adjudications.--With the consent 
        of the appellant, an adjudicator may use statistical sampling 
        and extrapolation methodologies in reaching a decision with 
        respect to a claim or claims for benefits for items or services 
        furnished under part A or B. When an appeal involves a decision 
        that was based on a statistical sample at the lower level, the 
        adjudicator's decision shall be based on the same statistical 
        sample.''.
    (b) Effective Date.--The amendments made by this section shall 
apply to requests for review that are pending at any level of appeal as 
of the date of the enactment of this Act and to those filed after such 
date.

SEC. 7. IDENTIFICATION AND REFERRAL OF FRAUD.

    Not later than January 1, 2017, the Secretary of Health and Human 
Services, in consultation with the Inspector General of the Department 
of Health and Human Services and the Attorney General of the United 
States, shall establish and implement a process under which the Office 
of Medicare Hearings and Appeals and the Departmental Appeals Board of 
the Department of Health and Human Services shall refer cases in which 
there is a credible suspicion of fraudulent activity to appropriate law 
enforcement agencies and to the Centers for Medicare & Medicaid 
Services.

SEC. 8. STUDY TO ASSESS HEARING PARTICIPATION.

    (a) Study.--Not later than January 1, 2017, the Secretary of Health 
and Human Services shall conduct a study to determine whether it would 
be feasible to increase the participation, with respect to hearings 
conducted by the Office of Medicare Hearings and Appeals, of--
            (1) the Centers for Medicare & Medicaid Services;
            (2) entities serving as qualified independent contractors 
        under section 1869(c) of the Social Security Act (42 U.S.C. 
        1395ff(c));
            (3) entities serving as medicare administrative contractors 
        under section 1874A of such Act (42 U.S.C. 1395kk-1);
            (4) entities services as recovery audit contractors under 
        section 1893(h) of such Act (42 U.S.C. 1395ddd(h)); and
            (5) other Medicare claims review entities determined 
        appropriate by the Secretary.
    (b) Report.--Not later than 1 year after the date of the enactment 
of this Act, the Secretary of Health and Human Services shall publish a 
report containing the results of the study required under subsection 
(a) on the Internet website of the Department of Health and Human 
Services.

SEC. 9. IMPROVEMENTS TO THE OFFICE OF MEDICARE HEARINGS AND APPEALS.

    (a) Training for ALJs and Medicare Magistrates.--Section 1869(e)(3) 
of the Social Security Act (42 U.S.C. 1395ff(e)(3)) is amended--
            (1) in the paragraph heading, by striking ``and 
        administrative law judges'' and inserting ``, administrative 
        law judges, and medicare magistrates; annual training for 
        administrative law judges and medicare magistrates'';
            (2) by striking ``The Secretary'' and inserting the 
        following:
                    ``(A) Continuing education requirement.--The 
                Secretary'';
            (3) by inserting ``and, beginning in 2017, to Medicare 
        magistrates'' after ``administrative law judges'' the first 
        place it appears;
            (4) by striking ``and administrative law judges'' and 
        inserting ``, administrative law judges, and Medicare 
        magistrates''; and
            (5) by adding at the end the following new subparagraph:
                    ``(B) Annual training.--Beginning with 2017, each 
                year the Secretary shall provide to each administrative 
                law judge and Medicare magistrate within the Office of 
                Medicare Hearings and Appeals training on Medicare 
                policies, including any policies that were changed or 
                instituted in the previous year.''.
    (b) Treatment of QIC Decisions.--Section 1869(d)(4) of the Social 
Security Act (42 U.S.C. 1395ff(d)(4)) is amended--
            (1) in subparagraph (B), by striking ``and'' at the end;
            (2) in subparagraph (C), by striking the period at the end 
        and inserting ``; and''; and
            (3) by adding at the end the following new subparagraph:
                    ``(D) in the case of a review conducted on or after 
                January 1, 2017, of a decision by a qualified 
                independent contractor in which the administrative law 
                judge reaches a different decision than the qualified 
                independent contractor, the reasons why the decision of 
                the administrative law judge differs from the decision 
                of the qualified independent contractor.''.
    (c) Publication of Appeals Information.--Section 1869(e) of the 
Social Security Act (42 U.S.C. 1395ff(e)) is amended by adding at the 
end the following new paragraph:
            ``(5) Publication of appeals information.--Not later than 
        January 1, 2017, and annually thereafter, the Secretary of 
        Health and Human Services shall publish and maintain on the 
        Internet website of the Department of Health and Human Services 
        the following information, which may be effectuated through the 
        use of statistical sampling, regarding appeals heard by the 
        Office of Medicare Hearings and Appeals for each fiscal year:
                    ``(A) The percentage of appeals that received fully 
                favorable, partially favorable, and unfavorable 
                decisions.
                    ``(B) For each administrative law judge, the 
                percentage of appeals that received fully favorable, 
                partially favorable, and unfavorable decisions.
                    ``(C) For each type of service, the percentage of 
                appeals that received fully favorable, partially 
                favorable, and unfavorable decisions.
                    ``(D) The average length of time elapsed between 
                the initial request for review and a final decision.
                    ``(E) Such other information as the Secretary 
                determines necessary to ensure greater transparency for 
                the Office of Medicare Hearings and Appeals.''.
    (d) GAO Review of Consistency of OMHA Decisions.--
            (1) Study.--
                    (A) In general.--The Comptroller General of the 
                United States shall conduct a study of decisions 
                rendered by the Office of Medicare Hearings and Appeals 
                to determine the frequency with which decisions by 
                administrative law judges or Medicare magistrates--
                            (i) diverge from the interpretation of 
                        Medicare policy and program instruction of the 
                        Centers for Medicare & Medicaid Services;
                            (ii) demonstrate significant variation in 
                        the interpretation of similar Medicare policies 
                        or instructions; and
                            (iii) fail to apply applicable Medicare 
                        law, regulation, policy, or instruction.
                    (B) Methodology.--In conducting the study required 
                under this paragraph, the Comptroller General of the 
                United States shall focus on decisions rendered by the 
                Office of Medicare Hearings and Appeals not less than 1 
                year after the date of the enactment of this Act and, 
                if the Comptroller so chooses, may use sampling to 
                identify decisions to evaluate.
            (2) Report.--Not later than January 1, 2018, the 
        Comptroller General of the United States shall submit a report 
        to Congress on the study required under paragraph (1), together 
        with recommendations for such legislative and administrative 
        actions as the Comptroller General determines appropriate.
    (e) Identification of Inconsistent Interpretations of Policies 
Across Review Entities.--Not later than January 1, 2017, the Secretary 
of Health and Human Services shall establish and implement a process 
for identifying policies or coverage determinations relating to title 
XVIII of the Social Security Act that are most frequently interpreted 
and applied differently by review entities, Medicare magistrates, 
administrative law judges, or the Department Appeals Board of the 
Department of Health and Human Services. As a part of such process, the 
Secretary shall, where appropriate, issue guidance or take other 
administrative action to clarify how a policy or coverage decision 
should be interpreted in order to prevent future conflicting 
interpretations.
    (f) Study and Report on Administrative Law Judge Specialization.--
            (1) Study.--The Secretary of Health and Human Services 
        shall conduct a study to determine if the specialization of 
        administrative law judges within the Office of Medicare 
        Hearings and Appeals by type of appeal would lead to more 
        consistent decisions by administrative law judges determining 
        cases with similar facts.
            (2) Report.--Not later than January 1, 2018, the Secretary 
        of Health and Human services shall submit to Congress a report 
        containing the results of the study required under paragraph 
        (1), together with recommendations for such legislative and 
        administrative action as the Secretary determines appropriate.
    (g) Alternative Dispute Resolution.--
            (1) In general.--Section 1869(b) of the Social Security Act 
        (42 U.S.C. 1395ff(b)), as amended by section 3(a), is amended 
        by adding at the end the following new paragraph:
            ``(5) Alternative dispute resolution.--
                    ``(A) In general.--
                            ``(i) Redetermination and reconsideration 
                        adr process.--The Secretary shall establish one 
                        or more alternative dispute resolution 
                        processes whereby, at the Secretary's 
                        discretion, an individual or entity entitled to 
                        a redetermination under subsection (a)(3) by a 
                        medicare administrative contractor or a 
                        reconsideration under subsection (c) by a 
                        qualified independent contractor may have the 
                        option to enter into alternative dispute 
                        resolution with the Centers for Medicare & 
                        Medicaid Services, consistent with the 
                        following:
                                    ``(I) During the alternative 
                                dispute resolution process, the request 
                                for review with respect to the claims 
                                covered by the alternative dispute 
                                resolution shall be suspended.
                                    ``(II) In the event that an 
                                alternative dispute resolution does not 
                                result in a settlement, the request for 
                                review with respect to the claims 
                                covered by the alternative dispute 
                                resolution shall resume under 
                                subsection (a)(3) or subsection (c), as 
                                applicable.
                            ``(ii) Hearing and review mediation.--The 
                        Secretary shall establish an alternative 
                        dispute resolution process whereby, at the 
                        Secretary's discretion, an individual or entity 
                        entitled to a review or hearing on a decision 
                        of a qualified independent contractor by a 
                        Medicare magistrate or an administrative law 
                        judge may have the option to enter into an 
                        alternative dispute resolution process mediated 
                        by staff members of the Office of Medicare 
                        Hearings and Appeals selected for the purpose 
                        of mediating alternative dispute resolutions 
                        under this paragraph.
                    ``(B) Effect of alternative dispute resolution.--
                            ``(i) In general.--As part of any 
                        alternative dispute resolution settlement under 
                        this paragraph, an appellant shall be required 
                        to--
                                    ``(I) forego the right to such 
                                redetermination, reconsideration, 
                                review, or hearing, as applicable; and
                                    ``(II) withdraw all requests for 
                                review with respect to the claims 
                                covered by the settlement.
                            ``(ii) No judicial review.--There shall be 
                        no administrative or judicial review under 
                        section 1869, 1878, or otherwise of the 
                        alternative dispute resolution settlement and 
                        the claims covered by the settlement.
                    ``(C) Coordination with law enforcement and cms.--
                The Secretary shall establish a process under which the 
                officers responsible for conducting an alternative 
                dispute resolution process shall coordinate with 
                appropriate law enforcement agencies and the Centers 
                for Medicare & Medicaid Services to avoid the 
                inadvertent settlement of cases that involve fraud or 
                other criminal activity.
                    ``(D) No entitlement to alternative dispute 
                resolution.--Nothing in this paragraph shall be 
                construed as creating an entitlement to alternative 
                dispute resolution.''.
            (2) Conforming amendments.--
                    (A) Section 1869(a)(3)(A) of the Social Security 
                Act (42 U.S.C. 1395ff(a)(3)(A)) is amended by inserting 
                ``, subject to subsection (b)(5),'' after ``regulations 
                shall''.
                    (B) Section 1869(b)(1)(A) of the Social Security 
                Act (42 U.S.C. 1395ff(b)(1)(A)), as amended by section 
                3(a)(2), is amended--
                            (i) by inserting ``and paragraph (5)'' 
                        after ``Subject to subparagraph (D)''; and
                            (ii) by striking ``and paragraph (4)'' and 
                        inserting ``and paragraphs (4) and (5)''.

SEC. 10. REVIEW PROGRAM IMPROVEMENTS.

    (a) In General.--Section 1893 of the Social Security Act (42 U.S.C. 
1395ddd) is amended--
            (1) in subsection (b), by adding at the end the following 
        new paragraph:
            ``(7) The review program improvements described in 
        subsection (j).'';
            (2) by redesignating subsection (i) as subsection (j); and
            (3) by inserting after subsection (h) the following new 
        subsection:
    ``(i) Review Program Improvements.--
            ``(1) In general.--''.
                    ``(A) Guidelines.--
                            ``(i) In general.--To ensure uniformity and 
                        consistency in initial determinations and 
                        appeals decisions relating to the 
                        appropriateness of payment with respect to 
                        items or services furnished under this title, 
                        the Secretary shall ensure that claim review 
                        guidelines are established for reviewing claims 
                        for payment submitted by providers of services 
                        and suppliers.
                            ``(ii) Requirements.--Prior to the 
                        implementation of the claim review guidelines 
                        described in subparagraph (A)(i), the Secretary 
                        shall--
                                    ``(I) approve the claim review 
                                guidelines;
                                    ``(II) make the claim review 
                                guidelines publicly available as 
                                described in subparagraph (B);
                                    ``(III) ensure that review 
                                contractors apply the claim review 
                                guidelines consistently, as 
                                appropriate; and
                                    ``(IV) ensure that Medicare 
                                magistrates, administrative law judges, 
                                and the Departmental Appeals Board are 
                                trained in the application of the claim 
                                review guidelines.
                            ``(iii) Transition period.--The Secretary 
                        may provide for or establish one or more 
                        transition periods, during which the use of 
                        existing claim review guidelines for reviewing 
                        claims submitted by providers of services and 
                        suppliers shall be permitted to continue until 
                        such time as the Secretary is able to review 
                        and approve the claim review guidelines 
                        established under this subparagraph.
                    ``(B) Transparency.--
                            ``(i) In general.--The Secretary shall 
                        ensure that the information described in clause 
                        (iii)--
                                    ``(I) is published on the Internet 
                                website of the Department of Health and 
                                Human Services for not less than 30 
                                days prior to its implementation;
                                    ``(II) remains available on such 
                                Internet website after such 
                                publication; and
                                    ``(III) is updated at least 
                                annually.
                            ``(ii) Expedited process.--The Secretary of 
                        Health and Human Services may expedite the 
                        process described in clause (i) for claims 
                        review guidelines that are expected to impact 
                        the improper payment rate, frequency of denials 
                        of payment, or costs to the Medicare program.
                            ``(iii) Information described.--The 
                        information described in this clause is the 
                        following:
                                    ``(I) Subject to clause (ii) and 
                                subparagraph (A), any new claim review 
                                guideline approved for use under this 
                                paragraph.
                                    ``(II) Any updates or revisions to 
                                existing claim review guidelines.
                    ``(C) Limitation.--Nothing in this section is 
                intended to--
                            ``(i) delineate sample size or how claims 
                        are to be selected for review;
                            ``(ii) require the publication of 
                        algorithms or methodologies used for claim 
                        selection; or
                            ``(iii) require the publication of 
                        information that could promote fraud or 
                        potential gaming.
                    ``(D) Review contractor defined.--In this 
                subsection, the term `review contractor' means--
                            ``(i) a medicare administrative contractor 
                        (as defined in section 1874A(a)(3)(A)) with a 
                        contract to conduct prepayment or post-payment 
                        reviews of claims for payment by providers of 
                        services or suppliers;
                            ``(ii) a recovery audit contractor with a 
                        contract under subsection (h); or
                            ``(iii) any other contractor the Secretary 
                        determines appropriate.
            ``(2) Program integrity initiatives.--To improve existing 
        and future Medicare program integrity initiatives, and to limit 
        unnecessary burdens on providers of services and suppliers, the 
        Secretary shall designate a point of contact to oversee and 
        undertake the following:
                    ``(A) Develop a comprehensive strategy for claim 
                review determinations made on a prepayment, post-
                payment, or prior-authorization basis that--
                            ``(i) focuses on identifying and reducing 
                        those claim errors that have the largest impact 
                        on the improper payment rate, pose the greatest 
                        risk to the Federal Hospital Insurance Trust 
                        Fund under section 1817 of the Social Security 
                        Act (42 U.S.C. 1395i) or the Federal 
                        Supplementary Medical Insurance Trust Fund 
                        under section 1841 of such Act (42 U.S.C. 
                        1395t), or are likely to negatively affect 
                        quality of care;
                            ``(ii) reduces unnecessary burden on 
                        providers of services and suppliers and 
                        minimizes any negative effects on Medicare 
                        beneficiaries; and
                            ``(iii) utilizes data and other sources, 
                        including claims data, improper payment rate 
                        data, and reports from the Office of the 
                        Inspector General of the Department of Health 
                        and Human Services, the General Accountability 
                        Office, the Medicare Payment Advisory 
                        Commission, and the media.
                    ``(B) Develop methods to ensure, using all 
                available data, that review contractors do not 
                unnecessarily conduct duplicate reviews of specific 
                individual claims.
                    ``(C) To the extent possible given the specific 
                mission of each entity that has contracted with the 
                Secretary, work with all review contractors to develop 
                a uniform, consistent, and transparent review process 
                to reduce the burden on providers of services and 
                suppliers to the greatest extent possible, including a 
                uniform approach for such entities to notify parties of 
                pending reviews and to request medical documentation, 
                improved communication with providers of services and 
                suppliers, better refinement of audits to target claims 
                that are at the highest risk for improper payments or 
                other errors, and any other areas in which the 
                Secretary determines that the burden on providers of 
                services and suppliers may be decreased.
                    ``(D) Identify local coverage determinations, 
                national coverage determinations, regulations, and 
                program instructions issued by the Centers for Medicare 
                & Medicaid Services for the Medicare program that need 
                updating or that inappropriately conflict with other 
                Medicare policies and make modifications where 
                appropriate, and, if necessary, establish new policies 
                or claim review guidelines with input from stakeholders 
                as appropriate.
                    ``(E) Publish on the Internet website of the 
                Department of Health and Human Services the volume and 
                type of prepayment and post-payment claim reviews 
                performed by medicare administrative contractors under 
                section 1874A of the Social Security Act (42 U.S.C. 
                1395kk-1) and recovery audit contractors under section 
                1893(h) of such Act (42 U.S.C. 1395ddd(h)).
                    ``(F) Coordinate with the Office of Medicare 
                Hearings and Appeals and the Departmental Appeals Board 
                of the Department of Health and Human Services to 
                ensure that the improved claim review guidelines and 
                evidentiary standards established by the provisions of, 
                and the amendments made by, this Act, such as the 
                decision to remand an appeal, are properly implemented.
                    ``(G) Ensure that providers of services and 
                suppliers subject to post-payment review by a medicare 
                administrative contractor are granted a discussion 
                period with the contractor of at least 30 days from the 
                letter from the contractor regarding the result of the 
                review.
                    ``(H) Develop qualification standards for review 
                contractors that require prepayment and post-payment 
                reviews of claims for payment submitted by providers of 
                services or suppliers to be conducted or approved by 
                medical doctors with knowledge of relevant Medicare 
                laws, regulations, and program instruction, as 
                appropriate.
                    ``(I) Verify, through the use of sampling if the 
                Secretary so chooses, that decisions by review 
                contractors are consistent with Medicare laws, 
                regulations, and program instruction (taking into 
                account geographical variations that are a result of 
                local coverage determinations).
                    ``(J) Determine whether additional punitive actions 
                against ineffective review contractors could be taken 
                and what, if any, financial incentives or disincentives 
                could be used to promote the accuracy of a review 
                contractor's reviews.
            ``(3) Medicare provider claim audit internet portal.--
                    ``(A) In general.--The Secretary shall establish a 
                secure, Internet-based system (which may be based on 
                the existing database system of claims under review 
                used by review contractors or a similar existing 
                system) through which a provider of services, a 
                supplier, or other appropriate entity may track the 
                status of any claim for payment submitted by such 
                provider or supplier that is being audited or processed 
                as an appeal by--
                            ``(i) a medicare administrative contractor 
                        under section 1874A; or
                            ``(ii) a qualified independent contractor, 
                        Medicare magistrate, administrative law judge, 
                        or the Departmental Appeals Board of the 
                        Department of Health and Human Services under 
                        section 1869.
                    ``(B) Fraud prevention.--The Secretary shall ensure 
                that the system established under paragraph (1) does 
                not impede any ongoing investigations of potential 
                fraud.
                    ``(C) Progress report.--Not later than 180 days 
                after the date of the enactment of this Act, the 
                Secretary shall submit a report to Congress describing 
                the plan to establish and operate the system described 
                in paragraph (1).''.
    (b) Annual RAC Report.--Section 1893(h)(8) is amended by inserting 
``, and, with respect to reports submitted after the date of the 
enactment of the Audit & Appeals Fairness, Integrity, and Reforms in 
Medicare Act of 2015, the number of claims corrected in the discussion 
period, the percentage of appeals of determinations by recovery audit 
contractors that were ultimately successful, a careful description of 
the denominator of total audits and appeals (given the likelihood that 
many appeals in a given year will not have a decision in that year), 
and separate reports on complex Medicare part A, complex Medicare part 
B, semiautomated, and automated reviews'' before the period at the end.
    (c) Independence of Adjudicators.--Nothing in this section or the 
amendments made thereby shall be construed as authorizing the Secretary 
to limit the authority or decisional independence of Medicare 
magistrates, administrative law judges, or the Departmental Appeals 
Board of the Department of Health and Human Services.

SEC. 11. CREATION OF MEDICARE PROVIDER AND SUPPLIER OMBUDSMAN FOR 
              REVIEWS AND APPEALS.

    Section 1808 of the Social Security Act (42 U.S.C. 1395b-9) is 
amended by adding at the end the following new subsection:
    ``(d) Medicare Reviews and Appeals Ombudsman.--
            ``(1) In general.--Not later than 1 year after the date of 
        the enactment of this subsection, the Secretary shall appoint 
        within the Centers for Medicare & Medicaid Services a Medicare 
        Reviews and Appeals Ombudsman.
            ``(2) Duties.--The Medicare Reviews and Appeals Ombudsman 
        shall--
                    ``(A) identify, investigate, and assist in the 
                resolution of complaints and inquiries related to the 
                Medicare audits and appeals process from providers of 
                services or suppliers with respect to benefits under 
                part A or B;
                    ``(B) identify trends in complaints and inquiries 
                regarding the current Medicare review and appeals 
                systems to provide recommendations for improvements to 
                the Secretary that would improve the efficacy and 
                efficiency of claim review and appeals systems, as well 
                as communication to beneficiaries, providers of 
                services, and suppliers;
                    ``(C) design a system by which to objectively 
                measure and evaluate reviewer responsiveness to 
                addressing inquiries from providers of services and 
                suppliers and inquiries from the Ombudsman;
                    ``(D) provide administrative and technical 
                assistance to appellants and those considering an 
                appeal;
                    ``(E) publish data regarding the number of review 
                determinations appealed, each appeal's outcome, and 
                aggregate appeal statistics--
                            ``(i) for each medicare administrative 
                        contractor conducting redeterminations under 
                        section 1869(a)(3);
                            ``(ii) for each qualified independent 
                        contractor conducting reconsiderations under 
                        section 1869(c);
                            ``(iii) for each recovery audit contractor 
                        conducting reviews under section 1893(h);
                            ``(iv) by type of provider of services; and
                            ``(v) by type of supplier;
                    ``(F) assist in education and training efforts for 
                providers of services, suppliers, and review 
                contractors (as defined in section 1893(i)(1)(D));
                    ``(G) communicate with the Medicare Beneficiary 
                Ombudsman to assist with the identification, 
                investigation, and resolution of beneficiary-related 
                complaints, including those that overlap with requests 
                for review and appeals submitted by providers of 
                services or suppliers; and
                    ``(H) perform such other duties as determined 
                appropriate by the Secretary.''.

SEC. 12. LIMITING THE AUDIT AND RECOVERY PERIOD FOR PATIENT STATUS 
              REVIEWS.

    (a) In General.--Section 1893(h)(4) of the Social Security Act (42 
U.S.C. 1395ddd(h)(4) is amended--
            (1) by redesignating subparagraphs (A) and (B) as clauses 
        (i) and (ii), respectively, and moving such clauses 2 ems to 
        the right;
            (2) by striking ``Each such'' and inserting the following:
                    ``(A) In general.--Except as provided in 
                subparagraph (B), each such''; and
            (3) by adding at the end the following new subparagraph:
                    ``(B) Limitation.--
                            ``(i) In general.--With respect to the 
                        classification of an individual entitled to, or 
                        enrolled for, benefits under part A or enrolled 
                        under part B, or both, as an inpatient or an 
                        outpatient for purposes of hospital claims for 
                        payment for items or services furnished to such 
                        individual under this title, such contracts 
                        shall provide that a recovery audit contractor 
                        shall only send additional documentation 
                        requests related to the appropriateness of such 
                        classification in the first 6 months after the 
                        date on which such items or services were 
                        furnished.
                            ``(ii) Exception.--The limitation described 
                        in clause (i) shall not apply where a claim for 
                        payment is submitted more than 3 months after 
                        the date on which such items or services were 
                        furnished.''.
    (b) Study on Shortening the Audit and Recovery Period for Other 
Reviews.--
            (1) Study.--The Secretary of Health and Human Services 
        shall conduct a study to assess--
                    (A) the potential burden on providers of services 
                (as defined in subsection (u) of section 1861 of the 
                Social Security Act (42 U.S.C. 1395x)) and suppliers 
                (as defined in subsection (d) of such section 1861) 
                under the Medicare program of the audit and recovery 
                period applicable to audit and recovery activities 
                conducted by recovery audit contractors under section 
                1893(h)(4) of such Act (42 U.S.C. 1395ddd(h)(4)); and
                    (B) the impact of shortening such period with 
                respect to different types of reviews.
            (2) Report.--Not later than 1 year after the date of the 
        enactment of this Act, the Secretary of Health and Human 
        Services shall publish a report containing the results of the 
        study required under paragraph (1) on the Internet website of 
        the Department of Health and Human Services.
    (c) Authority To Implement Shorter Audit and Recovery Period.--
Section 1893(h)(4) of the Social Security Act (42 U.S.C. 
1395ddd(h)(4)), as amended by subsection (a), is further amended--
            (1) in subparagraph (A), by striking ``subparagraph (B)'' 
        and inserting ``subparagraphs (B) and (C)''; and
            (2) by adding at the end the following new subparagraph:
                    ``(C) Authority to implement shorter audit and 
                recovery period.--Notwithstanding subparagraph (A)(ii), 
                with respect to payments made under this title for 
                specific categories of services, the Secretary may 
                enter into contracts under paragraph (1) that provide 
                for a retrospective period during which audit and 
                recovery activities may be conducted of not more than 3 
                years.''.
    (d) Report on RAC Payment Structure.--Not later than 6 months after 
the date of the enactment of this Act, the Secretary of Health and 
Human Services shall submit to Congress a report on ways to change, in 
a budget neutral manner, the payment structure for recovery audit 
contractors under section 1893(h)(1) of the Social Security Act (42 
U.S.C. 1395ddd(h)(1)) from an incentive-based model to a non-incentive 
based approach that does not impose additional financial burdens on 
providers.
    (e) Effective Date.--The amendments made by this section shall take 
effect on January 1, 2017, and shall apply to contracts between the 
Secretary and recovery audit contractors entered into on or after such 
date.

SEC. 13. INCENTIVES AND DISINCENTIVES FOR MEDICARE CONTRACTORS, 
              PROVIDERS, AND SUPPLIERS.

    Section 1893 of the Social Security Act (42 U.S.C. 1395ddd), as 
amended by section 10, is further amended--
            (1) by redesignating subsection (j) as subsection (k); and
            (2) by inserting after subsection (i) the following new 
        subsection:
    ``(j) Compliance Incentive Program.--
            ``(1) In general.--Not later than January 1, 2017, the 
        Secretary shall establish a compliance incentive program, 
        consisting of the components described in paragraphs (2) and 
        (3), to encourage--
                    ``(A) providers of services and suppliers to submit 
                accurate claims that comply with this title and the 
                policies, regulations, and program instructions 
                promulgated thereunder, as well as any applicable 
                national or local coverage determinations; and
                    ``(B) entities that have entered into contracts 
                with the Secretary under subsection (h) or section 
                1874A (referred to in this subsection as `review 
                contractors') to conduct reviews under this section or 
                section 1874A, as applicable, in a manner that is 
                consistent with the provisions of this title and the 
                claim review guidelines, regulations, and program 
                instructions promulgated thereunder, as well as any 
                applicable national or local coverage determinations.
            ``(2) Compliance with claim procedures by providers of 
        services and suppliers.--
                    ``(A) In general.--Not later than January 1, 2017, 
                the Secretary shall establish a system through which a 
                provider of services or supplier that has achieved a 
                low rate of denials of claims for payment subject to 
                additional documentation requests over a 2 year period, 
                as determined by the Secretary, shall be exempt for a 
                period of 1 year from any post-payment review of claims 
                for payment conducted by review contractors.
                    ``(B) Limitation.--The Secretary shall not exempt 
                or shall rescind an exemption granted to a provider of 
                services or supplier under subparagraph (A) if the 
                Secretary determines that there is evidence of 
                systematic gaming, fraud, abuse, or delay in the 
                provision of services or items by such provider or 
                services or supplier.
            ``(3) Compliance with review procedures by medicare 
        contractors.--
                    ``(A) In general.--Not later than January 1, 2017, 
                the Secretary shall establish a process, which may 
                include the use of sampling, for determining the 
                frequency with which the decisions made by a review 
                contractor with respect to reviews conducted under this 
                section or section 1874A are consistent with the 
                provisions of this title and the policies, regulations, 
                and program instructions promulgated thereunder, as 
                well as any applicable national or local coverage 
                determinations. The results of this process shall be 
                made available to the public on the Internet website of 
                the Department of Health and Human Services.
                    ``(B) Access to medical records by review 
                contractors.--
                            ``(i) Access to records based on 
                        performance review.--Not later than January 1, 
                        2017, the Secretary shall establish a system 
                        under which, for any incentive period--
                                    ``(I) the number of medical records 
                                that a review contractor that was a 
                                high-performing review contractor in 
                                the performance review period 
                                associated with such incentive period 
                                may request from a provider of services 
                                or supplier in carrying out activities 
                                under this section or section 1874, as 
                                applicable, may be increased (on a 
                                sliding scale); and
                                    ``(II) the number of medical 
                                records that a review contractor that 
                                was a low-performing review contractor 
                                in the performance review period 
                                associated with such incentive period 
                                may request from a provider of services 
                                or supplier in carrying out activities 
                                under this section or section 1874A, as 
                                applicable, may be decreased (on a 
                                sliding scale).
                            ``(ii) Definitions.--In this subparagraph:
                                    ``(I) High-performing review 
                                contractor.--The term `high-performing 
                                review contractor' means a review 
                                contractor that, for a given 
                                performance review period, makes 
                                decisions with respect to reviews 
                                conducted under this section or section 
                                1874A, as applicable, of the activities 
                                of providers of services and suppliers 
                                that are consistent with the provisions 
                                of this title and the policies, 
                                regulations, and program instructions 
                                promulgated thereunder, as well as any 
                                applicable national or local coverage 
                                determinations, at a rate that is equal 
                                to or greater than 95 percent.
                                    ``(II) Incentive period.--The term 
                                `incentive period' means, with respect 
                                to a performance review period, a 
                                period of time (to be determined by the 
                                Secretary) following such performance 
                                review period during which the number 
                                of medical records that a review 
                                contractor may request from a provider 
                                of services or supplier may be 
                                increased or decreased based on such 
                                contractor's status as a high-
                                performing review contractor or a low-
                                performing review contractor for such 
                                performance review period.
                                    ``(III) Low-performing review 
                                contractor.--The term `low-performing 
                                review contractor' means a review 
                                contractor that, for a given 
                                performance review period, is not 
                                described in subclause (I).
                                    ``(IV) Performance review period.--
                                The term `performance review period' 
                                means a period of time (to be 
                                determined by the Secretary) during 
                                which a review contractor's decisions 
                                with respect to reviews conducted under 
                                this section or section 1874A, as 
                                applicable, are evaluated to determine 
                                if such review contractor is a high-
                                performing contractor or a low-
                                performing contractor for such 
                                period.''.
                                                       Calendar No. 317

114th CONGRESS

  1st Session

                                S. 2368

                          [Report No. 114-177]

_______________________________________________________________________

                                 A BILL

    To amend title XVIII of the Social Security Act to improve the 
  efficiency of the Medicare appeals process, and for other purposes.

_______________________________________________________________________

                            December 8, 2015

                 Read twice and placed on the calendar