[Congressional Bills 115th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2445 Introduced in House (IH)]

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115th CONGRESS
  1st Session
                                H. R. 2445

To amend title XVIII of the Social Security Act to provide for a prior 
authorization process under the Medicare program for certain high cost 
    durable medical equipment, prosthetics, orthotics, and supplies.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                              May 16, 2017

Mrs. Blackburn introduced the following bill; which was referred to the 
 Committee on Energy and Commerce, and in addition to the Committee on 
   Ways and Means, for a period to be subsequently determined by the 
  Speaker, in each case for consideration of such provisions as fall 
           within the jurisdiction of the committee concerned

_______________________________________________________________________

                                 A BILL


 
To amend title XVIII of the Social Security Act to provide for a prior 
authorization process under the Medicare program for certain high cost 
    durable medical equipment, prosthetics, orthotics, and supplies.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``DMEPOS Access and Transparency Act 
of 2017'' or the ``DATA Act of 2017''.

SEC. 2. PRIOR AUTHORIZATION PROCESS FOR CERTAIN HIGH COST DURABLE 
              MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND SUPPLIES 
              UNDER THE MEDICARE PROGRAM.

    Section 1834(a)(15) of the Social Security Act (42 U.S.C. 
1395m(a)(15)) is amended--
            (1) in the paragraph heading, by striking ``items'' and 
        inserting ``items; prior authorization process for certain high 
        cost durable medical equipment, prosthetics, orthotics, and 
        supplies''; and
            (2) by adding at the end the following new subparagraphs:
                    ``(D) Prior authorization process for certain high 
                cost durable medical equipment, prosthetics, orthotics, 
                and supplies.--
                            ``(i) In general.--Not later than 1 year 
                        after the date of the enactment of this 
                        subparagraph, the Secretary shall develop and 
                        implement a prior authorization process for 
                        certain durable medical equipment, prosthetics, 
                        orthotics, and supplies. A claim for an item of 
                        durable medical equipment, a prosthetic, an 
                        orthotic, or a supply that has received prior 
                        approval through the prior authorization 
                        process shall be exempt from subsequent pre- 
                        and post-payment audits and only subject to 
                        audits for systematic fraud and abuse.
                            ``(ii) Consideration of factors.--The 
                        Secretary shall consider the following factors 
                        in developing and implementing the prior 
                        authorization process under this subparagraph:
                                    ``(I) Beneficiary access to timely 
                                care.
                                    ``(II) Alignment with the best 
                                practices of commercial managed care 
                                plans and Medicare Advantage plans 
                                under part C that have expertise in 
                                prior authorization processes.
                                    ``(III) Implementation of standard 
                                medical necessity evaluation prior 
                                authorization requests for physician 
                                and hospital referral agents and non-
                                physician practitioners.
                                    ``(IV) Accounting for same day 
                                delivery expectations by providing for 
                                expedited emergency review for certain 
                                items.
                            ``(iii) Implementation.--The Secretary 
                        shall promulgate a regulation to carry out the 
                        prior authorization process under this 
                        subparagraph. The regulation shall--
                                    ``(I) ensure that stakeholders 
                                participate in the development of the 
                                process; and
                                    ``(II) place priority on prior 
                                authorization of items that are subject 
                                to a high number of contractor audits.
                    ``(E) Prior authorization process for home 
                respiratory therapy.--
                            ``(i) In general.--In the case of home 
                        respiratory therapy (as defined in clause (v)) 
                        furnished on or after January 1, 2019, the 
                        Secretary shall establish and implement a 
                        process under which the Secretary shall 
                        determine, in advance of furnishing such 
                        therapy to an individual, whether payment for 
                        such therapy may not be made under this title 
                        because such therapy is not covered under this 
                        title or because of the application of section 
                        1862(a)(1).
                            ``(ii) Elements of process.--Under the 
                        process described in clause (i), with respect 
                        to home respiratory therapy for an individual, 
                        the following shall apply:
                                    ``(I) In order to obtain a prior 
                                authorization under such process, the 
                                prescribing practitioner (as defined by 
                                the Secretary) prescribing such therapy 
                                for such individual shall submit, for 
                                such therapy and individual--
                                            ``(aa) a prescription;
                                            ``(bb) in the case of home 
                                        respiratory therapy that is 
                                        oxygen or oxygen equipment, a 
                                        certificate of medical 
                                        necessity; and
                                            ``(cc) a prior 
                                        authorization form that 
                                        includes the information 
                                        described in subclause (II).
                                A prescription described in item (aa) 
                                with respect to such therapy is not 
                                required under this subclause if a 
                                certificate of medical necessity 
                                described in item (bb) with respect to 
                                such therapy is provided and if such 
                                certificate contains a narrative 
                                description that includes the elements 
                                for a prescription, as set forth by the 
                                Secretary.
                                    ``(II) The Secretary shall provide 
                                a prior authorization form (initially 
                                on paper and, not later than 3 years 
                                after the date of the enactment of this 
                                subparagraph, in an electronic format) 
                                for prescribing practitioners (as so 
                                defined by the Secretary) to complete 
                                when requesting a prior authorization 
                                under this subparagraph. The form shall 
                                constitute the complete request for 
                                information to determine medical 
                                necessity and require the prescribing 
                                practitioner (as so defined by the 
                                Secretary) to provide each of the 
                                following:
                                            ``(aa) The date that the 
                                        individual was seen by a 
                                        prescribing practitioner (as so 
                                        defined by the Secretary) 
                                        within the appropriate 
                                        timeframes for certification of 
                                        the need for the therapy.
                                            ``(bb) The result of the 
                                        original blood gas, saturation 
                                        test results, or sleep study 
                                        results, as applicable.
                                            ``(cc) A statement that the 
                                        individual needs or is using 
                                        the therapy.
                                    ``(III) The Secretary shall respond 
                                to the prescribing practitioner (as so 
                                defined by the Secretary) making the 
                                prior authorization request within 72 
                                hours (3 calendar days) of receiving 
                                the request. For hospital discharges, 
                                in the case of home respiratory therapy 
                                consisting of equipment or supplies, 
                                the Secretary shall establish an 
                                expedited review process to allow for 
                                the equipment or supplies to be 
                                delivered on the same day it is 
                                ordered.
                                    ``(IV) The Secretary shall 
                                communicate the response to the 
                                prescribing practitioner (as so defined 
                                by the Secretary) making the prior 
                                authorization request and to the 
                                supplier designated on the certificate 
                                of medical necessity.
                                    ``(V) A prior authorization 
                                approved under the process shall be 
                                deemed to constitute medical necessity 
                                for coverage and payment under this 
                                title but shall not eliminate the proof 
                                of delivery documentation requirement 
                                under section 424.57(c)(12) of title 
                                42, Code of Federal Regulations.
                                    ``(VI) A supplier of home 
                                respiratory therapy shall not be 
                                required to provide such therapy if a 
                                prior authorization request under this 
                                subparagraph for such therapy has not 
                                been approved.
                            ``(iii) Effect of prior authorization.--The 
                        approval of a prior authorization request under 
                        this subparagraph shall constitute a finding of 
                        medical necessity. The Secretary may not 
                        subject claims with such a prior authorization 
                        to pre- or post-payment audit for the purpose 
                        of determining medical necessity or improper 
                        payment reviews as they relate to documenting 
                        medical necessity.
                            ``(iv) Implementation.--The Secretary may 
                        carry out this subparagraph through notice and 
                        comment rulemaking or by interim final rule 
                        with comment period. In establishing and 
                        implementing the process under this 
                        subparagraph, the Secretary shall consult with 
                        stakeholders through formal and informal 
                        mechanisms.
                            ``(v) Home respiratory therapy defined.--
                        For purposes of this subparagraph, the term 
                        `home respiratory therapy' means--
                                    ``(I) equipment, supplies, and 
                                services for home oxygen, home sleep, 
                                and mechanical ventilation; and
                                    ``(II) any other equipment, supply, 
                                or service specified by the Secretary 
                                by regulation.''.
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