[Congressional Record Volume 147, Number 166 (Tuesday, December 4, 2001)]
[House]
[Pages H8778-H8801]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
MEDICARE REGULATORY AND CONTRACTING REFORM ACT OF 2001
Mrs. JOHNSON of Connecticut. Mr. Speaker, I move to suspend the rules
and pass the bill (H.R. 3391) to amend title XVIII of the Social
Security Act to provide regulatory relief and contracting flexibility
under the Medicare Program.
The Clerk read as follows:
H.R. 3391
Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; AMENDMENTS TO SOCIAL SECURITY ACT;
TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Medicare
Regulatory and Contracting Reform Act of 2001''.
(b) Amendments to Social Security Act.--Except as otherwise
specifically provided, whenever in this Act an amendment is
expressed in terms of an amendment to or repeal of a section
or other provision, the reference shall be considered to be
made to that section or other provision of the Social
Security Act.
(c) Table of Contents.--The table of contents of this Act
is as follows:
Sec. 1. Short title; amendments to Social Security Act; table of
contents.
Sec. 2. Findings and construction.
Sec. 3. Definitions.
TITLE I--REGULATORY REFORM
Sec. 101. Issuance of regulations.
Sec. 102. Compliance with changes in regulations and policies.
Sec. 103. Reports and studies relating to regulatory reform.
TITLE II--CONTRACTING REFORM
Sec. 201. Increased flexibility in medicare administration.
Sec. 202. Requirements for information security for medicare
administrative contractors.
TITLE III--EDUCATION AND OUTREACH
Sec. 301. Provider education and technical assistance.
Sec. 302. Small provider technical assistance demonstration program.
Sec. 303. Medicare Provider Ombudsman; Medicare Beneficiary Ombudsman.
Sec. 304. Beneficiary outreach demonstration program.
TITLE IV--APPEALS AND RECOVERY
Sec. 401. Transfer of responsibility for medicare appeals.
Sec. 402. Process for expedited access to review.
Sec. 403. Revisions to medicare appeals process.
Sec. 404. Prepayment review.
Sec. 405. Recovery of overpayments.
Sec. 406. Provider enrollment process; right of appeal.
Sec. 407. Process for correction of minor errors and omissions on
claims without pursuing appeals process.
Sec. 408. Prior determination process for certain items and services;
advance beneficiary notices.
TITLE V--MISCELLANEOUS PROVISIONS
Sec. 501. Policy development regarding evaluation and management (E &
M) documentation guidelines.
Sec. 502. Improvement in oversight of technology and coverage.
Sec. 503. Treatment of hospitals for certain services under medicare
secondary payor (MSP) provisions.
Sec. 504. EMTALA improvements.
Sec. 505. Emergency Medical Treatment and Active Labor Act (EMTALA)
Technical Advisory Group.
Sec. 506. Authorizing use of arrangements with other hospice programs
to provide core hospice services in certain
circumstances.
Sec. 507. Application of OSHA bloodborne pathogens standard to certain
hospitals.
Sec. 508. One-year delay in lock in procedures for Medicare+Choice
plans; change in Medicare+Choice reporting deadlines and
annual, coordinated election period for 2002.
Sec. 509. BIPA-related technical amendments and corrections.
Sec. 510. Conforming authority to waive a program exclusion.
Sec. 511. Treatment of certain dental claims.
Sec. 512. Miscellaneous reports, studies, and publication requirements.
SEC. 2. FINDINGS AND CONSTRUCTION.
(a) Findings.--Congress finds the following:
(1) The overwhelming majority of providers of services and
suppliers in the United States are law-abiding persons who
provide important health care services to patients each day.
(2) The Secretary of Health and Human Services should work
to streamline paperwork requirements under the medicare
program and communicate clearer instructions to providers of
services and suppliers so that they may spend more time
caring for patients.
(b) Construction.--Nothing in this Act shall be construed--
(1) to compromise or affect existing legal remedies for
addressing fraud or abuse, whether it be criminal
prosecution, civil enforcement, or administrative remedies,
including under sections 3729 through 3733 of title 31,
United States Code (known as the False Claims Act); or
(2) to prevent or impede the Department of Health and Human
Services in any way from its ongoing efforts to eliminate
waste, fraud, and abuse in the medicare program.
[[Page H8779]]
Furthermore, the consolidation of medicare administrative
contracting set forth in this Act does not constitute
consolidation of the Federal Hospital Insurance Trust Fund
and the Federal Supplementary Medical Insurance Trust Fund or
reflect any position on that issue.
SEC. 3. DEFINITIONS.
(a) Use of Term Supplier in Medicare.--Section 1861 (42
U.S.C. 1395x) is amended by inserting after subsection (c)
the following new subsection:
``Supplier
``(d) The term `supplier' means, unless the context
otherwise requires, a physician or other practitioner, a
facility, or other entity (other than a provider of services)
that furnishes items or services under this title.''.
(b) Other Terms Used in Act.--In this Act:
(1) BIPA.--The term ``BIPA'' means the Medicare, Medicaid,
and SCHIP Benefits Improvement and Protection Act of 2000, as
enacted into law by section 1(a)(6) of Public Law 106-554.
(2) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
TITLE I--REGULATORY REFORM
SEC. 101. ISSUANCE OF REGULATIONS.
(a) Consolidation of Promulgation to Once a Month.--
(1) In general.--Section 1871 (42 U.S.C. 1395hh) is amended
by adding at the end the following new subsection:
``(d)(1) Subject to paragraph (2), the Secretary shall
issue proposed or final (including interim final) regulations
to carry out this title only on one business day of every
month.
``(2) The Secretary may issue a proposed or final
regulation described in paragraph (1) on any other day than
the day described in paragraph (1) if the Secretary--
``(A) finds that issuance of such regulation on another day
is necessary to comply with requirements under law; or
``(B) finds that with respect to that regulation the
limitation of issuance on the date described in paragraph (1)
is contrary to the public interest.
If the Secretary makes a finding under this paragraph, the
Secretary shall include such finding, and brief statement of
the reasons for such finding, in the issuance of such
regulation.
``(3) The Secretary shall coordinate issuance of new
regulations described in paragraph (1) relating to a category
of provider of services or suppliers based on an analysis of
the collective impact of regulatory changes on that category
of providers or suppliers.''.
(2) GAO report on publication of regulations on a quarterly
basis.--Not later than 3 years after the date of the
enactment of this Act, the Comptroller General of the United
States shall submit to Congress a report on the feasibility
of requiring that regulations described in section 1871(d) of
the Social Security Act be promulgated on a quarterly basis
rather than on a monthly basis.
(3) Effective date.--The amendment made by paragraph (1)
shall apply to regulations promulgated on or after the date
that is 30 days after the date of the enactment of this Act.
(b) Regular Timeline for Publication of Final Rules.--
(1) In general.--Section 1871(a) (42 U.S.C. 1395hh(a)) is
amended by adding at the end the following new paragraph:
``(3)(A) The Secretary, in consultation with the Director
of the Office of Management and Budget, shall establish and
publish a regular timeline for the publication of final
regulations based on the previous publication of a proposed
regulation or an interim final regulation.
``(B) Such timeline may vary among different regulations
based on differences in the complexity of the regulation, the
number and scope of comments received, and other relevant
factors, but shall not be longer than 3 years except under
exceptional circumstances. If the Secretary intends to vary
such timeline with respect to the publication of a final
regulation, the Secretary shall cause to have published in
the Federal Register notice of the different timeline by not
later than the timeline previously established with respect
to such regulation. Such notice shall include a brief
explanation of the justification for such variation.
``(C) In the case of interim final regulations, upon the
expiration of the regular timeline established under this
paragraph for the publication of a final regulation after
opportunity for public comment, the interim final regulation
shall not continue in effect unless the Secretary publishes
(at the end of the regular timeline and, if applicable, at
the end of each succeeding 1-year period) a notice of
continuation of the regulation that includes an explanation
of why the regular timeline (and any subsequent 1-year
extension) was not complied with. If such a notice is
published, the regular timeline (or such timeline as
previously extended under this paragraph) for publication of
the final regulation shall be treated as having been extended
for 1 additional year.
``(D) The Secretary shall annually submit to Congress a
report that describes the instances in which the Secretary
failed to publish a final regulation within the applicable
regular timeline under this paragraph and that provides an
explanation for such failures.''.
(2) Effective date.--The amendment made by paragraph (1)
shall take effect on the date of the enactment of this Act.
The Secretary shall provide for an appropriate transition to
take into account the backlog of previously published interim
final regulations.
(c) Limitations on New Matter in Final Regulations.--
(1) In general.--Section 1871(a) (42 U.S.C. 1395hh(a)), as
amended by subsection (b), is further amended by adding at
the end the following new paragraph:
``(4) If the Secretary publishes notice of proposed
rulemaking relating to a regulation (including an interim
final regulation), insofar as such final regulation includes
a provision that is not a logical outgrowth of such notice of
proposed rulemaking, that provision shall be treated as a
proposed regulation and shall not take effect until there is
the further opportunity for public comment and a publication
of the provision again as a final regulation.''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply to final regulations published on or after the
date of the enactment of this Act.
SEC. 102. COMPLIANCE WITH CHANGES IN REGULATIONS AND
POLICIES.
(a) No Retroactive Application of Substantive Changes.--
(1) In general.--Section 1871 (42 U.S.C. 1395hh), as
amended by section 101(a), is amended by adding at the end
the following new subsection:
``(e)(1)(A) A substantive change in regulations, manual
instructions, interpretative rules, statements of policy, or
guidelines of general applicability under this title shall
not be applied (by extrapolation or otherwise) retroactively
to items and services furnished before the effective date of
the change, unless the Secretary determines that--
``(i) such retroactive application is necessary to comply
with statutory requirements; or
``(ii) failure to apply the change retroactively would be
contrary to the public interest.''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply to substantive changes issued on or after the
date of the enactment of this Act.
(b) Timeline for Compliance With Substantive Changes After
Notice.--
(1) In general.--Section 1871(e)(1), as added by subsection
(a), is amended by adding at the end the following:
``(B)(i) Except as provided in clause (ii), a substantive
change referred to in subparagraph (A) shall not become
effective before the end of the 30-day period that begins on
the date that the Secretary has issued or published, as the
case may be, the substantive change.
``(ii) The Secretary may provide for such a substantive
change to take effect on a date that precedes the end of the
30-day period under clause (i) if the Secretary finds that
waiver of such 30-day period is necessary to comply with
statutory requirements or that the application of such 30-day
period is contrary to the public interest. If the Secretary
provides for an earlier effective date pursuant to this
clause, the Secretary shall include in the issuance or
publication of the substantive change a finding described in
the first sentence, and a brief statement of the reasons for
such finding.
``(C) No action shall be taken against a provider of
services or supplier with respect to noncompliance with such
a substantive change for items and services furnished before
the effective date of such a change.''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply to compliance actions undertaken on or after the
date of the enactment of this Act.
(c) Reliance on Guidance.--
(1) In general.--Section 1871(e), as added by subsection
(a), is further amended by adding at the end the following
new paragraph:
``(2)(A) If--
``(i) a provider of services or supplier follows the
written guidance (which may be transmitted electronically)
provided by the Secretary or by a medicare contractor (as
defined in section 1889(g)) acting within the scope of the
contractor's contract authority, with respect to the
furnishing of items or services and submission of a claim for
benefits for such items or services with respect to such
provider or supplier;
``(ii) the Secretary determines that the provider of
services or supplier has accurately presented the
circumstances relating to such items, services, and claim to
the contractor in writing; and
``(iii) the guidance was in error;
the provider of services or supplier shall not be subject to
any sanction (including any penalty or requirement for
repayment of any amount) if the provider of services or
supplier reasonably relied on such guidance.
``(B) Subparagraph (A) shall not be construed as preventing
the recoupment or repayment (without any additional penalty)
relating to an overpayment insofar as the overpayment was
solely the result of a clerical or technical operational
error.''.
(2) Effective date.--The amendment made by paragraph (1)
shall take effect on the date of the enactment of this Act
but shall not apply to any sanction for which notice was
provided on or before the date of the enactment of this Act.
SEC. 103. REPORTS AND STUDIES RELATING TO REGULATORY REFORM.
(a) GAO Study on Advisory Opinion Authority.--
[[Page H8780]]
(1) Study.--The Comptroller General of the United States
shall conduct a study to determine the feasibility and
appropriateness of establishing in the Secretary authority to
provide legally binding advisory opinions on appropriate
interpretation and application of regulations to carry out
the medicare program under title XVIII of the Social Security
Act. Such study shall examine the appropriate timeframe for
issuing such advisory opinions, as well as the need for
additional staff and funding to provide such opinions.
(2) Report.--The Comptroller General shall submit to
Congress a report on the study conducted under paragraph (1)
by not later than January 1, 2003.
(b) Report on Legal and Regulatory Inconsistencies.--
Section 1871 (42 U.S.C. 1395hh), as amended by section 2(a),
is amended by adding at the end the following new subsection:
``(f)(1) Not later than 2 years after the date of the
enactment of this subsection, and every 2 years thereafter,
the Secretary shall submit to Congress a report with respect
to the administration of this title and areas of
inconsistency or conflict among the various provisions under
law and regulation.
``(2) In preparing a report under paragraph (1), the
Secretary shall collect--
``(A) information from individuals entitled to benefits
under part A or enrolled under part B, or both, providers of
services, and suppliers and from the Medicare Beneficiary
Ombudsman and the Medicare Provider Ombudsman with respect to
such areas of inconsistency and conflict; and
``(B) information from medicare contractors that tracks the
nature of written and telephone inquiries.
``(3) A report under paragraph (1) shall include a
description of efforts by the Secretary to reduce such
inconsistency or conflicts, and recommendations for
legislation or administrative action that the Secretary
determines appropriate to further reduce such inconsistency
or conflicts.''.
TITLE II--CONTRACTING REFORM
SEC. 201. INCREASED FLEXIBILITY IN MEDICARE ADMINISTRATION.
(a) Consolidation and Flexibility in Medicare
Administration.--
(1) In general.--Title XVIII is amended by inserting after
section 1874 the following new section:
``contracts with medicare administrative contractors
``Sec. 1874A. (a) Authority.--
``(1) Authority to enter into contracts.--The Secretary may
enter into contracts with any eligible entity to serve as a
medicare administrative contractor with respect to the
performance of any or all of the functions described in
paragraph (4) or parts of those functions (or, to the extent
provided in a contract, to secure performance thereof by
other entities).
``(2) Eligibility of entities.--An entity is eligible to
enter into a contract with respect to the performance of a
particular function described in paragraph (4) only if--
``(A) the entity has demonstrated capability to carry out
such function;
``(B) the entity complies with such conflict of interest
standards as are generally applicable to Federal acquisition
and procurement;
``(C) the entity has sufficient assets to financially
support the performance of such function; and
``(D) the entity meets such other requirements as the
Secretary may impose.
``(3) Medicare administrative contractor defined.--For
purposes of this title and title XI--
``(A) In general.--The term `medicare administrative
contractor' means an agency, organization, or other person
with a contract under this section.
``(B) Appropriate medicare administrative contractor.--With
respect to the performance of a particular function in
relation to an individual entitled to benefits under part A
or enrolled under part B, or both, a specific provider of
services or supplier (or class of such providers of services
or suppliers), the `appropriate' medicare administrative
contractor is the medicare administrative contractor that has
a contract under this section with respect to the performance
of that function in relation to that individual, provider of
services or supplier or class of provider of services or
supplier.
``(4) Functions described.--The functions referred to in
paragraphs (1) and (2) are payment functions, provider
services functions, and functions relating to services
furnished to individuals entitled to benefits under part A or
enrolled under part B, or both, as follows:
``(A) Determination of payment amounts.--Determining
(subject to the provisions of section 1878 and to such review
by the Secretary as may be provided for by the contracts) the
amount of the payments required pursuant to this title to be
made to providers of services, suppliers and individuals.
``(B) Making payments.--Making payments described in
subparagraph (A) (including receipt, disbursement, and
accounting for funds in making such payments).
``(C) Beneficiary education and assistance.--Providing
education and outreach to individuals entitled to benefits
under part A or enrolled under part B, or both, and providing
assistance to those individuals with specific issues,
concerns or problems.
``(D) Provider consultative services.--Providing
consultative services to institutions, agencies, and other
persons to enable them to establish and maintain fiscal
records necessary for purposes of this title and otherwise to
qualify as providers of services or suppliers.
``(E) Communication with providers.--Communicating to
providers of services and suppliers any information or
instructions furnished to the medicare administrative
contractor by the Secretary, and facilitating communication
between such providers and suppliers and the Secretary.
``(F) Provider education and technical assistance.--
Performing the functions relating to provider education,
training, and technical assistance.
``(G) Additional functions.--Performing such other
functions as are necessary to carry out the purposes of this
title.
``(5) Relationship to mip contracts.--
``(A) Nonduplication of duties.--In entering into contracts
under this section, the Secretary shall assure that functions
of medicare administrative contractors in carrying out
activities under parts A and B do not duplicate activities
carried out under the Medicare Integrity Program under
section 1893. The previous sentence shall not apply with
respect to the activity described in section 1893(b)(5)
(relating to prior authorization of certain items of durable
medical equipment under section 1834(a)(15)).
``(B) Construction.--An entity shall not be treated as a
medicare administrative contractor merely by reason of having
entered into a contract with the Secretary under section
1893.
``(6) Application of federal acquisition regulation.--
Except to the extent inconsistent with a specific requirement
of this title, the Federal Acquisition Regulation applies to
contracts under this title.
``(b) Contracting Requirements.--
``(1) Use of competitive procedures.--
``(A) In general.--Except as provided in laws with general
applicability to Federal acquisition and procurement or in
subparagraph (B), the Secretary shall use competitive
procedures when entering into contracts with medicare
administrative contractors under this section, taking into
account performance quality as well as price and other
factors.
``(B) Renewal of contracts.--The Secretary may renew a
contract with a medicare administrative contractor under this
section from term to term without regard to section 5 of
title 41, United States Code, or any other provision of law
requiring competition, if the medicare administrative
contractor has met or exceeded the performance requirements
applicable with respect to the contract and contractor,
except that the Secretary shall provide for the application
of competitive procedures under such a contract not less
frequently than once every five years.
``(C) Transfer of functions.--The Secretary may transfer
functions among medicare administrative contractors
consistent with the provisions of this paragraph. The
Secretary shall ensure that performance quality is considered
in such transfers. The Secretary shall provide public notice
(whether in the Federal Register or otherwise) of any such
transfer (including a description of the functions so
transferred, a description of the providers of services and
suppliers affected by such transfer, and contact information
for the contractors involved).
``(D) Incentives for quality.--The Secretary shall provide
incentives for medicare administrative contractors to provide
quality service and to promote efficiency.
``(2) Compliance with requirements.--No contract under this
section shall be entered into with any medicare
administrative contractor unless the Secretary finds that
such medicare administrative contractor will perform its
obligations under the contract efficiently and effectively
and will meet such requirements as to financial
responsibility, legal authority, quality of services
provided, and other matters as the Secretary finds pertinent.
``(3) Performance requirements.--
``(A) Development of specific performance requirements.--In
developing contract performance requirements, the Secretary
shall develop performance requirements applicable to
functions described in subsection (a)(4).
``(B) Consultation.-- In developing such requirements, the
Secretary may consult with providers of services and
suppliers, organizations representing individuals entitled to
benefits under part A or enrolled under part B, or both, and
organizations and agencies performing functions necessary to
carry out the purposes of this section with respect to such
performance requirements.
``(C) Inclusion in contracts.--All contractor performance
requirements shall be set forth in the contract between the
Secretary and the appropriate medicare administrative
contractor. Such performance requirements--
``(i) shall reflect the performance requirements developed
under subparagraph (A), but may include additional
performance requirements;
``(ii) shall be used for evaluating contractor performance
under the contract; and
``(iii) shall be consistent with the written statement of
work provided under the contract.
``(4) Information requirements.--The Secretary shall not
enter into a contract with a medicare administrative
contractor under this section unless the contractor agrees--
``(A) to furnish to the Secretary such timely information
and reports as the Secretary
[[Page H8781]]
may find necessary in performing his functions under this
title; and
``(B) to maintain such records and afford such access
thereto as the Secretary finds necessary to assure the
correctness and verification of the information and reports
under subparagraph (A) and otherwise to carry out the
purposes of this title.
``(5) Surety bond.--A contract with a medicare
administrative contractor under this section may require the
medicare administrative contractor, and any of its officers
or employees certifying payments or disbursing funds pursuant
to the contract, or otherwise participating in carrying out
the contract, to give surety bond to the United States in
such amount as the Secretary may deem appropriate.
``(c) Terms and Conditions.--
``(1) In general.--A contract with any medicare
administrative contractor under this section may contain such
terms and conditions as the Secretary finds necessary or
appropriate and may provide for advances of funds to the
medicare administrative contractor for the making of payments
by it under subsection (a)(4)(B).
``(2) Prohibition on mandates for certain data
collection.--The Secretary may not require, as a condition of
entering into, or renewing, a contract under this section,
that the medicare administrative contractor match data
obtained other than in its activities under this title with
data used in the administration of this title for purposes of
identifying situations in which the provisions of section
1862(b) may apply.
``(d) Limitation on Liability of Medicare Administrative
Contractors and Certain Officers.--
``(1) Certifying officer.--No individual designated
pursuant to a contract under this section as a certifying
officer shall, in the absence of gross negligence or intent
to defraud the United States, be liable with respect to any
payments certified by the individual under this section.
``(2) Disbursing officer.--No disbursing officer shall, in
the absence of gross negligence or intent to defraud the
United States, be liable with respect to any payment by such
officer under this section if it was based upon an
authorization (which meets the applicable requirements for
such internal controls established by the Comptroller
General) of a certifying officer designated as provided in
paragraph (1) of this subsection.
``(3) Liability of medicare administrative contractor.--No
medicare administrative contractor shall be liable to the
United States for a payment by a certifying or disbursing
officer unless in connection with such payment or in the
supervision of or selection of such officer the medicare
administrative contractor acted with gross negligence.
``(4) Indemnification by secretary.--
``(A) In general.--Subject to subparagraphs (B) and (D), in
the case of a medicare administrative contractor (or a person
who is a director, officer, or employee of such a contractor
or who is engaged by the contractor to participate directly
in the claims administration process) who is made a party to
any judicial or administrative proceeding arising from or
relating directly to the claims administration process under
this title, the Secretary may, to the extent the Secretary
determines to be appropriate and as specified in the contract
with the contractor, indemnify the contractor and such
persons.
``(B) Conditions.--The Secretary may not provide
indemnification under subparagraph (A) insofar as the
liability for such costs arises directly from conduct that is
determined by the judicial proceeding or by the Secretary to
be criminal in nature, fraudulent, or grossly negligent. If
indemnification is provided by the Secretary with respect to
a contractor before a determination that such costs arose
directly from such conduct, the contractor shall reimburse
the Secretary for costs of indemnification.
``(C) Scope of indemnification.--Indemnification by the
Secretary under subparagraph (A) may include payment of
judgments, settlements (subject to subparagraph (D)), awards,
and costs (including reasonable legal expenses).
``(D) Written approval for settlements.--A contractor or
other person described in subparagraph (A) may not propose to
negotiate a settlement or compromise of a proceeding
described in such subparagraph without the prior written
approval of the Secretary to negotiate such settlement or
compromise. Any indemnification under subparagraph (A) with
respect to amounts paid under a settlement or compromise of a
proceeding described in such subparagraph are conditioned
upon prior written approval by the Secretary of the final
settlement or compromise.
``(E) Construction.--Nothing in this paragraph shall be
construed--
``(i) to change any common law immunity that may be
available to a medicare administrative contractor or person
described in subparagraph (A); or
``(ii) to permit the payment of costs not otherwise
allowable, reasonable, or allocable under the Federal
Acquisition Regulations.''.
(2) Consideration of incorporation of current law
standards.--In developing contract performance requirements
under section 1874A(b) of the Social Security Act, as
inserted by paragraph (1), the Secretary shall consider
inclusion of the performance standards described in sections
1816(f)(2) of such Act (relating to timely processing of
reconsiderations and applications for exemptions) and section
1842(b)(2)(B) of such Act (relating to timely review of
determinations and fair hearing requests), as such sections
were in effect before the date of the enactment of this Act.
(b) Conforming Amendments to Section 1816 (Relating to
Fiscal Intermediaries).--Section 1816 (42 U.S.C. 1395h) is
amended as follows:
(1) The heading is amended to read as follows:
``provisions relating to the administration of part a''.
(2) Subsection (a) is amended to read as follows:
``(a) The administration of this part shall be conducted
through contracts with medicare administrative contractors
under section 1874A.''.
(3) Subsection (b) is repealed.
(4) Subsection (c) is amended--
(A) by striking paragraph (1); and
(B) in each of paragraphs (2)(A) and (3)(A), by striking
``agreement under this section'' and inserting ``contract
under section 1874A that provides for making payments under
this part''.
(5) Subsections (d) through (i) are repealed.
(6) Subsections (j) and (k) are each amended--
(A) by striking ``An agreement with an agency or
organization under this section'' and inserting ``A contract
with a medicare administrative contractor under section 1874A
with respect to the administration of this part''; and
(B) by striking ``such agency or organization'' and
inserting ``such medicare administrative contractor'' each
place it appears.
(7) Subsection (l) is repealed.
(c) Conforming Amendments to Section 1842 (Relating to
Carriers).--Section 1842 (42 U.S.C. 1395u) is amended as
follows:
(1) The heading is amended to read as follows:
``provisions relating to the administration of part b''.
(2) Subsection (a) is amended to read as follows:
``(a) The administration of this part shall be conducted
through contracts with medicare administrative contractors
under section 1874A.''.
(3) Subsection (b) is amended--
(A) by striking paragraph (1);
(B) in paragraph (2)--
(i) by striking subparagraphs (A) and (B);
(ii) in subparagraph (C), by striking ``carriers'' and
inserting ``medicare administrative contractors''; and
(iii) by striking subparagraphs (D) and (E);
(C) in paragraph (3)--
(i) in the matter before subparagraph (A), by striking
``Each such contract shall provide that the carrier'' and
inserting ``The Secretary'';
(ii) by striking ``will'' the first place it appears in
each of subparagraphs (A), (B), (F), (G), (H), and (L) and
inserting ``shall'';
(iii) in subparagraph (B), in the matter before clause (i),
by striking ``to the policyholders and subscribers of the
carrier'' and inserting ``to the policyholders and
subscribers of the medicare administrative contractor'';
(iv) by striking subparagraphs (C), (D), and (E);
(v) in subparagraph (H)--
(I) by striking ``if it makes determinations or payments
with respect to physicians' services,''; and
(II) by striking ``carrier'' and inserting ``medicare
administrative contractor'';
(vi) by striking subparagraph (I);
(vii) in subparagraph (L), by striking the semicolon and
inserting a period;
(viii) in the first sentence, after subparagraph (L), by
striking ``and shall contain'' and all that follows through
the period; and
(ix) in the seventh sentence, by inserting ``medicare
administrative contractor,'' after ``carrier,''; and
(D) by striking paragraph (5);
(E) in paragraph (6)(D)(iv), by striking ``carrier'' and
inserting ``medicare administrative contractor''; and
(F) in paragraph (7), by striking ``the carrier'' and
inserting ``the Secretary'' each place it appears.
(4) Subsection (c) is amended--
(A) by striking paragraph (1);
(B) in paragraph (2), by striking ``contract under this
section which provides for the disbursement of funds, as
described in subsection (a)(1)(B),'' and inserting ``contract
under section 1874A that provides for making payments under
this part'';
(C) in paragraph (3)(A), by striking ``subsection
(a)(1)(B)'' and inserting ``section 1874A(a)(3)(B)'';
(D) in paragraph (4), by striking ``carrier'' and inserting
``medicare administrative contractor''; and
(E) by striking paragraphs (5) and (6).
(5) Subsections (d), (e), and (f) are repealed.
(6) Subsection (g) is amended by striking ``carrier or
carriers'' and inserting ``medicare administrative contractor
or contractors''.
(7) Subsection (h) is amended--
(A) in paragraph (2)--
(i) by striking ``Each carrier having an agreement with the
Secretary under subsection (a)'' and inserting ``The
Secretary''; and
(ii) by striking ``Each such carrier'' and inserting ``The
Secretary'';
(B) in paragraph (3)(A)--
(i) by striking ``a carrier having an agreement with the
Secretary under subsection
[[Page H8782]]
(a)'' and inserting ``medicare administrative contractor
having a contract under section 1874A that provides for
making payments under this part''; and
(ii) by striking ``such carrier'' and inserting ``such
contractor'';
(C) in paragraph (3)(B)--
(i) by striking ``a carrier'' and inserting ``a medicare
administrative contractor'' each place it appears; and
(ii) by striking ``the carrier'' and inserting ``the
contractor'' each place it appears; and
(D) in paragraphs (5)(A) and (5)(B)(iii), by striking
``carriers'' and inserting ``medicare administrative
contractors'' each place it appears.
(8) Subsection (l) is amended--
(A) in paragraph (1)(A)(iii), by striking ``carrier'' and
inserting ``medicare administrative contractor''; and
(B) in paragraph (2), by striking ``carrier'' and inserting
``medicare administrative contractor''.
(9) Subsection (p)(3)(A) is amended by striking ``carrier''
and inserting ``medicare administrative contractor''.
(10) Subsection (q)(1)(A) is amended by striking
``carrier''.
(d) Effective Date; Transition Rule.--
(1) Effective date.--
(A) In general.--Except as otherwise provided in this
subsection, the amendments made by this section shall take
effect on October 1, 2003, and the Secretary is authorized to
take such steps before such date as may be necessary to
implement such amendments on a timely basis.
(B) Construction for current contracts.--Such amendments
shall not apply to contracts in effect before the date
specified under subparagraph (A) that continue to retain the
terms and conditions in effect on such date (except as
otherwise provided under this Act, other than under this
section) until such date as the contract is let out for
competitive bidding under such amendments.
(C) Deadline for competitive bidding.--The Secretary shall
provide for the letting by competitive bidding of all
contracts for functions of medicare administrative
contractors for annual contract periods that begin on or
after October 1, 2008.
(D) Waiver of provider nomination provisions during
transition.--During the period beginning on the date of the
enactment of this Act and before the date specified under
subparagraph (A), the Secretary may enter into new agreements
under section 1816 of the Social Security Act (42 U.S.C.
1395h) without regard to any of the provider nomination
provisions of such section.
(2) General transition rules.--The Secretary shall take
such steps, consistent with paragraph (1)(B) and (1)(C), as
are necessary to provide for an appropriate transition from
contracts under section 1816 and section 1842 of the Social
Security Act (42 U.S.C. 1395h, 1395u) to contracts under
section 1874A, as added by subsection (a)(1).
(3) Authorizing continuation of mip functions under current
contracts and agreements and under rollover contracts.--The
provisions contained in the exception in section 1893(d)(2)
of the Social Security Act (42 U.S.C. 1395ddd(d)(2)) shall
continue to apply notwithstanding the amendments made by this
section, and any reference in such provisions to an agreement
or contract shall be deemed to include a contract under
section 1874A of such Act, as inserted by subsection (a)(1),
that continues the activities referred to in such provisions.
(e) References.--On and after the effective date provided
under subsection (d)(1), any reference to a fiscal
intermediary or carrier under title XI or XVIII of the Social
Security Act (or any regulation, manual instruction,
interpretative rule, statement of policy, or guideline issued
to carry out such titles) shall be deemed a reference to an
appropriate medicare administrative contractor (as provided
under section 1874A of the Social Security Act).
(f) Reports on Implementation.--
(1) Plan for implementation.--By not later than October 1,
2002, the Secretary shall submit a report to Congress and the
Comptroller General of the United States that describes the
plan for implementation of the amendments made by this
section. The Comptroller General shall conduct an evaluation
of such plan and shall submit to Congress, not later than 6
months after the date the report is received, a report on
such evaluation and shall include in such report such
recommendations as the Comptroller General deems appropriate.
(2) Status of implementation.--The Secretary shall submit a
report to Congress not later than October 1, 2006, that
describes the status of implementation of such amendments and
that includes a description of the following:
(A) The number of contracts that have been competitively
bid as of such date.
(B) The distribution of functions among contracts and
contractors.
(C) A timeline for complete transition to full competition.
(D) A detailed description of how the Secretary has
modified oversight and management of medicare contractors to
adapt to full competition.
SEC. 202. REQUIREMENTS FOR INFORMATION SECURITY FOR MEDICARE
ADMINISTRATIVE CONTRACTORS.
(a) In General.--Section 1874A, as added by section
201(a)(1), is amended by adding at the end the following new
subsection:
``(e) Requirements for Information Security.--
``(1) Development of information security program.--A
medicare administrative contractor that performs the
functions referred to in subparagraphs (A) and (B) of
subsection (a)(4) (relating to determining and making
payments) shall implement a contractor-wide information
security program to provide information security for the
operation and assets of the contractor with respect to such
functions under this title. An information security program
under this paragraph shall meet the requirements for
information security programs imposed on Federal agencies
under section 3534(b)(2) of title 44, United States Code
(other than requirements under subparagraphs (B)(ii),
(F)(iii), and (F)(iv) of such section).
``(2) Independent audits.--
``(A) Performance of annual evaluations.--Each year a
medicare administrative contractor that performs the
functions referred to in subparagraphs (A) and (B) of
subsection (a)(4) (relating to determining and making
payments) shall undergo an evaluation of the information
security of the contractor with respect to such functions
under this title. The evaluation shall--
``(i) be performed by an entity that meets such
requirements for independence as the Inspector General of the
Department of Health and Human Services may establish; and
``(ii) test the effectiveness of information security
control techniques for an appropriate subset of the
contractor's information systems (as defined in section
3502(8) of title 44, United States Code) relating to such
functions under this title and an assessment of compliance
with the requirements of this subsection and related
information security policies, procedures, standards and
guidelines.
``(B) Deadline for initial evaluation.--
``(i) New contractors.--In the case of a medicare
administrative contractor covered by this subsection that has
not previously performed the functions referred to in
subparagraphs (A) and (B) of subsection (a)(4) (relating to
determining and making payments) as a fiscal intermediary or
carrier under section 1816 or 1842, the first independent
evaluation conducted pursuant subparagraph (A) shall be
completed prior to commencing such functions.
``(ii) Other contractors.--In the case of a medicare
administrative contractor covered by this subsection that is
not described in clause (i), the first independent evaluation
conducted pursuant subparagraph (A) shall be completed within
1 year after the date the contractor commences functions
referred to in clause (i) under this section.
``(C) Reports on evaluations.--
``(i) To the inspector general.--The results of independent
evaluations under subparagraph (A) shall be submitted
promptly to the Inspector General of the Department of Health
and Human Services.
``(ii) To congress.--The Inspector General of Department of
Health and Human Services shall submit to Congress annual
reports on the results of such evaluations.''.
(b) Application of Requirements to Fiscal Intermediaries
and Carriers.--
(1) In general.--The provisions of section 1874A(e)(2) of
the Social Security Act (other than subparagraph (B)), as
added by subsection (a), shall apply to each fiscal
intermediary under section 1816 of the Social Security Act
(42 U.S.C. 1395h) and each carrier under section 1842 of such
Act (42 U.S.C. 1395u) in the same manner as they apply to
medicare administrative contractors under such provisions.
(2) Deadline for initial evaluation.--In the case of such a
fiscal intermediary or carrier with an agreement or contract
under such respective section in effect as of the date of the
enactment of this Act, the first evaluation under section
1874A(e)(2)(A) of the Social Security Act (as added by
subsection (a)), pursuant to paragraph (1), shall be
completed (and a report on the evaluation submitted to the
Secretary) by not later than 1 year after such date.
TITLE III--EDUCATION AND OUTREACH
SEC. 301. PROVIDER EDUCATION AND TECHNICAL ASSISTANCE.
(a) Coordination of Education Funding.--
(1) In general.--The Social Security Act is amended by
inserting after section 1888 the following new section:
``provider education and technical assistance
``Sec. 1889. (a) Coordination of Education Funding.--The
Secretary shall coordinate the educational activities
provided through medicare contractors (as defined in
subsection (g), including under section 1893) in order to
maximize the effectiveness of Federal education efforts for
providers of services and suppliers.''.
(2) Effective date.--The amendment made by paragraph (1)
shall take effect on the date of the enactment of this Act.
(3) Report.--Not later than October 1, 2002, the Secretary
shall submit to Congress a report that includes a description
and evaluation of the steps taken to coordinate the funding
of provider education under section 1889(a) of the Social
Security Act, as added by paragraph (1).
(b) Incentives To Improve Contractor Performance.--
(1) In general.--Section 1874A, as added by section
201(a)(1) and as amended by section 202(a), is amended by
adding at the end the following new subsection:
``(f) Incentives To Improve Contractor Performance in
Provider Education and
[[Page H8783]]
Outreach.--In order to give medicare administrative
contractors an incentive to implement effective education and
outreach programs for providers of services and suppliers,
the Secretary shall develop and implement a methodology to
measure the specific claims payment error rates of such
contractors in the processing or reviewing of medicare
claims.''.
(2) Application to fiscal intermediaries and carriers.--The
provisions of section 1874A(f) of the Social Security Act, as
added by paragraph (1), shall apply to each fiscal
intermediary under section 1816 of the Social Security Act
(42 U.S.C. 1395h) and each carrier under section 1842 of such
Act (42 U.S.C. 1395u) in the same manner as they apply to
medicare administrative contractors under such provisions.
(3) GAO report on adequacy of methodology.--Not later than
October 1, 2002, the Comptroller General of the United States
shall submit to Congress and to the Secretary a report on the
adequacy of the methodology under section 1874A(f)(1) of the
Social Security Act, as added by paragraph (1), and shall
include in the report such recommendations as the Comptroller
General determines appropriate with respect to the
methodology.
(4) Report on Use of methodology in assessing contractor
performance.--Not later than October 1, 2002, the Secretary
shall submit to Congress a report that describes how the
Secretary intends to use such methodology in assessing
medicare contractor performance in implementing effective
education and outreach programs, including whether to use
such methodology as a basis for performance bonuses. The
report shall include an analysis of the sources of identified
errors and potential changes in systems of contractors and
rules of the Secretary that could reduce claims error rates.
(c) Provision of Access to and Prompt Responses From
Medicare Administrative Contractors.--
(1) In general.--Section 1874A, as added by section
201(a)(1) and as amended by section 202(a) and subsection
(b), is further amended by adding at the end the following
new subsection:
``(g) Communications with Beneficiaries, Providers of
Services and Suppliers.--
``(1) Communication strategy.--The Secretary shall develop
a strategy for communications with individuals entitled to
benefits under part A or enrolled under part B, or both, and
with providers of services and suppliers under this title.
``(2) Response to written inquiries.--Each medicare
administrative contractor shall, for those providers of
services and suppliers which submit claims to the contractor
for claims processing and for those individuals entitled to
benefits under part A or enrolled under part B, or both, with
respect to whom claims are submitted for claims processing,
provide general written responses (which may be through
electronic transmission) in a clear, concise, and accurate
manner to inquiries of providers of services, suppliers and
individuals entitled to benefits under part A or enrolled
under part B, or both, concerning the programs under this
title within 45 business days of the date of receipt of such
inquiries.
``(3) Response to toll-free lines.--The Secretary shall
ensure that each medicare administrative contractor shall
provide, for those providers of services and suppliers which
submit claims to the contractor for claims processing and for
those individuals entitled to benefits under part A or
enrolled under part B, or both, with respect to whom claims
are submitted for claims processing, a toll-free telephone
number at which such individuals, providers of services and
suppliers may obtain information regarding billing, coding,
claims, coverage, and other appropriate information under
this title.
``(4) Monitoring of contractor responses.--
``(A) In general.--Each medicare administrative contractor
shall, consistent with standards developed by the Secretary
under subparagraph (B)--
``(i) maintain a system for identifying who provides the
information referred to in paragraphs (2) and (3); and
``(ii) monitor the accuracy, consistency, and timeliness of
the information so provided.
``(B) Development of standards.--
``(i) In general.--The Secretary shall establish and make
public standards to monitor the accuracy, consistency, and
timeliness of the information provided in response to written
and telephone inquiries under this subsection. Such standards
shall be consistent with the performance requirements
established under subsection (b)(3).
``(ii) Evaluation.--In conducting evaluations of individual
medicare administrative contractors, the Secretary shall take
into account the results of the monitoring conducted under
subparagraph (A) taking into account as performance
requirements the standards established under clause (i). The
Secretary shall, in consultation with organizations
representing providers of services, suppliers, and
individuals entitled to benefits under part A or enrolled
under part B, or both, establish standards relating to the
accuracy, consistency, and timeliness of the information so
provided.''.
``(C) Direct monitoring.--Nothing in this paragraph shall
be construed as preventing the Secretary from directly
monitoring the accuracy, consistency, and timeliness of the
information so provided.''.
(2) Effective date.--The amendment made by paragraph (1)
shall take effect October 1, 2002.
(3) Application to fiscal intermediaries and carriers.--The
provisions of section 1874A(g) of the Social Security Act, as
added by paragraph (1), shall apply to each fiscal
intermediary under section 1816 of the Social Security Act
(42 U.S.C. 1395h) and each carrier under section 1842 of such
Act (42 U.S.C. 1395u) in the same manner as they apply to
medicare administrative contractors under such provisions.
(d) Improved Provider Education and Training.--
(1) In general.--Section 1889, as added by subsection (a),
is amended by adding at the end the following new
subsections:
``(b) Enhanced Education and Training.--
``(1) Additional resources.--There are authorized to be
appropriated to the Secretary (in appropriate part from the
Federal Hospital Insurance Trust Fund and the Federal
Supplementary Medical Insurance Trust Fund) $25,000,000 for
each of fiscal years 2003 and 2004 and such sums as may be
necessary for succeeding fiscal years.
``(2) Use.--The funds made available under paragraph (1)
shall be used to increase the conduct by medicare contractors
of education and training of providers of services and
suppliers regarding billing, coding, and other appropriate
items and may also be used to improve the accuracy,
consistency, and timeliness of contractor responses.
``(c) Tailoring Education and Training Activities for Small
Providers or Suppliers.--
``(1) In general.--Insofar as a medicare contractor
conducts education and training activities, it shall tailor
such activities to meet the special needs of small providers
of services or suppliers (as defined in paragraph (2)).
``(2) Small provider of services or supplier.--In this
subsection, the term `small provider of services or supplier'
means--
``(A) a provider of services with fewer than 25 full-time-
equivalent employees; or
``(B) a supplier with fewer than 10 full-time-equivalent
employees.''.
(2) Effective date.--The amendment made by paragraph (1)
shall take effect on October 1, 2002.
(e) Requirement To Maintain Internet Sites.--
(1) In general.--Section 1889, as added by subsection (a)
and as amended by subsection (d), is further amended by
adding at the end the following new subsection:
``(d) Internet Sites; FAQs.--The Secretary, and each
medicare contractor insofar as it provides services
(including claims processing) for providers of services or
suppliers, shall maintain an Internet site which--
``(1) provides answers in an easily accessible format to
frequently asked questions, and
``(2) includes other published materials of the contractor,
that relate to providers of services and suppliers under the
programs under this title (and title XI insofar as it relates
to such programs).''.
(2) Effective date.--The amendment made by paragraph (1)
shall take effect on October 1, 2002.
(f) Additional Provider Education Provisions.--
(1) In general.--Section 1889, as added by subsection (a)
and as amended by subsections (d) and (e), is further amended
by adding at the end the following new subsections:
``(e) Encouragement of Participation in Education Program
Activities.--A medicare contractor may not use a record of
attendance at (or failure to attend) educational activities
or other information gathered during an educational program
conducted under this section or otherwise by the Secretary to
select or track providers of services or suppliers for the
purpose of conducting any type of audit or prepayment review.
``(f) Construction.--Nothing in this section or section
1893(g) shall be construed as providing for disclosure by a
medicare contractor of information that would compromise
pending law enforcement activities or reveal findings of law
enforcement-related audits.
``(g) Definitions.--For purposes of this section, the term
`medicare contractor' includes the following:
``(1) A medicare administrative contractor with a contract
under section 1874A, including a fiscal intermediary with a
contract under section 1816 and a carrier with a contract
under section 1842.
``(2) An eligible entity with a contract under section
1893.
Such term does not include, with respect to activities of a
specific provider of services or supplier an entity that has
no authority under this title or title IX with respect to
such activities and such provider of services or supplier.''.
(2) Effective date.--The amendment made by paragraph (1)
shall take effect on the date of the enactment of this Act.
SEC. 302. SMALL PROVIDER TECHNICAL ASSISTANCE DEMONSTRATION
PROGRAM.
(a) Establishment.--
(1) In general.--The Secretary shall establish a
demonstration program (in this section referred to as the
``demonstration program'') under which technical assistance
described in paragraph (2) is made available, upon request
and on a voluntary basis, to small providers of services or
suppliers in order to improve compliance with the applicable
requirements of the programs under
[[Page H8784]]
medicare program under title XVIII of the Social Security Act
(including provisions of title XI of such Act insofar as they
relate to such title and are not administered by the Office
of the Inspector General of the Department of Health and
Human Services).
(2) Forms of technical assistance.--The technical
assistance described in this paragraph is--
(A) evaluation and recommendations regarding billing and
related systems; and
(B) information and assistance regarding policies and
procedures under the medicare program, including coding and
reimbursement.
(3) Small providers of services or suppliers.--In this
section, the term ``small providers of services or
suppliers'' means--
(A) a provider of services with fewer than 25 full-time-
equivalent employees; or
(B) a supplier with fewer than 10 full-time-equivalent
employees.
(b) Qualification of Contractors.--In conducting the
demonstration program, the Secretary shall enter into
contracts with qualified organizations (such as peer review
organizations or entities described in section 1889(g)(2) of
the Social Security Act, as inserted by section 5(f)(1)) with
appropriate expertise with billing systems of the full range
of providers of services and suppliers to provide the
technical assistance. In awarding such contracts, the
Secretary shall consider any prior investigations of the
entity's work by the Inspector General of Department of
Health and Human Services or the Comptroller General of the
United States.
(c) Description of Technical Assistance.--The technical
assistance provided under the demonstration program shall
include a direct and in-person examination of billing systems
and internal controls of small providers of services or
suppliers to determine program compliance and to suggest more
efficient or effective means of achieving such compliance.
(d) Avoidance of Recovery Actions for Problems Identified
as Corrected.--The Secretary shall provide that, absent
evidence of fraud and notwithstanding any other provision of
law, any errors found in a compliance review for a small
provider of services or supplier that participates in the
demonstration program shall not be subject to recovery action
if the technical assistance personnel under the program
determine that--
(1) the problem that is the subject of the compliance
review has been corrected to their satisfaction within 30
days of the date of the visit by such personnel to the small
provider of services or supplier; and
(2) such problem remains corrected for such period as is
appropriate.
The previous sentence applies only to claims filed as part of
the demonstration program and lasts only for the duration of
such program and only as long as the small provider of
services or supplier is a participant in such program.
(e) GAO Evaluation.--Not later than 2 years after the date
of the date the demonstration program is first implemented,
the Comptroller General, in consultation with the Inspector
General of the Department of Health and Human Services, shall
conduct an evaluation of the demonstration program. The
evaluation shall include a determination of whether claims
error rates are reduced for small providers of services or
suppliers who participated in the program and the extent of
improper payments made as a result of the demonstration
program. The Comptroller General shall submit a report to the
Secretary and the Congress on such evaluation and shall
include in such report recommendations regarding the
continuation or extension of the demonstration program.
(f) Financial Participation by Providers.--The provision of
technical assistance to a small provider of services or
supplier under the demonstration program is conditioned upon
the small provider of services or supplier paying an amount
estimated (and disclosed in advance of a provider's or
supplier's participation in the program) to be equal to 25
percent of the cost of the technical assistance.
(g) Authorization of Appropriations.--There are authorized
to be appropriated to the Secretary (in appropriate part from
the Federal Hospital Insurance Trust Fund and the Federal
Supplementary Medical Insurance Trust Fund) to carry out the
demonstration program--
(1) for fiscal year 2003, $1,000,000, and
(2) for fiscal year 2004, $6,000,000.
SEC. 303. MEDICARE PROVIDER OMBUDSMAN; MEDICARE BENEFICIARY
OMBUDSMAN.
(a) Medicare Provider Ombudsman.--Section 1868 (42 U.S.C.
1395ee) is amended--
(1) by adding at the end of the heading the following: ``;
medicare provider ombudsman'';
(2) by inserting ``Practicing Physicians Advisory
Council.--(1)'' after ``(a)'';
(3) in paragraph (1), as so redesignated under paragraph
(2), by striking ``in this section'' and inserting ``in this
subsection'';
(4) by redesignating subsections (b) and (c) as paragraphs
(2) and (3), respectively; and
(5) by adding at the end the following new subsection:
``(b) Medicare Provider Ombudsman.--The Secretary shall
appoint within the Department of Health and Human Services a
Medicare Provider Ombudsman. The Ombudsman shall--
``(1) provide assistance, on a confidential basis, to
providers of services and suppliers with respect to
complaints, grievances, and requests for information
concerning the programs under this title (including
provisions of title XI insofar as they relate to this title
and are not administered by the Office of the Inspector
General of the Department of Health and Human Services) and
in the resolution of unclear or conflicting guidance given by
the Secretary and medicare contractors to such providers of
services and suppliers regarding such programs and provisions
and requirements under this title and such provisions; and
``(2) submit recommendations to the Secretary for
improvement in the administration of this title and such
provisions, including--
``(A) recommendations to respond to recurring patterns of
confusion in this title and such provisions (including
recommendations regarding suspending imposition of sanctions
where there is widespread confusion in program
administration), and
``(B) recommendations to provide for an appropriate and
consistent response (including not providing for audits) in
cases of self-identified overpayments by providers of
services and suppliers.
The Ombudsman shall not serve as an advocate for any
increases in payments or new coverage of services, but may
identify issues and problems in payment or coverage
policies.''.
(b) Medicare Beneficiary Ombudsman.--Title XVIII is amended
by inserting after section 1806 the following new section:
``medicare beneficiary ombudsman
``Sec. 1807. (a) In General.--The Secretary shall appoint
within the Department of Health and Human Services a Medicare
Beneficiary Ombudsman who shall have expertise and experience
in the fields of health care and education of (and assistance
to) individuals entitled to benefits under this title.
``(b) Duties.--The Medicare Beneficiary Ombudsman shall--
``(1) receive complaints, grievances, and requests for
information submitted by individuals entitled to benefits
under part A or enrolled under part B, or both, with respect
to any aspect of the medicare program;
``(2) provide assistance with respect to complaints,
grievances, and requests referred to in paragraph (1),
including--
``(A) assistance in collecting relevant information for
such individuals, to seek an appeal of a decision or
determination made by a fiscal intermediary, carrier,
Medicare+Choice organization, or the Secretary; and
``(B) assistance to such individuals with any problems
arising from disenrollment from a Medicare+Choice plan under
part C; and
``(3) submit annual reports to Congress and the Secretary
that describe the activities of the Office and that include
such recommendations for improvement in the administration of
this title as the Ombudsman determines appropriate.
The Ombudsman shall not serve as an advocate for any
increases in payments or new coverage of services, but may
identify issues and problems in payment or coverage policies.
``(c) Working with Health Insurance Counseling Programs.--
To the extent possible, the Ombudsman shall work with health
insurance counseling programs (receiving funding under
section 4360 of Omnibus Budget Reconciliation Act of 1990) to
facilitate the provision of information to individuals
entitled to benefits under part A or enrolled under part B,
or both regarding Medicare+Choice plans and changes to those
plans. Nothing in this subsection shall preclude further
collaboration between the Ombudsman and such programs.''.
(c) Deadline for Appointment.--The Secretary shall appoint
the Medicare Provider Ombudsman and the Medicare Beneficiary
Ombudsman, under the amendments made by subsections (a) and
(b), respectively, by not later than 1 year after the date of
the enactment of this Act.
(d) Funding.--There are authorized to be appropriated to
the Secretary (in appropriate part from the Federal Hospital
Insurance Trust Fund and the Federal Supplementary Medical
Insurance Trust Fund) to carry out the provisions of
subsection (b) of section 1868 of the Social Security Act
(relating to the Medicare Provider Ombudsman), as added by
subsection (a)(5) and section 1807 of such Act (relating to
the Medicare Beneficiary Ombudsman), as added by subsection
(b), such sums as are necessary for fiscal year 2002 and each
succeeding fiscal year.
(e) Use of Central, Toll-Free Number (1-800-MEDICARE).--
(1) Phone triage system; listing in medicare handbook
instead of other toll-free numbers.--Section 1804(b) (42
U.S.C. 1395b-2(b)) is amended by adding at the end the
following: ``The Secretary shall provide, through the toll-
free number 1-800-MEDICARE, for a means by which individuals
seeking information about, or assistance with, such programs
who phone such toll-free number are transferred (without
charge) to appropriate entities for the provision of such
information or assistance. Such toll-free number shall be the
toll-free number listed for general information and
assistance in the annual notice under subsection (a) instead
of the listing of numbers of individual contractors.''.
(2) Monitoring accuracy.--
(A) Study.--The Comptroller General of the United States
shall conduct a study to monitor the accuracy and consistency
of information provided to individuals entitled to
[[Page H8785]]
benefits under part A or enrolled under part B, or both,
through the toll-free number 1-800-MEDICARE, including an
assessment of whether the information provided is sufficient
to answer questions of such individuals. In conducting the
study, the Comptroller General shall examine the education
and training of the individuals providing information through
such number.
(B) Report.--Not later than 1 year after the date of the
enactment of this Act, the Comptroller General shall submit
to Congress a report on the study conducted under
subparagraph (A).
SEC. 304. BENEFICIARY OUTREACH DEMONSTRATION PROGRAM.
(a) In General.--The Secretary shall establish a
demonstration program (in this section referred to as the
``demonstration program'') under which medicare specialists
employed by the Department of Health and Human Services
provide advice and assistance to individuals entitled to
benefits under part A of title XVIII of the Social Security
Act, or enrolled under part B of such title, or both,
regarding the medicare program at the location of existing
local offices of the Social Security Administration.
(b) Locations.--
(1) In general.--The demonstration program shall be
conducted in at least 6 offices or areas. Subject to
paragraph (2), in selecting such offices and areas, the
Secretary shall provide preference for offices with a high
volume of visits by individuals referred to in subsection
(a).
(2) Assistance for rural beneficiaries.--The Secretary
shall provide for the selection of at least 2 rural areas to
participate in the demonstration program. In conducting the
demonstration program in such rural areas, the Secretary
shall provide for medicare specialists to travel among local
offices in a rural area on a scheduled basis.
(c) Duration.--The demonstration program shall be conducted
over a 3-year period.
(d) Evaluation and Report.--
(1) Evaluation.--The Secretary shall provide for an
evaluation of the demonstration program. Such evaluation
shall include an analysis of--
(A) utilization of, and satisfaction of those individuals
referred to in subsection (a) with, the assistance provided
under the program; and
(B) the cost-effectiveness of providing beneficiary
assistance through out-stationing medicare specialists at
local offices of the Social Security Administration.
(2) Report.--The Secretary shall submit to Congress a
report on such evaluation and shall include in such report
recommendations regarding the feasibility of permanently out-
stationing medicare specialists at local offices of the
Social Security Administration.
TITLE IV--APPEALS AND RECOVERY
SEC. 401. TRANSFER OF RESPONSIBILITY FOR MEDICARE APPEALS.
(a) Transition Plan.--
(1) In general.--Not later than October 1, 2002, the
Commissioner of Social Security and the Secretary shall
develop and transmit to Congress and the Comptroller General
of the United States a plan under which the functions of
administrative law judges responsible for hearing cases under
title XVIII of the Social Security Act (and related
provisions in title XI of such Act) are transferred from the
responsibility of the Commissioner and the Social Security
Administration to the Secretary and the Department of Health
and Human Services.
(2) GAO evaluation.--The Comptroller General of the United
States shall evaluate the plan and, not later than April 1,
2003, shall submit to Congress a report on such evaluation.
(b) Transfer of Adjudication Authority.--
(1) In general.--Not earlier than July 1, 2003, and not
later than October 1, 2003, the Commissioner of Social
Security and the Secretary shall implement the transition
plan under subsection (a) and transfer the administrative law
judge functions described in such subsection from the Social
Security Administration to the Secretary.
(2) Assuring independence of judges.--The Secretary shall
assure the independence of administrative law judges
performing the administrative law judge functions transferred
under paragraph (1) from the Centers for Medicare & Medicaid
Services and its contractors.
(3) Geographic distribution.--The Secretary shall provide
for an appropriate geographic distribution of administrative
law judges performing the administrative law judge functions
transferred under paragraph (1) throughout the United States
to ensure timely access to such judges.
(4) Hiring authority.--Subject to the amounts provided in
advance in appropriations Act, the Secretary shall have
authority to hire administrative law judges to hear such
cases, giving priority to those judges with prior experience
in handling medicare appeals and in a manner consistent with
paragraph (3), and to hire support staff for such judges.
(5) Financing.--Amounts payable under law to the
Commissioner for administrative law judges performing the
administrative law judge functions transferred under
paragraph (1) from the Federal Hospital Insurance Trust Fund
and the Federal Supplementary Medical Insurance Trust Fund
shall become payable to the Secretary for the functions so
transferred.
(6) Shared resources.--The Secretary shall enter into such
arrangements with the Commissioner as may be appropriate with
respect to transferred functions of administrative law judges
to share office space, support staff, and other resources,
with appropriate reimbursement from the Trust Funds described
in paragraph (5).
(c) Increased Financial Support.--In addition to any
amounts otherwise appropriated, to ensure timely action on
appeals before administrative law judges and the Departmental
Appeals Board consistent with section 1869 of the Social
Security Act (as amended by section 521 of BIPA, 114 Stat.
2763A-534), there are authorized to be appropriated (in
appropriate part from the Federal Hospital Insurance Trust
Fund and the Federal Supplementary Medical Insurance Trust
Fund) to the Secretary such sums as are necessary for fiscal
year 2003 and each subsequent fiscal year to--
(1) increase the number of administrative law judges (and
their staffs) under subsection (b)(4);
(2) improve education and training opportunities for
administrative law judges (and their staffs); and
(3) increase the staff of the Departmental Appeals Board.
(d) Conforming Amendment.--Section 1869(f)(2)(A)(i) (42
U.S.C. 1395ff(f)(2)(A)(i)), as added by section 522(a) of
BIPA (114 Stat. 2763A-543), is amended by striking ``of the
Social Security Administration''.
SEC. 402. PROCESS FOR EXPEDITED ACCESS TO REVIEW.
(a) Expedited Access to Judicial Review.--Section 1869(b)
(42 U.S.C. 1395ff(b)) as amended by BIPA, is amended--
(1) in paragraph (1)(A), by inserting ``, subject to
paragraph (2),'' before ``to judicial review of the
Secretary's final decision'';
(2) in paragraph (1)(F)--
(A) by striking clause (ii);
(B) by striking ``proceeding'' and all that follows through
``determination'' and inserting ``determinations and
reconsiderations''; and
(C) by redesignating subclauses (I) and (II) as clauses (i)
and (ii) and by moving the indentation of such subclauses
(and the matter that follows) 2 ems to the left; and
(3) by adding at the end the following new paragraph:
``(2) Expedited access to judicial review.--
``(A) In general.--The Secretary shall establish a process
under which a provider of services or supplier that furnishes
an item or service or an individual entitled to benefits
under part A or enrolled under part B, or both, who has filed
an appeal under paragraph (1) may obtain access to judicial
review when a review panel (described in subparagraph (D)),
on its own motion or at the request of the appellant,
determines that no entity in the administrative appeals
process has the authority to decide the question of law or
regulation relevant to the matters in controversy and that
there is no material issue of fact in dispute. The appellant
may make such request only once with respect to a question of
law or regulation in a case of an appeal.
``(B) Prompt determinations.--If, after or coincident with
appropriately filing a request for an administrative hearing,
the appellant requests a determination by the appropriate
review panel that no review panel has the authority to decide
the question of law or regulations relevant to the matters in
controversy and that there is no material issue of fact in
dispute and if such request is accompanied by the documents
and materials as the appropriate review panel shall require
for purposes of making such determination, such review panel
shall make a determination on the request in writing within
60 days after the date such review panel receives the request
and such accompanying documents and materials. Such a
determination by such review panel shall be considered a
final decision and not subject to review by the Secretary.
``(C) Access to judicial review.--
``(i) In general.--If the appropriate review panel--
``(I) determines that there are no material issues of fact
in dispute and that the only issue is one of law or
regulation that no review panel has the authority to decide;
or
``(II) fails to make such determination within the period
provided under subparagraph (B);
then the appellant may bring a civil action as described in
this subparagraph.
``(ii) Deadline for filing.--Such action shall be filed, in
the case described in--
``(I) clause (i)(I), within 60 days of date of the
determination described in such subparagraph; or
``(II) clause (i)(II), within 60 days of the end of the
period provided under subparagraph (B) for the determination.
``(iii) Venue.--Such action shall be brought in the
district court of the United States for the judicial district
in which the appellant is located (or, in the case of an
action brought jointly by more than one applicant, the
judicial district in which the greatest number of applicants
are located) or in the district court for the District of
Columbia.
``(iv) Interest on amounts in controversy.--Where a
provider of services or supplier seeks judicial review
pursuant to this paragraph, the amount in controversy shall
be subject to annual interest beginning on the first day of
the first month beginning after the 60-day period as
determined pursuant to clause (ii) and equal to the rate of
interest on obligations issued for purchase by the Federal
Hospital Insurance Trust Fund
[[Page H8786]]
and by the Federal Supplementary Medical Insurance Trust Fund
for the month in which the civil action authorized under this
paragraph is commenced, to be awarded by the reviewing court
in favor of the prevailing party. No interest awarded
pursuant to the preceding sentence shall be deemed income or
cost for the purposes of determining reimbursement due
providers of services or suppliers under this Act.
``(D) Review panels.--For purposes of this subsection, a
`review panel' is a panel consisting of 3 members (who shall
be administrative law judges, members of the Departmental
Appeals Board, or qualified individuals associated with a
qualified independent contractor (as defined in subsection
(c)(2)) or with another independent entity) designated by the
Secretary for purposes of making determinations under this
paragraph.''.
(b) Application to Provider Agreement Determinations.--
Section 1866(h)(1) (42 U.S.C. 1395cc(h)(1)) is amended--
(1) by inserting ``(A)'' after ``(h)(1)''; and
(2) by adding at the end the following new subparagraph:
``(B) An institution or agency described in subparagraph
(A) that has filed for a hearing under subparagraph (A) shall
have expedited access to judicial review under this
subparagraph in the same manner as providers of services,
suppliers, and individuals entitled to benefits under part A
or enrolled under part B, or both, may obtain expedited
access to judicial review under the process established under
section 1869(b)(2). Nothing in this subparagraph shall be
construed to affect the application of any remedy imposed
under section 1819 during the pendency of an appeal under
this subparagraph.''.
(c) Effective Date.--The amendments made by this section
shall apply to appeals filed on or after October 1, 2002.
(d) Expedited Review of Certain Provider Agreement
Determinations.--
(1) Termination and certain other immediate remedies.--The
Secretary shall develop and implement a process to expedite
proceedings under sections 1866(h) of the Social Security Act
(42 U.S.C. 1395cc(h)) in which the remedy of termination of
participation, or a remedy described in clause (i) or (iii)
of section 1819(h)(2)(B) of such Act (42 U.S.C. 1395i-
3(h)(2)(B)) which is applied on an immediate basis, has been
imposed. Under such process priority shall be provided in
cases of termination.
(2) Increased financial support.--In addition to any
amounts otherwise appropriated, to reduce by 50 percent the
average time for administrative determinations on appeals
under section 1866(h) of the Social Security Act (42 U.S.C.
1395cc(h)), there are authorized to be appropriated (in
appropriate part from the Federal Hospital Insurance Trust
Fund and the Federal Supplementary Medical Insurance Trust
Fund) to the Secretary such additional sums for fiscal year
2003 and each subsequent fiscal year as may be necessary. The
purposes for which such amounts are available include
increasing the number of administrative law judges (and their
staffs) and the appellate level staff at the Departmental
Appeals Board of the Department of Health and Human Services
and educating such judges and staffs on long-term care
issues.
SEC. 403. REVISIONS TO MEDICARE APPEALS PROCESS.
(a) Requiring Full and Early Presentation of Evidence.--
(1) In general.--Section 1869(b) (42 U.S.C. 1395ff(b)), as
amended by BIPA and as amended by section 402(a), is further
amended by adding at the end the following new paragraph:
``(3) Requiring full and early presentation of evidence by
providers.--A provider of services or supplier may not
introduce evidence in any appeal under this section that was
not presented at the reconsideration conducted by the
qualified independent contractor under subsection (c), unless
there is good cause which precluded the introduction of such
evidence at or before that reconsideration.''.
(2) Effective date.--The amendment made by paragraph (1)
shall take effect on October 1, 2002.
(b) Use of Patients' Medical Records.--Section
1869(c)(3)(B)(i) (42 U.S.C. 1395ff(c)(3)(B)(i)), as amended
by BIPA, is amended by inserting ``(including the medical
records of the individual involved)'' after ``clinical
experience''.
(c) Notice Requirements for Medicare Appeals.--
(1) Initial determinations and redeterminations.--Section
1869(a) (42 U.S.C. 1395ff(a)), as amended by BIPA, is amended
by adding at the end the following new paragraph:
``(4) Requirements of notice of determinations and
redeterminations.--A written notice of a determination on an
initial determination or on a redetermination, insofar as
such determination or redetermination results in a denial of
a claim for benefits, shall include--
``(A) the specific reasons for the determination,
including--
``(i) upon request, the provision of the policy, manual, or
regulation used in making the determination; and
``(ii) as appropriate in the case of a redetermination, a
summary of the clinical or scientific evidence used in making
the determination;
``(B) the procedures for obtaining additional information
concerning the determination or redetermination; and
``(C) notification of the right to seek a redetermination
or otherwise appeal the determination and instructions on how
to initiate such a redetermination or appeal under this
section.
The written notice on a redetermination shall be provided in
printed form and written in a manner calculated to be
understood by the individual entitled to benefits under part
A or enrolled under part B, or both.''.
(2) Reconsiderations.--Section 1869(c)(3)(E) (42 U.S.C.
1395ff(c)(3)(E)), as amended by BIPA, is amended--
(A) by inserting ``be written in a manner calculated to be
understood by the individual entitled to benefits under part
A or enrolled under part B, or both, and shall include (to
the extent appropriate)'' after ``in writing, ''; and
(B) by inserting ``and a notification of the right to
appeal such determination and instructions on how to initiate
such appeal under this section'' after ``such decision, ''.
(3) Appeals.--Section 1869(d) (42 U.S.C. 1395ff(d)), as
amended by BIPA, is amended--
(A) in the heading, by inserting ``; Notice'' after
``Secretary''; and
(B) by adding at the end the following new paragraph:
``(4) Notice.--Notice of the decision of an administrative
law judge shall be in writing in a manner calculated to be
understood by the individual entitled to benefits under part
A or enrolled under part B, or both, and shall include--
``(A) the specific reasons for the determination
(including, to the extent appropriate, a summary of the
clinical or scientific evidence used in making the
determination);
``(B) the procedures for obtaining additional information
concerning the decision; and
``(C) notification of the right to appeal the decision and
instructions on how to initiate such an appeal under this
section.''.
(4) Submission of record for appeal.--Section
1869(c)(3)(J)(i) (42 U.S.C. 1395ff(c)(3)(J)(i)) by striking
``prepare'' and inserting ``submit'' and by striking ``with
respect to'' and all that follows through ``and relevant
policies''.
(d) Qualified Independent Contractors.--
(1) Eligibility requirements of qualified independent
contractors.--Section 1869(c)(3) (42 U.S.C. 1395ff(c)(3)), as
amended by BIPA, is amended--
(A) in subparagraph (A), by striking ``sufficient training
and expertise in medical science and legal matters'' and
inserting ``sufficient medical, legal, and other expertise
(including knowledge of the program under this title) and
sufficient staffing''; and
(B) by adding at the end the following new subparagraph:
``(K) Independence requirements.--
``(i) In general.--Subject to clause (ii), a qualified
independent contractor shall not conduct any activities in a
case unless the entity--
``(I) is not a related party (as defined in subsection
(g)(5));
``(II) does not have a material familial, financial, or
professional relationship with such a party in relation to
such case; and
``(III) does not otherwise have a conflict of interest with
such a party.
``(ii) Exception for reasonable compensation.--Nothing in
clause (i) shall be construed to prohibit receipt by a
qualified independent contractor of compensation from the
Secretary for the conduct of activities under this section if
the compensation is provided consistent with clause (iii).
``(iii) Limitations on entity compensation.--Compensation
provided by the Secretary to a qualified independent
contractor in connection with reviews under this section
shall not be contingent on any decision rendered by the
contractor or by any reviewing professional.''.
(2) Eligibility requirements for reviewers.--Section 1869
(42 U.S.C. 1395ff), as amended by BIPA, is amended--
(A) by amending subsection (c)(3)(D) to read as follows:
``(D) Qualifications for reviewers.--The requirements of
subsection (g) shall be met (relating to qualifications of
reviewing professionals).''; and
(B) by adding at the end the following new subsection:
``(g) Qualifications of Reviewers.--
``(1) In general.--In reviewing determinations under this
section, a qualified independent contractor shall assure
that--
``(A) each individual conducting a review shall meet the
qualifications of paragraph (2);
``(B) compensation provided by the contractor to each such
reviewer is consistent with paragraph (3); and
``(C) in the case of a review by a panel described in
subsection (c)(3)(B) composed of physicians or other health
care professionals (each in this subsection referred to as a
`reviewing professional'), each reviewing professional meets
the qualifications described in paragraph (4) and, where a
claim is regarding the furnishing of treatment by a physician
(allopathic or osteopathic) or the provision of items or
services by a physician (allopathic or osteopathic), each
reviewing professional shall be a physician (allopathic or
osteopathic).
``(2) Independence.--
``(A) In general.--Subject to subparagraph (B), each
individual conducting a review in a case shall--
``(i) not be a related party (as defined in paragraph (5));
[[Page H8787]]
``(ii) not have a material familial, financial, or
professional relationship with such a party in the case under
review; and
``(iii) not otherwise have a conflict of interest with such
a party.
``(B) Exception.--Nothing in subparagraph (A) shall be
construed to--
``(i) prohibit an individual, solely on the basis of a
participation agreement with a fiscal intermediary, carrier,
or other contractor, from serving as a reviewing professional
if--
``(I) the individual is not involved in the provision of
items or services in the case under review;
``(II) the fact of such an agreement is disclosed to the
Secretary and the individual entitled to benefits under part
A or enrolled under part B, or both, (or authorized
representative) and neither party objects; and
``(III) the individual is not an employee of the
intermediary, carrier, or contractor and does not provide
services exclusively or primarily to or on behalf of such
intermediary, carrier, or contractor;
``(ii) prohibit an individual who has staff privileges at
the institution where the treatment involved takes place from
serving as a reviewer merely on the basis of having such
staff privileges if the existence of such privileges is
disclosed to the Secretary and such individual (or authorized
representative), and neither party objects; or
``(iii) prohibit receipt of compensation by a reviewing
professional from a contractor if the compensation is
provided consistent with paragraph (3).
For purposes of this paragraph, the term `participation
agreement' means an agreement relating to the provision of
health care services by the individual and does not include
the provision of services as a reviewer under this
subsection.
``(3) Limitations on reviewer compensation.--Compensation
provided by a qualified independent contractor to a reviewer
in connection with a review under this section shall not be
contingent on the decision rendered by the reviewer.
``(4) Licensure and expertise.--Each reviewing professional
shall be--
``(A) a physician (allopathic or osteopathic) who is
appropriately credentialed or licensed in one or more States
to deliver health care services and has medical expertise in
the field of practice that is appropriate for the items or
services at issue; or
``(B) a health care professional who is legally authorized
in one or more States (in accordance with State law or the
State regulatory mechanism provided by State law) to furnish
the health care items or services at issue and has medical
expertise in the field of practice that is appropriate for
such items or services.
``(5) Related party defined.--For purposes of this section,
the term `related party' means, with respect to a case under
this title involving a specific individual entitled to
benefits under part A or enrolled under part B, or both, any
of the following:
``(A) The Secretary, the medicare administrative contractor
involved, or any fiduciary, officer, director, or employee of
the Department of Health and Human Services, or of such
contractor.
``(B) The individual (or authorized representative).
``(C) The health care professional that provides the items
or services involved in the case.
``(D) The institution at which the items or services (or
treatment) involved in the case are provided.
``(E) The manufacturer of any drug or other item that is
included in the items or services involved in the case.
``(F) Any other party determined under any regulations to
have a substantial interest in the case involved.''.
(3) Effective date.--The amendments made by paragraphs (1)
and (2) shall be effective as if included in the enactment of
the respective provisions of subtitle C of title V of BIPA,
(114 Stat. 2763A-534).
(4) Transition.--In applying section 1869(g) of the Social
Security Act (as added by paragraph (2)), any reference to a
medicare administrative contractor shall be deemed to include
a reference to a fiscal intermediary under section 1816 of
the Social Security Act (42 U.S.C. 1395h) and a carrier under
section 1842 of such Act (42 U.S.C. 1395u).
SEC. 404. PREPAYMENT REVIEW.
(a) In General.--Section 1874A, as added by section
201(a)(1) and as amended by sections 202(b), 301(b)(1), and
301(c)(1), is further amended by adding at the end the
following new subsection:
``(h) Conduct of Prepayment Review.--
``(1) Conduct of random prepayment review.--
``(A) In general.--A medicare administrative contractor may
conduct random prepayment review only to develop a
contractor-wide or program-wide claims payment error rates or
under such additional circumstances as may be provided under
regulations, developed in consultation with providers of
services and suppliers.
``(B) Use of standard protocols when conducting prepayment
reviews.--When a medicare administrative contractor conducts
a random prepayment review, the contractor may conduct such
review only in accordance with a standard protocol for random
prepayment audits developed by the Secretary.
``(C) Construction.--Nothing in this paragraph shall be
construed as preventing the denial of payments for claims
actually reviewed under a random prepayment review.
``(D) Random prepayment review.--For purposes of this
subsection, the term `random prepayment review' means a
demand for the production of records or documentation absent
cause with respect to a claim.
``(2) Limitations on non-random prepayment review.--
``(A) Limitations on initiation of non-random prepayment
review.--A medicare administrative contractor may not
initiate non-random prepayment review of a provider of
services or supplier based on the initial identification by
that provider of services or supplier of an improper billing
practice unless there is a likelihood of sustained or high
level of payment error (as defined in subsection (i)(3)(A)).
``(B) Termination of non-random prepayment review.--The
Secretary shall issue regulations relating to the
termination, including termination dates, of non-random
prepayment review. Such regulations may vary such a
termination date based upon the differences in the
circumstances triggering prepayment review.''.
(b) Effective Date.--
(1) In general.--Except as provided in this subsection, the
amendment made by subsection (a) shall take effect 1 year
after the date of the enactment of this Act.
(2) Deadline for promulgation of certain regulations.--The
Secretary shall first issue regulations under section
1874A(h) of the Social Security Act, as added by subsection
(a), by not later than 1 year after the date of the enactment
of this Act.
(3) Application of standard protocols for random prepayment
review.--Section 1874A(h)(1)(B) of the Social Security Act,
as added by subsection (a), shall apply to random prepayment
reviews conducted on or after such date (not later than 1
year after the date of the enactment of this Act) as the
Secretary shall specify.
(c) Application to Fiscal Intermediaries and Carriers.--The
provisions of section 1874A(h) of the Social Security Act, as
added by subsection (a), shall apply to each fiscal
intermediary under section 1816 of the Social Security Act
(42 U.S.C. 1395h) and each carrier under section 1842 of such
Act (42 U.S.C. 1395u) in the same manner as they apply to
medicare administrative contractors under such provisions.
SEC. 405. RECOVERY OF OVERPAYMENTS.
(a) In General.--Section 1893 (42 U.S.C. 1395ddd) is
amended by adding at the end the following new subsection:
``(f) Recovery of Overpayments.--
``(1) Use of repayment plans.--
``(A) In general.--If the repayment, within 30 days by a
provider of services or supplier, of an overpayment under
this title would constitute a hardship (as defined in
subparagraph (B)), subject to subparagraph (C), upon request
of the provider of services or supplier the Secretary shall
enter into a plan with the provider of services or supplier
for the repayment (through offset or otherwise) of such
overpayment over a period of at least 6 months but not longer
than 3 years (or not longer than 5 years in the case of
extreme hardship, as determined by the Secretary). Interest
shall accrue on the balance through the period of repayment.
Such plan shall meet terms and conditions determined to be
appropriate by the Secretary.
``(B) Hardship.--
``(i) In general.--For purposes of subparagraph (A), the
repayment of an overpayment (or overpayments) within 30 days
is deemed to constitute a hardship if--
``(I) in the case of a provider of services that files cost
reports, the aggregate amount of the overpayments exceeds 10
percent of the amount paid under this title to the provider
of services for the cost reporting period covered by the most
recently submitted cost report; or
``(II) in the case of another provider of services or
supplier, the aggregate amount of the overpayments exceeds 10
percent of the amount paid under this title to the provider
of services or supplier for the previous calendar year.
``(ii) Rule of application.--The Secretary shall establish
rules for the application of this subparagraph in the case of
a provider of services or supplier that was not paid under
this title during the previous year or was paid under this
title only during a portion of that year.
``(iii) Treatment of previous overpayments.--If a provider
of services or supplier has entered into a repayment plan
under subparagraph (A) with respect to a specific overpayment
amount, such payment amount under the repayment plan shall
not be taken into account under clause (i) with respect to
subsequent overpayment amounts.
``(C) Exceptions.--Subparagraph (A) shall not apply if--
``(i) the Secretary has reason to suspect that the provider
of services or supplier may file for bankruptcy or otherwise
cease to do business or discontinue participation in the
program under this title; or
``(ii) there is an indication of fraud or abuse committed
against the program.
``(D) Immediate collection if violation of repayment
plan.--If a provider of services or supplier fails to make a
payment in accordance with a repayment plan under this
paragraph, the Secretary may immediately seek to offset or
otherwise recover the total balance outstanding (including
applicable interest) under the repayment plan.
``(E) Relation to no fault provision.--Nothing in this
paragraph shall be construed
[[Page H8788]]
as affecting the application of section 1870(c) (relating to
no adjustment in the cases of certain overpayments).
``(2) Limitation on recoupment.--
``(A) In general.--In the case of a provider of services or
supplier that is determined to have received an overpayment
under this title and that seeks a reconsideration by a
qualified independent contractor on such determination under
section 1869(b)(1), the Secretary may not take any action (or
authorize any other person, including any medicare
contractor, as defined in subparagraph (C) to recoup the
overpayment until the date the decision on the
reconsideration has been rendered. If the provisions of
section 1869(b)(1) (providing for such a reconsideration by a
qualified independent contractor) are not in effect, in
applying the previous sentence any reference to such a
reconsideration shall be treated as a reference to a
redetermination by the fiscal intermediary or carrier
involved.
``(B) Collection with interest.--Insofar as the
determination on such appeal is against the provider of
services or supplier, interest on the overpayment shall
accrue on and after the date of the original notice of
overpayment. Insofar as such determination against the
provider of services or supplier is later reversed, the
Secretary shall provide for repayment of the amount recouped
plus interest at the same rate as would apply under the
previous sentence for the period in which the amount was
recouped.
``(C) Medicare contractor defined.--For purposes of this
subsection, the term `medicare contractor' has the meaning
given such term in section 1889(g).
``(3) Limitation on use of extrapolation.--A medicare
contractor may not use extrapolation to determine overpayment
amounts to be recovered by recoupment, offset, or otherwise
unless--
``(A) there is a sustained or high level of payment error
(as defined by the Secretary by regulation); or
``(B) documented educational intervention has failed to
correct the payment error (as determined by the Secretary).
``(4) Provision of supporting documentation.--In the case
of a provider of services or supplier with respect to which
amounts were previously overpaid, a medicare contractor may
request the periodic production of records or supporting
documentation for a limited sample of submitted claims to
ensure that the previous practice is not continuing.
``(5) Consent settlement reforms.--
``(A) In general.--The Secretary may use a consent
settlement (as defined in subparagraph (D)) to settle a
projected overpayment.
``(B) Opportunity to submit additional information before
consent settlement offer.--Before offering a provider of
services or supplier a consent settlement, the Secretary
shall--
``(i) communicate to the provider of services or supplier--
``(I) that, based on a review of the medical records
requested by the Secretary, a preliminary evaluation of those
records indicates that there would be an overpayment;
``(II) the nature of the problems identified in such
evaluation; and
``(III) the steps that the provider of services or supplier
should take to address the problems; and
``(ii) provide for a 45-day period during which the
provider of services or supplier may furnish additional
information concerning the medical records for the claims
that had been reviewed.
``(C) Consent settlement offer.--The Secretary shall review
any additional information furnished by the provider of
services or supplier under subparagraph (B)(ii). Taking into
consideration such information, the Secretary shall determine
if there still appears to be an overpayment. If so, the
Secretary--
``(i) shall provide notice of such determination to the
provider of services or supplier, including an explanation of
the reason for such determination; and
``(ii) in order to resolve the overpayment, may offer the
provider of services or supplier--
``(I) the opportunity for a statistically valid random
sample; or
``(II) a consent settlement.
The opportunity provided under clause (ii)(I) does not waive
any appeal rights with respect to the alleged overpayment
involved.
``(D) Consent settlement defined.--For purposes of this
paragraph, the term `consent settlement' means an agreement
between the Secretary and a provider of services or supplier
whereby both parties agree to settle a projected overpayment
based on less than a statistically valid sample of claims and
the provider of services or supplier agrees not to appeal the
claims involved.
``(6) Notice of over-utilization of codes.--The Secretary
shall establish, in consultation with organizations
representing the classes of providers of services and
suppliers, a process under which the Secretary provides for
notice to classes of providers of services and suppliers
served by the contractor in cases in which the contractor has
identified that particular billing codes may be overutilized
by that class of providers of services or suppliers under the
programs under this title (or provisions of title XI insofar
as they relate to such programs).
``(7) Payment audits.--
``(A) Written notice for post-payment audits.--Subject to
subparagraph (C), if a medicare contractor decides to conduct
a post-payment audit of a provider of services or supplier
under this title, the contractor shall provide the provider
of services or supplier with written notice (which may be in
electronic form) of the intent to conduct such an audit.
``(B) Explanation of findings for all audits.--Subject to
subparagraph (C), if a medicare contractor audits a provider
of services or supplier under this title, the contractor
shall--
``(i) give the provider of services or supplier a full
review and explanation of the findings of the audit in a
manner that is understandable to the provider of services or
supplier and permits the development of an appropriate
corrective action plan;
``(ii) inform the provider of services or supplier of the
appeal rights under this title as well as consent settlement
options (which are at the discretion of the Secretary);
``(iii) give the provider of services or supplier an
opportunity to provide additional information to the
contractor; and
``(iv) take into account information provided, on a timely
basis, by the provider of services or supplier under clause
(iii).
``(C) Exception.--Subparagraphs (A) and (B) shall not apply
if the provision of notice or findings would compromise
pending law enforcement activities, whether civil or
criminal, or reveal findings of law enforcement-related
audits.
``(8) Standard methodology for probe sampling.--The
Secretary shall establish a standard methodology for medicare
contractors to use in selecting a sample of claims for review
in the case of an abnormal billing pattern.''.
(b) Effective Dates and Deadlines.--
(1) Use of repayment plans.--Section 1893(f)(1) of the
Social Security Act, as added by subsection (a), shall apply
to requests for repayment plans made after the date of the
enactment of this Act.
(2) Limitation on recoupment.--Section 1893(f)(2) of the
Social Security Act, as added by subsection (a), shall apply
to actions taken after the date of the enactment of this Act.
(3) Use of extrapolation.--Section 1893(f)(3) of the Social
Security Act, as added by subsection (a), shall apply to
statistically valid random samples initiated after the date
that is 1 year after the date of the enactment of this Act.
(4) Provision of supporting documentation.--Section
1893(f)(4) of the Social Security Act, as added by subsection
(a), shall take effect on the date of the enactment of this
Act.
(5) Consent settlement.--Section 1893(f)(5) of the Social
Security Act, as added by subsection (a), shall apply to
consent settlements entered into after the date of the
enactment of this Act.
(6) Notice of overutilization.--Not later than 1 year after
the date of the enactment of this Act, the Secretary shall
first establish the process for notice of overutilization of
billing codes under section 1893A(f)(6) of the Social
Security Act, as added by subsection (a).
(7) Payment audits.--Section 1893A(f)(7) of the Social
Security Act, as added by subsection (a), shall apply to
audits initiated after the date of the enactment of this Act.
(8) Standard for abnormal billing patterns.--Not later than
1 year after the date of the enactment of this Act, the
Secretary shall first establish a standard methodology for
selection of sample claims for abnormal billing patterns
under section 1893(f)(8) of the Social Security Act, as added
by subsection (a).
SEC. 406. PROVIDER ENROLLMENT PROCESS; RIGHT OF APPEAL.
(a) In General.--Section 1866 (42 U.S.C. 1395cc) is
amended--
(1) by adding at the end of the heading the following: ``;
enrollment processes''; and
(2) by adding at the end the following new subsection:
``(j) Enrollment Process for Providers of Services and
Suppliers.--
``(1) Enrollment process.--
``(A) In general.--The Secretary shall establish by
regulation a process for the enrollment of providers of
services and suppliers under this title.
``(B) Deadlines.--The Secretary shall establish by
regulation procedures under which there are deadlines for
actions on applications for enrollment (and, if applicable,
renewal of enrollment). The Secretary shall monitor the
performance of medicare administrative contractors in meeting
the deadlines established under this subparagraph.
``(C) Consultation before changing provider enrollment
forms.--The Secretary shall consult with providers of
services and suppliers before making changes in the provider
enrollment forms required of such providers and suppliers to
be eligible to submit claims for which payment may be made
under this title.
``(2) Hearing rights in cases of denial or non-renewal.--A
provider of services or supplier whose application to enroll
(or, if applicable, to renew enrollment) under this title is
denied may have a hearing and judicial review of such denial
under the procedures that apply under subsection (h)(1)(A) to
a provider of services that is dissatisfied with a
determination by the Secretary.''.
(b) Effective Dates.--
(1) Enrollment process.--The Secretary shall provide for
the establishment of the enrollment process under section
1866(j)(1) of the Social Security Act, as added by subsection
(a)(2), within 6 months after the date of the enactment of
this Act.
[[Page H8789]]
(2) Consultation.--Section 1866(j)(1)(C) of the Social
Security Act, as added by subsection (a)(2), shall apply with
respect to changes in provider enrollment forms made on or
after January 1, 2002.
(3) Hearing rights.--Section 1866(j)(2) of the Social
Security Act, as added by subsection (a)(2), shall apply to
denials occurring on or after such date (not later than 1
year after the date of the enactment of this Act) as the
Secretary specifies.
SEC. 407. PROCESS FOR CORRECTION OF MINOR ERRORS AND
OMISSIONS ON CLAIMS WITHOUT PURSUING APPEALS
PROCESS.
The Secretary shall develop, in consultation with
appropriate medicare contractors (as defined in section
1889(g) of the Social Security Act, as inserted by section
301(a)(1)) and representatives of providers of services and
suppliers, a process whereby, in the case of minor errors or
omissions (as defined by the Secretary) that are detected in
the submission of claims under the programs under title XVIII
of such Act, a provider of services or supplier is given an
opportunity to correct such an error or omission without the
need to initiate an appeal. Such process shall include the
ability to resubmit corrected claims.
SEC. 408. PRIOR DETERMINATION PROCESS FOR CERTAIN ITEMS AND
SERVICES; ADVANCE BENEFICIARY NOTICES.
(a) In General.--Section 1869 (42 U.S.C. 1395ff(b)), as
amended by sections 521 and 522 of BIPA and section
403(d)(2)(B), is further amended by adding at the end the
following new subsection:
``(h) Prior Determination Process for Certain Items and
Services.--
``(1) Establishment of process.--
``(A) In general.--With respect to a medicare
administrative contractor that has a contract under section
1874A that provides for making payments under this title with
respect to eligible items and services described in
subparagraph (C), the Secretary shall establish a prior
determination process that meets the requirements of this
subsection and that shall be applied by such contractor in
the case of eligible requesters.
``(B) Eligible requester.--For purposes of this subsection,
each of the following shall be an eligible requester:
``(i) A physician, but only with respect to eligible items
and services for which the physician may be paid directly.
``(ii) An individual entitled to benefits under this title,
but only with respect to an item or service for which the
individual receives, from the physician who may be paid
directly for the item or service, an advance beneficiary
notice under section 1879(a) that payment may not be made (or
may no longer be made) for the item or service under this
title.
``(C) Eligible items and services.--For purposes of this
subsection and subject to paragraph (2), eligible items and
services are items and services which are physicians'
services (as defined in paragraph (4)(A) of section 1848(f)
for purposes of calculating the sustainable growth rate under
such section).
``(2) Secretarial flexibility.--The Secretary shall
establish by regulation reasonable limits on the categories
of eligible items and services for which a prior
determination of coverage may be requested under this
subsection. In establishing such limits, the Secretary may
consider the dollar amount involved with respect to the item
or service, administrative costs and burdens, and other
relevant factors.
``(3) Request for prior determination.--
``(A) In general.--Subject to paragraph (2), under the
process established under this subsection an eligible
requester may submit to the contractor a request for a
determination, before the furnishing of an eligible item or
service involved as to whether the item or service is covered
under this title consistent with the applicable requirements
of section 1862(a)(1)(A) (relating to medical necessity).
``(B) Accompanying documentation.--The Secretary may
require that the request be accompanied by a description of
the item or service, supporting documentation relating to the
medical necessity for the item or service, and any other
appropriate documentation. In the case of a request submitted
by an eligible requester who is described in paragraph
(1)(B)(ii), the Secretary may require that the request also
be accompanied by a copy of the advance beneficiary notice
involved.
``(4) Response to request.--
``(A) In general.--Under such process, the contractor shall
provide the eligible requester with written notice of a
determination as to whether--
``(i) the item or service is so covered;
``(ii) the item or service is not so covered; or
``(iii) the contractor lacks sufficient information to make
a coverage determination.
If the contractor makes the determination described in clause
(iii), the contractor shall include in the notice a
description of the additional information required to make
the coverage determination.
``(B) Deadline to respond.--Such notice shall be provided
within the same time period as the time period applicable to
the contractor providing notice of initial determinations on
a claim for benefits under subsection (a)(2)(A).
``(C) Informing beneficiary in case of physician request.--
In the case of a request in which an eligible requester is
not the individual described in paragraph (1)(B)(ii), the
process shall provide that the individual to whom the item or
service is proposed to be furnished shall be informed of any
determination described in clause (ii) (relating to a
determination of non-coverage) and the right (referred to in
paragraph (6)(B)) to obtain the item or service and have a
claim submitted for the item or service.
``(5) Effect of determinations.--
``(A) Binding nature of positive determination.--If the
contractor makes the determination described in paragraph
(4)(A)(i), such determination shall be binding on the
contractor in the absence of fraud or evidence of
misrepresentation of facts presented to the contractor.
``(B) Notice and right to redetermination in case of a
denial.--
``(i) In general.--If the contractor makes the
determination described in paragraph (4)(A)(ii)--
``(I) the eligible requester has the right to a
redetermination by the contractor on the determination that
the item or service is not so covered; and
``(II) the contractor shall include in notice under
paragraph (4)(A) a brief explanation of the basis for the
determination, including on what national or local coverage
or noncoverage determination (if any) the determination is
based, and the right to such a redetermination.
``(ii) Deadline for redeterminations.--The contractor shall
complete and provide notice of such redetermination within
the same time period as the time period applicable to the
contractor providing notice of redeterminations relating to a
claim for benefits under subsection (a)(3)(C)(ii).
``(6) Limitation on further review.--
``(A) In general.--Contractor determinations described in
paragraph (4)(A)(ii) or (4)(A)(iii) (and redeterminations
made under paragraph (5)(B)), relating to pre-service claims
are not subject to further administrative appeal or judicial
review under this section or otherwise.
``(B) Decision not to seek prior determination or negative
determination does not impact right to obtain services, seek
reimbursement, or appeal rights.--Nothing in this subsection
shall be construed as affecting the right of an individual
who--
``(i) decides not to seek a prior determination under this
subsection with respect to items or services; or
``(ii) seeks such a determination and has received a
determination described in paragraph (4)(A)(ii)), from
receiving (and submitting a claim for) such items services
and from obtaining administrative or judicial review
respecting such claim under the other applicable provisions
of this section. Failure to seek a prior determination under
this subsection with respect to items and services shall not
be taken into account in such administrative or judicial
review.
``(C) No prior determination after receipt of services.--
Once an individual is provided items and services, there
shall be no prior determination under this subsection with
respect to such items or services.''.
(b) Effective Date; Transition.--
(1) Effective date.--The Secretary shall establish the
prior determination process under the amendment made by
subsection (a) in such a manner as to provide for the
acceptance of requests for determinations under such process
filed not later than 18 months after the date of the
enactment of this Act.
(2) Transition.--During the period in which the amendment
made by subsection (a) has become effective but contracts are
not provided under section 1874A of the Social Security Act
with medicare administrative contractors, any reference in
section 1869(g) of such Act (as added by such amendment) to
such a contractor is deemed a reference to a fiscal
intermediary or carrier with an agreement under section 1816,
or contract under section 1842, respectively, of such Act.
(3) Limitation on application to sgr.--For purposes of
applying section 1848(f)(2)(D) of the Social Security Act (42
U.S.C. 1395w-4(f)(2)(D)), the amendment made by subsection
(a) shall not be considered to be a change in law or
regulation.
(c) Provisions Relating to Advance Beneficiary Notices;
Report on Prior Determination Process.--
(1) Data collection.--The Secretary shall establish a
process for the collection of information on the instances in
which an advance beneficiary notice (as defined in paragraph
(4)) has been provided and on instances in which a
beneficiary indicates on such a notice that the beneficiary
does not intend to seek to have the item or service that is
the subject of the notice furnished.
(2) Outreach and education.--The Secretary shall establish
a program of outreach and education for beneficiaries and
providers of services and other persons on the appropriate
use of advance beneficiary notices and coverage policies
under the medicare program.
(3) GAO report report on use of advance beneficiary
notices.--Not later than 18 months after the date on which
section 1869(g) of the Social Security Act (as added by
subsection (a)) takes effect, the Comptroller General of the
United States shall submit to Congress a report on the use of
advance beneficiary notices under title XVIII of such Act.
Such report shall include information concerning the
providers of services and other persons that have provided
such notices and the response of beneficiaries to such
notices.
[[Page H8790]]
(4) GAO report on use of prior determination process.--Not
later than 18 months after the date on which section 1869(g)
of the Social Security Act (as added by subsection (a)) takes
effect, the Comptroller General of the United States shall
submit to Congress a report on the use of the prior
determination process under such section. Such report shall
include--
(A) information concerning the types of procedures for
which a prior determination has been sought, determinations
made under the process, and changes in receipt of services
resulting from the application of such process; and
(B) an evaluation of whether the process was useful for
physicians (and other suppliers) and beneficiaries, whether
it was timely, and whether the amount of information required
was burdensome to physicians and beneficiaries.
(5) Advance beneficiary notice defined.--In this
subsection, the term ``advance beneficiary notice'' means a
written notice provided under section 1879(a) of the Social
Security Act (42 U.S.C. 1395pp(a)) to an individual entitled
to benefits under part A or B of title XVIII of such Act
before items or services are furnished under such part in
cases where a provider of services or other person that would
furnish the item or service believes that payment will not be
made for some or all of such items or services under such
title.
TITLE V--MISCELLANEOUS PROVISIONS
SEC. 501. POLICY DEVELOPMENT REGARDING EVALUATION AND
MANAGEMENT (E & M) DOCUMENTATION GUIDELINES.
(a) In General.--The Secretary may not implement any new
documentation guidelines for evaluation and management
physician services under the title XVIII of the Social
Security Act on or after the date of the enactment of this
Act unless the Secretary--
(1) has developed the guidelines in collaboration with
practicing physicians (including both generalists and
specialists) and provided for an assessment of the proposed
guidelines by the physician community;
(2) has established a plan that contains specific goals,
including a schedule, for improving the use of such
guidelines;
(3) has conducted appropriate and representative pilot
projects under subsection (b) to test modifications to the
evaluation and management documentation guidelines;
(4) finds that the objectives described in subsection (c)
will be met in the implementation of such guidelines; and
(5) has established, and is implementing, a program to
educate physicians on the use of such guidelines and that
includes appropriate outreach.
The Secretary shall make changes to the manner in which
existing evaluation and management documentation guidelines
are implemented to reduce paperwork burdens on physicians.
(b) Pilot Projects to Test Evaluation and Management
Documentation Guidelines.--
(1) In general.--The Secretary shall conduct under this
subsection appropriate and representative pilot projects to
test new evaluation and management documentation guidelines
referred to in subsection (a).
(2) Length and consultation.--Each pilot project under this
subsection shall--
(A) be voluntary;
(B) be of sufficient length as determined by the Secretary
to allow for preparatory physician and medicare contractor
education, analysis, and use and assessment of potential
evaluation and management guidelines; and
(C) be conducted, in development and throughout the
planning and operational stages of the project, in
consultation with practicing physicians (including both
generalists and specialists).
(3) Range of pilot projects.--Of the pilot projects
conducted under this subsection--
(A) at least one shall focus on a peer review method by
physicians (not employed by a medicare contractor) which
evaluates medical record information for claims submitted by
physicians identified as statistical outliers relative to
definitions published in the Current Procedures Terminology
(CPT) code book of the American Medical Association;
(B) at least one shall focus on an alternative method to
detailed guidelines based on physician documentation of face
to face encounter time with a patient;
(C) at least one shall be conducted for services furnished
in a rural area and at least one for services furnished
outside such an area; and
(D) at least one shall be conducted in a setting where
physicians bill under physicians' services in teaching
settings and at least one shall be conducted in a setting
other than a teaching setting.
(4) Banning of targeting of pilot project participants.--
Data collected under this subsection shall not be used as the
basis for overpayment demands or post-payment audits. Such
limitation applies only to claims filed as part of the pilot
project and lasts only for the duration of the pilot project
and only as long as the provider is a participant in the
pilot project.
(5) Study of impact.--Each pilot project shall examine the
effect of the new evaluation and management documentation
guidelines on--
(A) different types of physician practices, including those
with fewer than 10 full-time-equivalent employees (including
physicians); and
(B) the costs of physician compliance, including education,
implementation, auditing, and monitoring.
(6) Periodic reports.--The Secretary shall submit to
Congress periodic reports on the pilot projects under this
subsection.
(c) Objectives for Evaluation and Management Guidelines.--
The objectives for modified evaluation and management
documentation guidelines developed by the Secretary shall be
to--
(1) identify clinically relevant documentation needed to
code accurately and assess coding levels accurately;
(2) decrease the level of non-clinically pertinent and
burdensome documentation time and content in the physician's
medical record;
(3) increase accuracy by reviewers; and
(4) educate both physicians and reviewers.
(d) Study of Simpler, Alternative Systems of Documentation
for Physician Claims.--
(1) Study.--The Secretary shall carry out a study of the
matters described in paragraph (2).
(2) Matters described.--The matters referred to in
paragraph (1) are--
(A) the development of a simpler, alternative system of
requirements for documentation accompanying claims for
evaluation and management physician services for which
payment is made under title XVIII of the Social Security Act;
and
(B) consideration of systems other than current coding and
documentation requirements for payment for such physician
services.
(3) Consultation with practicing physicians.--In designing
and carrying out the study under paragraph (1), the Secretary
shall consult with practicing physicians, including
physicians who are part of group practices and including both
generalists and specialists.
(4) Application of hipaa uniform coding requirements.--In
developing an alternative system under paragraph (2), the
Secretary shall consider requirements of administrative
simplification under part C of title XI of the Social
Security Act.
(5) Report to congress.--(A) Not later than October 1,
2003, the Secretary shall submit to Congress a report on the
results of the study conducted under paragraph (1).
(B) The Medicare Payment Advisory Commission shall conduct
an analysis of the results of the study included in the
report under subparagraph (A) and shall submit a report on
such analysis to Congress.
(e) Study on Appropriate Coding of Certain Extended Office
Visits.--The Secretary shall conduct a study of the
appropriateness of coding in cases of extended office visits
in which there is no diagnosis made. Not later than October
1, 2003, the Secretary shall submit a report to Congress on
such study and shall include recommendations on how to code
appropriately for such visits in a manner that takes into
account the amount of time the physician spent with the
patient.
(f) Definitions.--In this section--
(1) the term ``rural area'' has the meaning given that term
in section 1886(d)(2)(D) of the Social Security Act, 42
U.S.C. 1395ww(d)(2)(D); and
(2) the term ``teaching settings'' are those settings
described in section 415.150 of title 42, Code of Federal
Regulations.
SEC. 502. IMPROVEMENT IN OVERSIGHT OF TECHNOLOGY AND
COVERAGE.
(a) Improved Coordination Between FDA and CMS on Coverage
of Breakthrough Medical Devices.--
(1) In general.--Upon request by an applicant and to the
extent feasible (as determined by the Secretary), the
Secretary shall, in the case of a class III medical device
that is subject to premarket approval under section 515 of
the Federal Food, Drug, and Cosmetic Act, ensure the sharing
of appropriate information from the review for application
for premarket approval conducted by the Food and Drug
Administration for coverage decisions under title XVIII of
the Social Security Act.
(2) Publication of plan.--Not later than 6 months after the
date of the enactment of this Act, the Secretary shall submit
to appropriate Committees of Congress a report that contains
the plan for improving such coordination and for shortening
the time lag between the premarket approval by the Food and
Drug Administration and coding and coverage decisions by the
Centers for Medicare & Medicaid Services.
(3) Construction.--Nothing in this subsection shall be
construed as changing the criteria for coverage of a medical
device under title XVIII of the Social Security Act nor
premarket approval by the Food and Drug Administration and
nothing in this subsection shall be construed to increase
premarket approval application requirements under the Federal
Food, Drug, and Cosmetic Act.
(b) Council for Technology and Innovation.--Section 1868
(42 U.S.C. 1395ee), as amended by section 301(a), is amended
by adding at the end the following new subsection:
``(c) Council for Technology and Innovation.--
``(1) Establishment.--The Secretary shall establish a
Council for Technology and Innovation within the Centers for
Medicare & Medicaid Services (in this section referred to as
`CMS').
``(2) Composition.--The Council shall be composed of senior
CMS staff and clinicians
[[Page H8791]]
and shall be chaired by the Executive Coordinator for
Technology and Innovation (appointed or designated under
paragraph (4)).
``(3) Duties.--The Council shall coordinate the activities
of coverage, coding, and payment processes under this title
with respect to new technologies and procedures, including
new drug therapies, and shall coordinate the exchange of
information on new technologies between CMS and other
entities that make similar decisions.
``(4) Executive coordinator for technology and
innovation.--The Secretary shall appoint (or designate) a
noncareer appointee (as defined in section 3132(a)(7) of
title 5, United States Code) who shall serve as the Executive
Coordinator for Technology and Innovation. Such executive
coordinator shall report to the Administrator of CMS, shall
chair the Council, shall oversee the execution of its duties,
and shall serve as a single point of contact for outside
groups and entities regarding the coverage, coding, and
payment processes under this title.''.
(c) GAO Study on Improvements in External Data Collection
for Use in the Medicare Inpatient Payment System.--
(1) Study.--The Comptroller General of the United States
shall conduct a study that analyzes which external data can
be collected in a shorter time frame by the Centers for
Medicare & Medicaid Services for use in computing payments
for inpatient hospital services. The study may include an
evaluation of the feasibility and appropriateness of using of
quarterly samples or special surveys or any other methods.
The study shall include an analysis of whether other
executive agencies, such as the Bureau of Labor Statistics in
the Department of Commerce, are best suited to collect this
information.
(2) Report.--By not later than October 1, 2002, the
Comptroller General shall submit a report to Congress on the
study under paragraph (1).
(d) IOM Study on Local Coverage Determinations.--
(1) Study.--The Secretary shall enter into an arrangement
with the Institute of Medicine of the National Academy of
Sciences under which the Institute shall conduct a study on
local coverage determinations (including the application of
local medical review policies) under the medicare program
under title XVIII of the Social Security Act. Such study
shall examine--
(A) the consistency of the definitions used in such
determinations;
(B) the types of evidence on which such determinations are
based, including medical and scientific evidence;
(C) the advantages and disadvantages of local coverage
decisionmaking, including the flexibility it offers for
ensuring timely patient access to new medical technology for
which data are still be collected;
(D) the manner in which the local coverage determination
process is used to develop data needed for a national
coverage determination, including the need for collection of
such data within a protocol and informed consent by
individuals entitled to benefits under part A of title XVIII
of the Social Security Act, or enrolled under part B of such
title, or both; and
(E) the advantages and disadvantages of maintaining local
medicare contractor advisory committees that can advise on
local coverage decisions based on an open, collaborative
public process.
(2) Report.--Such arrangement shall provide that the
Institute shall submit to the Secretary a report on such
study by not later than 3 years after the date of the
enactment of this Act. The Secretary shall promptly transmit
a copy of such report to Congress.
(e) Methods for Determining Payment Basis For New Lab
Tests.--Section 1833(h) (42 U.S.C. 1395l(h)) is amended by
adding at the end the following:
``(8)(A) The Secretary shall establish by regulation
procedures for determining the basis for, and amount of,
payment under this subsection for any clinical diagnostic
laboratory test with respect to which a new or substantially
revised HCPCS code is assigned on or after January 1, 2003
(in this paragraph referred to as `new tests').
``(B) Determinations under subparagraph (A) shall be made
only after the Secretary--
``(i) makes available to the public (through an Internet
site and other appropriate mechanisms) a list that includes
any such test for which establishment of a payment amount
under this subsection is being considered for a year;
``(ii) on the same day such list is made available, causes
to have published in the Federal Register notice of a meeting
to receive comments and recommendations (and data on which
recommendations are based) from the public on the appropriate
basis under this subsection for establishing payment amounts
for the tests on such list;
``(iii) not less than 30 days after publication of such
notice convenes a meeting, that includes representatives of
officials of the Centers for Medicare & Medicaid Services
involved in determining payment amounts, to receive such
comments and recommendations (and data on which the
recommendations are based);
``(iv) taking into account the comments and recommendations
(and accompanying data) received at such meeting, develops
and makes available to the public (through an Internet site
and other appropriate mechanisms) a list of proposed
determinations with respect to the appropriate basis for
establishing a payment amount under this subsection for each
such code, together with an explanation of the reasons for
each such determination, the data on which the determinations
are based, and a request for public written comments on the
proposed determination; and
``(v) taking into account the comments received during the
public comment period, develops and makes available to the
public (through an Internet site and other appropriate
mechanisms) a list of final determinations of the payment
amounts for such tests under this subsection, together with
the rationale for each such determination, the data on which
the determinations are based, and responses to comments and
suggestions received from the public.
``(C) Under the procedures established pursuant to
subparagraph (A), the Secretary shall--
``(i) set forth the criteria for making determinations
under subparagraph (A); and
``(ii) make available to the public the data (other than
proprietary data) considered in making such determinations.
``(D) The Secretary may convene such further public
meetings to receive public comments on payment amounts for
new tests under this subsection as the Secretary deems
appropriate.
``(E) For purposes of this paragraph:
``(i) The term `HCPCS' refers to the Health Care Procedure
Coding System.
``(ii) A code shall be considered to be `substantially
revised' if there is a substantive change to the definition
of the test or procedure to which the code applies (such as a
new analyte or a new methodology for measuring an existing
analyte-specific test).''.
SEC. 503. TREATMENT OF HOSPITALS FOR CERTAIN SERVICES UNDER
MEDICARE SECONDARY PAYOR (MSP) PROVISIONS.
(a) In General.--The Secretary shall not require a hospital
(including a critical access hospital) to ask questions (or
obtain information) relating to the application of section
1862(b) of the Social Security Act (relating to medicare
secondary payor provisions) in the case of reference
laboratory services described in subsection (b), if the
Secretary does not impose such requirement in the case of
such services furnished by an independent laboratory.
(b) Reference Laboratory Services Described.--Reference
laboratory services described in this subsection are clinical
laboratory diagnostic tests (or the interpretation of such
tests, or both) furnished without a face-to-face encounter
between the individual entitled to benefits under part A or
enrolled under part B, or both, and the hospital involved and
in which the hospital submits a claim only for such test or
interpretation.
SEC. 504. EMTALA IMPROVEMENTS.
(a) Payment for EMTALA-Mandated Screening and Stabilization
Services.--
(1) In general.--Section 1862 (42 U.S.C. 1395y) is amended
by inserting after subsection (c) the following new
subsection:
``(d) For purposes of subsection (a)(1)(A), in the case of
any item or service that is required to be provided pursuant
to section 1867 to an individual who is entitled to benefits
under this title, determinations as to whether the item or
service is reasonable and necessary shall be made on the
basis of the information available to the treating physician
or practitioner (including the patient's presenting symptoms
or complaint) at the time the item or service was ordered or
furnished by the physician or practitioner (and not on the
patient's principal diagnosis). When making such
determinations with respect to such an item or service, the
Secretary shall not consider the frequency with which the
item or service was provided to the patient before or after
the time of the admission or visit.''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply to items and services furnished on or after
January 1, 2002.
(b) Notification of Providers When EMTALA Investigation
Closed.--Section 1867(d) (42 U.S.C. 42 U.S.C. 1395dd(d)) is
amended by adding at the end the following new paragraph:
``(4) Notice upon closing an investigation.--The Secretary
shall establish a procedure to notify hospitals and
physicians when an investigation under this section is
closed.''.
(c) Prior Review by Peer Review Organizations in EMTALA
Cases Involving Termination of Participation.--
(1) In general.--Section 1867(d)(3) (42 U.S.C.
1395dd(d)(3)) is amended--
(A) in the first sentence, by inserting ``or in terminating
a hospital's participation under this title'' after ``in
imposing sanctions under paragraph (1)''; and
(B) by adding at the end the following new sentences:
``Except in the case in which a delay would jeopardize the
health or safety of individuals, the Secretary shall also
request such a review before making a compliance
determination as part of the process of terminating a
hospital's participation under this title for violations
related to the appropriateness of a medical screening
examination, stabilizing treatment, or an appropriate
transfer as required by this section, and shall provide a
period of 5 days for such review. The Secretary shall provide
a copy of the report on the organization's report to the
hospital or physician consistent with confidentiality
requirements imposed on the organization under such part
B.''.
(2) Effective date.--The amendments made by paragraph (1)
shall apply to terminations of participation initiated on or
after the date of the enactment of this Act.
[[Page H8792]]
SEC. 505. EMERGENCY MEDICAL TREATMENT AND ACTIVE LABOR ACT
(EMTALA) TECHNICAL ADVISORY GROUP.
(a) Establishment.--The Secretary shall establish a
Technical Advisory Group (in this section referred to as the
``Advisory Group'') to review issues related to the Emergency
Medical Treatment and Active Labor Act (EMTALA) and its
implementation. In this section, the term ``EMTALA'' refers
to the provisions of section 1867 of the Social Security Act
(42 U.S.C. 1395dd).
(b) Membership.--The Advisory Group shall be composed of 19
members, including the Administrator of the Centers for
Medicare & Medicaid Services and the Inspector General of the
Department of Health and Human Services and of which--
(1) 4 shall be representatives of hospitals, including at
least one public hospital, that have experience with the
application of EMTALA and at least 2 of which have not been
cited for EMTALA violations;
(2) 7 shall be practicing physicians drawn from the fields
of emergency medicine, cardiology or cardiothoracic surgery,
orthopedic surgery, neurosurgery, pediatrics or a pediatric
subspecialty, obstetrics-gynecology, and psychiatry, with not
more than one physician from any particular field;
(3) 2 shall represent patients;
(4) 2 shall be staff involved in EMTALA investigations from
different regional offices of the Centers for Medicare &
Medicaid Services; and
(5) 1 shall be from a State survey office involved in
EMTALA investigations and 1 shall be from a peer review
organization, both of whom shall be from areas other than the
regions represented under paragraph (4).
In selecting members described in paragraphs (1) through (3),
the Secretary shall consider qualified individuals nominated
by organizations representing providers and patients.
(c) General Responsibilities.--The Advisory Group--
(1) shall review EMTALA regulations;
(2) may provide advice and recommendations to the Secretary
with respect to those regulations and their application to
hospitals and physicians;
(3) shall solicit comments and recommendations from
hospitals, physicians, and the public regarding the
implementation of such regulations; and
(4) may disseminate information on the application of such
regulations to hospitals, physicians, and the public.
(d) Administrative Matters.--
(1) Chairperson.--The members of the Advisory Group shall
elect a member to serve as chairperson of the Advisory Group
for the life of the Advisory Group.
(2) Meetings.--The Advisory Group shall first meet at the
direction of the Secretary. The Advisory Group shall then
meet twice per year and at such other times as the Advisory
Group may provide.
(e) Termination.--The Advisory Group shall terminate 30
months after the date of its first meeting.
(f) Waiver of Administrative Limitation.--The Secretary
shall establish the Advisory Group notwithstanding any
limitation that may apply to the number of advisory
committees that may be established (within the Department of
Health and Human Services or otherwise).
SEC. 506. AUTHORIZING USE OF ARRANGEMENTS WITH OTHER HOSPICE
PROGRAMS TO PROVIDE CORE HOSPICE SERVICES IN
CERTAIN CIRCUMSTANCES.
(a) In General.--Section 1861(dd)(5) (42 U.S.C.
1395x(dd)(5)) is amended by adding at the end the following
new subparagraph:
``(D) In extraordinary, exigent, or other non-routine
circumstances, such as unanticipated periods of high patient
loads, staffing shortages due to illness or other events, or
temporary travel of a patient outside a hospice program's
service area, a hospice program may enter into arrangements
with another hospice program for the provision by that other
program of services described in paragraph (2)(A)(ii)(I). The
provisions of paragraph (2)(A)(ii)(II) shall apply with
respect to the services provided under such arrangements.''.
(b) Conforming Payment Provision.--Section 1814(i) (42
U.S.C. 1395f(i)) is amended by adding at the end the
following new paragraph:
``(4) In the case of hospice care provided by a hospice
program under arrangements under section 1861(dd)(5)(D) made
by another hospice program, the hospice program that made the
arrangements shall bill and be paid for the hospice care.''.
(c) Effective Date.--The amendments made by this section
shall apply to hospice care provided on or after the date of
the enactment of this Act.
SEC. 507. APPLICATION OF OSHA BLOODBORNE PATHOGENS STANDARD
TO CERTAIN HOSPITALS.
(a) In General.--Section 1866 (42 U.S.C. 1395cc) is
amended--
(1) in subsection (a)(1)--
(A) in subparagraph (R), by striking ``and'' at the end;
(B) in subparagraph (S), by striking the period at the end
and inserting ``, and''; and
(C) by inserting after subparagraph (S) the following new
subparagraph:
``(T) in the case of hospitals that are not otherwise
subject to the Occupational Safety and Health Act of 1970, to
comply with the Bloodborne Pathogens standard under section
1910.1030 of title 29 of the Code of Federal Regulations (or
as subsequently redesignated).''; and
(B) by adding at the end of subsection (b) the following
new paragraph:
``(4)(A) A hospital that fails to comply with the
requirement of subsection (a)(1)(T) (relating to the
Bloodborne Pathogens standard) is subject to a civil money
penalty in an amount described in subparagraph (B), but is
not subject to termination of an agreement under this
section.
``(B) The amount referred to in subparagraph (A) is an
amount that is similar to the amount of civil penalties that
may be imposed under section 17 of the Occupational Safety
and Health Act of 1970 for a violation of the Bloodborne
Pathogens standard referred to in subsection (a)(1)(T) by a
hospital that is subject to the provisions of such Act.
``(C) A civil money penalty under this paragraph shall be
imposed and collected in the same manner as civil money
penalties under subsection (a) of section 1128A are imposed
and collected under that section.''.
(b) Effective Date.--The amendments made by this subsection
(a) shall apply to hospitals as of July 1, 2002.
SEC. 508. ONE-YEAR DELAY IN LOCK IN PROCEDURES FOR
MEDICARE+CHOICE PLANS; CHANGE IN
MEDICARE+CHOICE REPORTING DEADLINES AND ANNUAL,
COORDINATED ELECTION PERIOD FOR 2002.
(a) Lock-In Delay.--Section 1851(e) (42 U.S.C. 1395w-21(e))
is amended--
(1) in paragraph (2)(A), by striking ``through 2001'' and
``and 2001'' and inserting ``through 2002'' and ``2001, and
2002'', respectively;
(2) in paragraph (2)(B), by striking ``during 2002'' and
inserting ``during 2003'';
(3) in paragraphs (2)(B)(i) and (2)(C)(i), by striking
``2002'' and inserting ``2003'' each place it appears;
(4) in paragraph (2)(D), by striking ``2001'' and inserting
``2002''; and
(5) in paragraph (4), by striking ``2002'' and inserting
``2003'' each place it appears.
(b) Change in Deadlines and Election Period.--
(1) In general.--Notwithstanding any other provision of
law--
(A) the deadline for submittal of information under section
1854(a)(1) of the Social Security Act (42 U.S.C. 1395w-
24(a)(1)) for 2002 is changed from July 1, 2002, to the third
Monday in September of 2002; and
(B) the annual, coordinated election period under section
1851(e)(3)(B) of such Act (42 U.S.C. 1395w-21(e)(3)(B)) with
respect to 2003 shall be the period beginning on November 15,
2002, and ending on December 31, 2002.
(2) GAO study on impact of change on beneficiaries and
plans.--The Comptroller General of the United States shall
conduct a review of the Medicare+Choice open enrollment
process that occurred during 2001, including the offering of
Medicare+Choice plans for 2002. By not later than May 31,
2002, the Comptroller General shall submit a report to
Congress and the Secretary on such review. Such report shall
include the following:
(A) An analysis of the effect of allowing additional time
for the submittal of adjusted community rates and other data
on the extent of participation of Medicare+Choice
organizations and on the benefits offered under
Medicare+Choice plans.
(B) An evaluation of the plan-specific information provided
to beneficiaries, the timeliness of the receipt of such
information, the adequacy of the duration of the open
enrollment period, and relevant operational issues that arise
as a result of the timing and duration of the open enrollment
period, including any problems related to the provision
services immediately following enrollment.
(C) The results of surveys of beneficiaries and
Medicare+Choice organizations.
(D) Such recommendations regarding the appropriateness of
the changes provided under paragraph (1) as the Comptroller
General finds appropriate.
SEC. 509. BIPA-RELATED TECHNICAL AMENDMENTS AND CORRECTIONS.
(a) Technical Amendments Relating to Advisory Committee
under BIPA Section 522.--(1) Subsection (i) of section 1114
(42 U.S.C. 1314)--
(A) is transferred to section 1862 and added at the end of
such section; and
(B) is redesignated as subsection (j).
(2) Section 1862 (42 U.S.C. 1395y) is amended--
(A) in the last sentence of subsection (a), by striking
``established under section 1114(f)''; and
(B) in subsection (j), as so transferred and redesignated--
(i) by striking ``under subsection (f)''; and
(ii) by striking ``section 1862(a)(1)'' and inserting
``subsection (a)(1)''.
(b) Terminology Corrections.--(1) Section 1869(c)(3)(I)(ii)
(42 U.S.C. 1395ff(c)(3)(I)(ii)), as amended by section 521 of
BIPA, is amended--
(A) in subclause (III), by striking ``policy'' and
inserting ``determination''; and
(B) in subclause (IV), by striking ``medical review --
policies'' and inserting ``coverage determinations''.
(2) Section 1852(a)(2)(C) (42 U.S.C. 1395w-22(a)(2)(C)) is
amended by striking ``policy'' and ``policy'' and inserting
``determination'' each place it appears and
``determination'', respectively.
(c) Reference Corrections.--Section 1869(f)(4) (42 U.S.C.
1395ff(f)(4)), as added by section 522 of BIPA, is amended--
(1) in subparagraph (A)(iv), by striking ``subclause -(I),
(II), or (III)'' and inserting ``clause (i), (ii), or
(iii)'';
[[Page H8793]]
(2) in subparagraph (B), by striking ``clause (i)(IV)'' -
and ``clause (i)(III)'' and inserting ``subparagraph
(A)(iv)'' and ``subparagraph (A)(iii)'', respectively; and
(3) in subparagraph (C), by striking ``clause (i)'',
``subclause (IV)'' and ``subparagraph (A)'' and inserting
``subparagraph (A)'', ``clause (iv)'' and ``paragraph
(1)(A)'', respectively each place it appears.
(d) Other Corrections.--Effective as if included in the
enactment of section 521(c) of BIPA, section 1154(e) (42
U.S.C. 1320c-3(e)) is amended by striking paragraph (5).
(e) Effective Date.--Except as otherwise provided, the
amendments made by this section shall be effective as if
included in the enactment of BIPA.
SEC. 510. CONFORMING AUTHORITY TO WAIVE A PROGRAM EXCLUSION.
The first sentence of section 1128(c)(3)(B) (42 U.S.C.
1320a-7(c)(3)(B)) is amended to read as follows: ``Subject to
subparagraph (G), in the case of an exclusion under
subsection (a), the minimum period of exclusion shall be not
less than five years, except that, upon the request of the
administrator of a Federal health care program (as defined in
section 1128B(f)) who determines that the exclusion would
impose a hardship on individuals entitled to benefits under
part A of title XVIII or enrolled under part B of such title,
or both, the Secretary may waive the exclusion under
subsection (a)(1), (a)(3), or (a)(4) with respect to that
program in the case of an individual or entity that is the
sole community physician or sole source of essential
specialized services in a community.''.
SEC. 511. TREATMENT OF CERTAIN DENTAL CLAIMS.
(a) In General.--Section 1862 (42 U.S.C. 1395y) is amended
by inserting after subsection (c) the following new
subsection:
``(d)(1) Subject to paragraph (2), a group health plan (as
defined in subsection (a)(1)(A)(v)) providing supplemental or
secondary coverage to individuals also entitled to services
under this title shall not require a medicare claims
determination under this title for dental benefits
specifically excluded under subsection (a)(12) as a condition
of making a claims determination for such benefits under the
group health plan.
``(2) A group health plan may require a claims
determination under this title in cases involving or
appearing to involve inpatient dental hospital services or
dental services expressly covered under this title pursuant
to actions taken by the Secretary.''.
(b) Effective Date.--The amendment made by subsection (a)
shall take effect on the date that is 60 days after the date
of the enactment of this Act.
SEC. 512. MISCELLANEOUS REPORTS, STUDIES, AND PUBLICATION
REQUIREMENTS.
(a) GAO Reports on the Physician Compensation.--
(1) Sustainable Growth Rate and Updates.--Not later than 6
months after the date of the enactment of this Act, the
Comptroller General of the United States shall submit to
Congress a report on the appropriateness of the updates in
the conversion factor under subsection (d)(3) of section 1848
of the Social Security Act (42 U.S.C. 1395w-4), including the
appropriateness of the sustainable growth rate formula under
subsection (f) of such section for 2002 and succeeding years.
Such report shall examine the stability and predictability of
such updates and rate and alternatives for the use of such
rate in the updates.
(2) Physician compensation generally.--Not later than 12
months after the date of the enactment of this Act, the
Comptroller General shall submit to Congress a report on all
aspects of physician compensation for services furnished
under title XVIII of the Social Security Act, and how those
aspects interact and the effect on appropriate compensation
for physician services. Such report shall review alternatives
for the physician fee schedule under section 1848 of such
title (42 U.S.C. 1395w-4).
(b) Prompt Submission of Overdue Reports on Payment and
Utilization of Outpatient Therapy Services.--The Secretary
shall submit to Congress as expeditiously as practicable the
reports required under section 4541(d)(2) of the Balanced
Budget Act of 1997 (relating to alternatives to a single
annual dollar cap on outpatient therapy) and under section
221(d) of the Medicare, Medicaid, and SCHIP Balanced Budget
Refinement Act of 1999 (relating to utilization patterns for
outpatient therapy).
(c) Annual Publication of List of National Coverage
Determinations.--The Secretary shall provide, in an
appropriate annual publication available to the public, a
list of national coverage determinations made under title
XVIII of the Social Security Act in the previous year and
information on how to get more information with respect to
such determinations.
The SPEAKER pro tempore. Pursuant to the rule, the gentlewoman from
Connecticut (Mrs. Johnson) and the gentleman from California (Mr.
Stark) each will control 20 minutes.
The Chair recognizes the gentlewoman from Connecticut (Mrs. Johnson).
Mrs. JOHNSON of Connecticut. Mr. Speaker, I yield 10 minutes to the
gentleman from Louisiana (Mr. Tauzin), and I ask unanimous consent that
he be allowed to control that time.
The SPEAKER pro tempore. Is there objection to the request of the
gentlewoman from Connecticut?
There was no objection.
Mrs. JOHNSON of Connecticut. Mr. Speaker, I yield myself such time as
I may consume.
Mr. Speaker, Secretary Thompson said about Medicare, ``Complexity is
over the system, criminalizing honest mistakes, and driving doctors,
nurses, and other health care professionals out of the program.''
I agree.
Medicare and Medicaid are governed by 132,000 pages of regulations.
That is 3 times the IRS Code and its regulations and the result is
exactly as the Secretary described.
Memorial Hospital in Gonzales, Texas has 33 beds and 20 billing
staff. Northwestern Memorial Hospital in Chicago just hired 26 new
full-time employees to meet new regulatory requirements.
At a time when we need Medicare dollars for more nursing care,
prescription drugs, annual physicals, and new systems to help seniors
manage multiple chronic illnesses, we cannot in good conscience ignore
the costly administrative burdens and the multitude of injustices being
heaped on Medicare doctors, hospitals, home health care providers,
nursing homes, and other providers by a literal explosion of complex
law, regulation directives, and paperwork.
To address what I consider to be a crisis endangering the ability of
small providers and many doctors to continue to serve our Nation's
seniors, last January my subcommittee began taking a hard look at
provider complaints. Today we bring to you a bipartisan bill to address
the severe problems that have developed in Medicare.
The bill before us does many radical things. It disciplines the
regulatory process so regulations will be issued through a predictable
and timely process, with provider input before proposed regulations are
made public.
Another radical thing it does, it stops, it prohibits government from
imposing regulations retroactively. There will be no more changing the
rules of the game and then punishing providers for noncompliance. It
prohibits, read that ``stops,'' government from imposing sanctions and
demanding repayment if they provided care to seniors in compliance with
written guidance from the government. It speeds up the process Medicare
uses to set payments for new diagnostic and treatment technologies by
creating a Council of Technology and Innovation. It requires a simple
process to correct technical error, relieving our caregivers of all the
paperwork and severe cash flow problems that result from the laborious
appeals process, a killer of small providers.
Radically, we require through this bill that the people who process
payments for Medicare services answer questions accurately. GAO found
that these contractors answered only 15 percent of routine questions
accurately, and, worse yet, 32 percent of provider questions were
answered completely inaccurately.
By setting performance standards in competitive contracting, Medicare
can assure better-quality provider support services.
Under this bill, doctors get fairer treatment when audited for
billing inaccuracy. They will get explanations, the right to discuss
coding differences, and written explanations when differences remain.
This should stop the arbitrary decisions that result in tens of
thousands of dollars of unjust fines.
When a physician who is responsible for running the Medicare program
tells me she cannot tell the difference between a comprehensive
physical and a detailed physical, two entirely different levels of care
for billing purposes, should we be surprised that doctors who make
coding errors are frustrated and angered by Medicare's arbitrary,
confrontational audits by nonmedical people and its complex, irrational
documentation requirements?
{time} 1700
I am proud that this is a bipartisan bill. It has been developed with
the study and input of every member of the Ways and Means Subcommittee
on Health, and then the follow-on input of the Committee on Energy and
Commerce, Republicans and Democrats, as well as the administration and
the Inspector General.
I want to especially thank John McManus, Jennifer Baxendell, Deborah
[[Page H8794]]
Williams, Joel White, Cybele Bjorklund and Carl Taylor, our Republican
and Democratic staff members of the Committee on Ways and Means,
because this has been an incredibly time-consuming, work-intensive
bill. Without their endless attention to detail and thoughtful, sound
judgments, it would not be before us today.
Please support H.R. 3391. It is a giant step toward a stronger
Medicare program.
Thank Yous on H.R. 3391
legislative counsel
Ed Grossman.
Pierre Poisson.
congressional research service
Siby Tilson.
congressional budget office
Tom Bradley.
Alexis Ahlstrom.
ways and means minority
Cybele Bjorklund.
Carl Taylor.
energy and commerce staff
Pat Morrisey.
Erin Kuhls.
Julie Corcoran.
Bridgett Taylor.
Karen Folk.
Amy Hall.
Susan Christensen.
Jayna Gadomski.
dept. of health and human services
Staff.
Mr. Speaker, I reserve the balance of my time.
Mr. STARK. Mr. Speaker, I ask unanimous consent that at the
conclusion of 10 minutes of my time that 10 minutes be yielded to the
gentleman from Ohio (Mr. Brown) for the purposes of control.
The SPEAKER pro tempore (Mr. Culberson). Is there objection to the
request of the gentleman from California?
There was no objection.
Mr. STARK. Mr. Speaker, I yield myself such time as I may consume.
The bill we are moving today embodies basically the way Congress used
to work, with the majority and minority working together to enact
improvements to the Medicare program. On this bill, the Medicare
Regulatory and Contracting Reform Act, both sides have worked closely
with the administration, with providers, consumers groups and others.
It has been a bipartisan, consultative process as it should be.
In addition, Mr. Speaker, I think it is important to acknowledge the
outstanding leadership and hard work of the gentlewoman from Nevada
(Ms. Berkley). She brought this matter to the attention of Congress and
has shepherded it along the way and has been an invaluable help in
seeing this legislation be completed.
The legislation contains important beneficiary provisions which I
think are important to emphasize. We have established a beneficiary
ombudsman program that will provide a voice for beneficiaries within
the Centers for Medicare and Medicaid Services, now CMS, I still want
to call it HCFA, but will enable that agency to better respond to and
anticipate beneficiary needs. As every Member knows, Members must now
help Medicare beneficiaries with their casework because no office
really exists within CMS to help the beneficiaries.
We have also established a single national toll free telephone
number, 1-800-MEDICARE, I hope it answers, for the beneficiaries to
call with their questions; and this single telephone number will
replace the many pages of telephone numbers that beneficiaries now must
sort through in the Medicare handbook to find the correct place to call
with their questions.
I am particularly pleased that a demonstration program will place
Medicare staff in Social Security field offices to answer beneficiary
questions and provide assistance on Medicare issues. Beneficiaries are
accustomed to going to Social Security offices, as indeed are the
caseworkers in our local offices, for help and assistance in these
programs. This will help by having Medicare assistance for them in
these same offices.
I would also like to suggest accolades for the gentleman from
Pennsylvania (Mr. English), who has worked with me on a bill to protect
nurses and other health care workers from needle stick injuries by
requiring the use of safe needle technology in public hospitals, as
well as has been required by those hospitals under OSHA supervision. We
have been working on this issue for years, and we have made significant
progress; and this legislation completes those efforts, and this
provision in the bill will save lives. It is an important component of
the bill.
Importantly, this bill delays for a year the requirement in law that
would begin in 2002 to lock beneficiaries into the Medicare+Choice
plans, and under this legislation beneficiaries would continue to be
able to enroll in and disenroll from these plans throughout the year. I
would strongly prefer to repeal the lock-in altogether, but I believe a
1-year delay is a good start.
Finally, the bill takes long overdue steps to fundamentally reform
Medicare's contracting system. We have worked on this for years. I am
confident under this new system we can get a better deal for our
government and still maintain quality service and performance goals for
the beneficiary.
This will place additional administrative burdens on CMS; and as we
discussed earlier today with the gentleman from Ohio (Mr. Hobson) and
others, we will continue to see that Labor HHS appropriation bills
provide modest increases in administrative resources for CMS to
complete this work.
I guess that said, Mr. Speaker, I have to add that I think it is
somewhat disgraceful that this ends up being our really only Medicare
legislation this year. We started the 107th Congress with a record
budget surplus and the ability to easily enact and pay for
comprehensive, affordable prescription drug coverage and other
significant improvements through all Medicare beneficiaries, in
addition to funding other key national priorities in education and
other social areas.
The surplus, instead, was squandered on excessive tax breaks for the
wealthy, and it is now clear that the Bush recession that began last
spring and the Republican tax package have sealed the deal. Our
legislative record at the end of the first session of the 107th
Congress is a tribute to misplaced priorities.
I look forward to changing that and working with my colleagues as we
have on this bill on the Subcommittee on Health to see if in the next
session of Congress we can reverse this course and improve the Medicare
system as it has long been set aside from doing.
Mr. Speaker, I reserve the balance of my time.
Mrs. JOHNSON of Connecticut. Mr. Speaker, it is my privilege to yield
1\1/2\ minutes to the gentlewoman from Washington (Ms. Dunn), a
hardworking member of our subcommittee.
Ms. DUNN. Mr. Speaker, I rise in support of this bill to provide
regulatory relief to doctors throughout the Nation. I want to thank the
gentleman from California (Mr. Thomas) for being involved in developing
this legislation; but I want to give special kudos to the gentlewoman
from Connecticut (Mrs. Johnson), the subcommittee chairman, and the
gentleman from California (Mr. Stark), her ranking member, because they
worked together. This is bipartisan and we are very pleased with the
result of our work. It will cost nothing, but it does true regulatory
reform.
I also want to thank my colleagues, the gentleman from Maryland (Mr.
Ehrlich) and the gentleman from Washington (Mr. McDermott), for working
with me to ensure that in this bill our seniors have access to the
latest clinical laboratory tests.
I am very pleased that this regulatory relief bill creates a
transparent, timely and public process at CMS to evaluate and to
incorporate new technologies into the Medicare program. This is a
critical step in ensuring that doctors have every tool available to
assist our seniors.
Medical innovations are moving too fast to wait for Medicare's
coverage and payments. This is especially true for new laboratory
tests, a field that has been rapidly advancing in innovations
exponentially.
The quality of our health care system here in the United States
depends on our ability to prevent, diagnose, and treat illnesses and
diseases. Support this legislation so that our Nation's seniors will be
able to access breakthrough tests that can help save their lives.
Mr. STARK. Mr. Speaker, I am pleased to yield 2 minutes to the
gentlewoman from Nevada (Ms. Berkley), who is one of the originators of
this legislation.
Ms. BERKLEY. Mr. Speaker, I rise today in strong support of H.R.
3391, to
[[Page H8795]]
provide long-awaited Medicare regulatory relief to health care
providers. I would like to particularly thank my colleagues who have
worked so hard to make this piece of legislation a reality, the
gentlewoman from Connecticut (Mrs. Johnson); the gentleman from
California (Mr. Stark), especially for his very generous praise, I
appreciate that; the gentleman from Ohio (Mr. Brown); the gentleman
from Florida (Mr. Bilirakis); the gentleman from New York (Mr. Rangel);
the gentleman from California (Mr. Thomas); the gentleman from
Louisiana (Mr. Tauzin); and the gentleman from Michigan (Mr. Dingell)
for their hard work on this legislation. I would especially like to
thank the gentleman from Pennsylvania (Mr. Toomey) for his leadership
on this issue.
I became involved with this legislation when doctor after doctor in
the Las Vegas area came to me with horror stories of how they had been
treated by HCFA and how it had inhibited their ability to care for
their patients. The cornerstone of health care in this country is the
doctor-patient relationship, and many of us have fought consistently to
maintain the integrity of this fundamental and very personal
relationship.
Over the years, excessive paperwork and overburdensome government
regulation have interfered with that relationship. This legislation
will help cut red tape and bureaucratic excesses so doctors can spend
more time with their patients and less time on paperwork.
Reform is important to the doctors, important to our seniors, and
vital to the health of Medicare. While this bill, as the gentleman from
California (Mr. Stark) says, does not include everything I had hoped
for, it is a very significant step in the right direction. I am proud
that my name is associated with this bill, and I urge all of my
colleagues to support it.
Mrs. JOHNSON of Connecticut. Mr. Speaker, I yield myself such time as
I may consume.
I would like to thank the gentlewoman from Nevada (Ms. Berkley) and
the gentleman from Pennsylvania (Mr. Toomey), who is going to speak
later, for their hard work on behalf of physicians, most of which is
reflected in this legislation.
Mr. Speaker, I yield 2 minutes to the gentleman from New York (Mr.
Gilman).
(Mr. GILMAN asked and was given permission to revise and extend his
remarks.)
Mr. GILMAN. Mr. Speaker, I am pleased to rise in support of H.R.
3391. This legislation makes extensive changes and modifications in the
regulatory and contracting systems within Medicare, and I commend the
gentlewoman from Connecticut (Mrs. Johnson) and the gentleman from
California (Mr. Stark) for their work on this measure.
Along with many of our colleagues, I have heard in recent years that
increasing drumbeat of criticism, from health care providers and
patients in my own district, over a cumbersome Medicare system that was
slow to adapt to rapid changes in health care, cumbersome in its
management of existing benefits, and required far too much time spent
in processing paperwork for claims reimbursements.
Moreover, there is also a widespread perception that the Centers for
Medicare and Medicaid Services, formerly known as HCFA, has in the past
issued new regulations in an arbitrary and capricious manner, with
little regard for the interests and situations of those health care
providers who would be impacted by a regulatory change. The fact that
many of these changes came without sufficient accompanying explanations
further exacerbated problems for providers and patients who often have
difficulty divining the arcane and often confusing world of Medicare
regulations.
There is also the issue of the Medicare contracting program which, in
this age of open government, remains a closed system. This has fostered
inefficiency and prevented the Medicare contracting program from
keeping up with rapid developments in the delivery of health care in
the private sector.
H.R. 3391 is a bipartisan solution to address these problems and to
serve as the first step in modernizing overhaul of the Medicare system,
which streamlines the regulatory process, reforms the contracting
system to make it more open and accountable, expanding outreach and
education to better inform both providers and patients of their rights
and responsibilities, and makes important improvements to the appeals
and recovery process.
Mr. Speaker, Medicare, along with the Social Security system,
represents the most popular and successful program for seniors ever
enacted. This bill will ensure the continued success of the system by
making it easier for Medicare health care providers to operate within
the system, as well as to offer relief through the reduction of
paperwork burdens.
This measure will both reform the Medicare system and improve
confidence in its future on the part of both providers and patients.
Accordingly, I urge my colleagues to fully join in supporting this
measure.
Mr. STARK. Mr. Speaker, I am pleased to yield 2\1/2\ minutes to the
gentlewoman from Florida (Mrs. Thurman), who has worked diligently on
this legislation in behalf of all the seniors, most of whom I think
reside in her district in Florida, but for all of the rest of us
seniors who do not.
Mrs. THURMAN. Mr. Speaker, I want to thank the gentleman from
California (Mr. Stark) for yielding me this time and those nice
remarks, but I also want to thank the gentlewoman from Connecticut
(Mrs. Johnson) and the gentleman from Florida (Mr. Bilirakis) and the
gentleman from Ohio (Mr. Brown). Without their diligence and all of the
committees working together, this piece of legislation would not have
been brought forward to this floor.
People sometimes do not realize how complicated Medicare can be at
times; and when one is trying to balance beneficiaries and the doctors
and the contractors, sometimes we have to work through some very
difficult situations.
I will tell my colleagues that in talking with my doctors in the
fifth district, one of the things that I heard over and over again was
the sheer volume and complexity of the Medicare regulations and what it
has meant to them. Most of what it means to them is they do not have
the time to spend with their patients because they are spending so much
time on the complexities.
Another issue that I think is very important about this is that these
doctors also tell me, in talking with their staffs and their offices,
that their administrative expenses can represent as much as 25 percent
of their cost. That means, again, the cost to Medicare and the dollars
that we have available is not being spent on the patient, but on
administrative costs. So hiring an extra person, doing something more
for the patient can sometimes cause a problem.
In seeing that in this piece of legislation, one of the things that
we fought very hard for and I think is going to be a wonderful
opportunity for us to look at in the future is the demonstration
program that we provided to on-site technical assistance for doctors to
help with the complexity of Medicare coding.
{time} 1715
We heard an awful lot about that. So this was an issue we thought put
them on site, they get the opportunity to really sit down with folks
and figure out where their problems might be.
Then I also want to thank the gentleman from Minnesota (Mr. Ramstad)
for his leadership on a piece of legislation that he and I introduced
for a couple of years in a row dealing with technology. And so what we
have done in this bill is we have actually set up a Council for
Technology and Innovation within CMS. This council will have an
executive coordinator who acts as a single point of contact between CMS
and outside entities to help explain coverage, coding, and payment
questions about new and innovative technologies.
We are all very proud of what happens in this country with
innovation. So I would just like to take this opportunity to thank all,
and our staffs, that were involved in this, and ask for my colleagues'
support for this bill.
Mr. STARK. Mr. Speaker, I yield back the balance of my time.
Mrs. JOHNSON of Connecticut. Mr. Speaker, I yield myself such time as
I may consume.
Mr. Speaker, I conclude by thanking the gentleman from California for
his
[[Page H8796]]
cooperation throughout this long process, and our joint efforts, and
also his staff, as I did earlier. They have worked very, very long
hours on this.
And I would like to say that this bill is only the beginning of
strengthening Medicare. The administration is organizing task forces
with real-world providers on them to rethink the most time consuming
forms that health care providers have to fill out. If we can collect
only the data we need, streamline and simplify billing systems and
administrative processes, we can literally free millions of hours of
caregiver time for the benefit of our seniors. It will take the
leadership of Secretary Thompson and Administrator Scully, and it will
take long hearings and attention to detail next year and the year
after, working together, our committee and the Committee on Energy and
Commerce.
Together, we can make Medicare a model of smart, responsive
government and reverse the belief expressed by so many in our hearings,
but summed up by a doctor who said, ``Medicare has lost a sense of
fairness, due process and common sense.'' We intend to restore those
qualities to the most beloved and important program in our Nation not
just for seniors but for their children and grandchildren as well.
Mr. TAUZIN. Mr. Speaker, I yield myself such time as I may consume,
and I rise today in strong support of H.R. 3391, the Medicare
Regulatory Contracting Reform Act of 2001.
The bill captures the best of two bills. The legislation reported out
of the Committee on Ways and Means, and H.R. 3046, the Medicare RACER
Act, which was reported from the Committee on Energy and Commerce. It
represents the diligent work of the many Members of Congress to make
the Medicare program more flexible and less bureaucratic. It is also a
shining example of what can be achieved when we have true bipartisan
cooperation.
Earlier this year, the Committee on Energy and Commerce began a
project we called ``patients first.'' The idea was indeed to try to see
if we could not reform the regulations and the burdens at CMS to indeed
put patients first; to make sure that physicians and health care
providers, who are forced to spend too much time filling out forms and
trying to learn the rules of the road and the changing rules of the
road, might in fact get some relief.
Our committee held a number of hearings and we disseminated surveys
to elicit input from beneficiaries and health care providers about the
complexities of the Medicare program and its rules. We also brought
together beneficiary groups, provider associations, and government
officials to talk about regulatory relief.
Because of the leadership particularly of the gentleman from
Pennsylvania (Mr. Toomey) and the gentlewoman from Nevada (Ms.
Berkley), we are standing here today with an opportunity to vote on
legislation that will enable doctors to spend more of their time caring
for patients, putting patients first, and putting in less time
completing paperwork for the government and bureaucrats.
The Toomey-Berkley Medicare RACER Act was successfully reported from
the Subcommittee on Health, thanks to the dedication and commitment of
the chairman, the gentleman from Florida (Mr. Bilirakis) and the
gentleman from Georgia (Mr. Norwood). It was also successfully reported
out of the full Committee on Energy and Commerce. It requires
contractors to provide general written responses to written inquiries
from beneficiaries and health care providers within 45 business days,
and it requires Medicare contractors to notify health care providers of
problems that have been identified in a probe sample, and to alert
providers as to the steps they should take to resolve the problems.
Each of these improvements is significant and each of them has been
included in the bill we are about to vote on today. And I wish to thank
my colleagues from the Committee on Ways and Means for working so well
with the gentleman from Florida (Mr. Bilirakis), the gentleman from
Ohio (Mr. Brown), the gentleman from Michigan (Mr. Dingell), and myself
to consolidate the work of our two committees. Lord knows, we need to
thank the staff who put in hours and hours and hours, late nights and
weekends, to bring all this together.
We worked to strike an appropriate balance between the need for
regulatory relief and the government's obligation to protect taxpayer
funds from waste, fraud, and abuse. This captures the hard work of both
committees. It has broad support with the beneficiary groups, the
health care community and, by the way, the administration.
I urge my colleagues to join us in full support of the legislation.
Mr. Speaker, I reserve the balance of my time.
Mr. BROWN of Ohio. Mr. Speaker, I yield myself such time as I may
consume.
I am pleased to join my colleagues both on the Committee on Ways and
Means and the Committee on Energy and Commerce in support of H.R. 3391.
I want to thank my colleagues, the gentleman from Pennsylvania (Mr.
Toomey) and the gentlewoman from Nevada (Ms. Berkley) for taking on
this daunting task. In a resource-limited environment, they were
determined to identify reforms in Medicare operations that serve the
best interests of beneficiaries and respond to a host of legitimate
issues raised by providers, while making sure to in no way compromise
the program's efforts to fight fraud, waste and abuse. It is a tall
order and the gentleman from Pennsylvania and the gentlewoman from
Nevada did an excellent job.
This bipartisan legislation was a collective effort, to say the
least. It was written and rewritten and rewritten with the input of the
health care community, consumer advocates, the committees of
jurisdiction, and the administration. It took months, it took difficult
compromises, but the final product will make a tangible, positive
difference for beneficiaries and providers alike.
Key provisions of the bill bolster communications between and among
the Medicare program and its beneficiaries and providers, improve the
Medicare appeals process, and establish new performance standards for
Medicare contractors.
No one is well served when providers either cannot get the
information they need or coverage policies are unclear, or anti-fraud
and abuse measures elicit such mistrust that providers second-guess
every treatment decision. This legislation takes those issues seriously
and does something about them. Importantly, the bill also provides and
improves Medicare responsiveness to its 39 million beneficiaries.
I want to thank my colleagues, the gentleman from Louisiana (Mr.
Tauzin), the gentleman from Florida (Mr. Bilirakis), and the gentleman
from Michigan (Mr. Dingell) especially, and staff members Bridgett
Taylor, Karen Folk, Amy Hall, and on my staff, Katie Porter and Ellie
Dehoney for fighting tooth and nail to ensure this legislation, in
effect, keeps our eye on the ball. They made sure the bill contains
provisions that relate directly to Medicare's fundamental mission, to
make sure seniors and disabled individuals receive the care that they
need.
Thanks largely to their resolve and hard work, this legislation
ensures that seniors know definitively and up front whether Medicare
covers the health care their doctor recommends. Especially for low-
income seniors, that is a crucial and overdue change in Medicare rules,
and I appreciate the negotiated work that we all could do on that
issue.
The Medicare fee-for-service program is the largest insurance program
in the United States, serving 36 million Americans, contracting with
almost 1 million providers. Recent surveys document what most of us
know from speaking with our constituents; that is, an overwhelming
majority of Medicare beneficiaries trust in and are very satisfied with
their coverage under fee-for-service Medicare.
Americans overwhelmingly oppose Republican efforts to privatize this
system, Americans overwhelmingly reject Republican efforts to allow
more insurance company intrusion into fee-for-service Medicare, and
Americans overwhelmingly want prescription drug coverage, an area where
this Congress and the Bush administration have so far failed miserably
to achieve. But since that level of trust and satisfaction the people
in this country have for Medicare is a fundamental measure of this
program's success, changing the
[[Page H8797]]
Medicare rules was a high-stakes exercise that we, bipartisanly, were
able to achieve.
I am confident that the changes encompassed in this bill are in the
best interest of beneficiaries, most importantly; also to providers and
taxpayers, and I encourage my colleagues to support it.
Mr. TAUZIN. Mr. Speaker, I am pleased to yield 2 minutes to the
gentleman from Florida (Mr. Bilirakis), the distinguished chairman of
the Subcommittee on Health of the Committee on Energy and Commerce.
Mr. BILIRAKIS. Mr. Speaker, I too rise today in support of patients.
The legislation before us is good for patients. By reducing regulatory
burdens and easing paperwork requirements, this legislation allows
doctors to spend more of their time providing health care and less of
their time wading through pages over rules and regulations.
At the beginning of this session, the Committee on Energy and
Commerce launched an ambitious bipartisan initiative to reform the
Centers for Medicare and Medicaid Services and to put patients first.
This initiative became known as the ``patients first'' project. Much of
the legislation before us today stems from the committee's work on this
project, which was led by my colleague, the gentleman from Georgia (Mr.
Norwood). Foundational to this work was the prior work of the gentleman
from Pennsylvania (Mr. Toomey) and the gentlewoman from Nevada (Ms.
Berkley).
The bill we will vote on today includes many of the provisions of the
Medicare RACER Act, which was favorably reported out of my Subcommittee
on Health as well as the full Committee on Energy and Commerce last
month. It includes improvements focused on the Emergency Medical
Treatment and Labor Act. Also included in the legislation is important
language regarding advanced beneficiary notices. This language allows
physicians to find out whether a specific physician service they are
providing will be covered by Medicare before delivering the care.
Mr. Speaker, I would like to thank all of the staff who put so much
time into this legislation, especially Erin Kuhls, Julie Corcoran,
Nandan Kenkeremath, Pat Morriset, Anne Esposito, Steve Tilton, Karen
Folk, Amy Hall, and, of course, last but not least, Karen Taylor.
H.R. 3391 is good for patients and providers alike, and I encourage
my fellow colleagues to vote in favor of this legislation today.
Mr. BROWN of Ohio. Mr. Speaker, I yield 3 minutes to the gentleman
from Michigan (Mr. Dingell), the ranking Democrat on the Committee on
Energy and Commerce that was here and presided over this House when
Medicare was passed in 1965.
(Mr. DINGELL asked and was given permission to revise and extend his
remarks.)
Mr. DINGELL. Mr. Speaker, I thank my good friend for yielding me this
time, and I rise today to speak in favor of H.R. 3391, the Medicare
Regulatory and Contracting Reform Act of 2001. I rise also to praise my
colleagues on the committee, the distinguished chairman of the
committee, the distinguished chairman of the subcommittee, and my good
friend, the gentleman from Ohio, Mr. Brown and others, including the
very fine staffs on both sides of the aisle that worked so hard.
The legislation is a product of bipartisan collaboration between two
great committees, the Committee on Energy and Commerce and the
Committee on Ways and Means, and also with seniors' groups, providers,
and others. This is a bill which is fair. It strikes a balance between
addressing the program administration concerns of beneficiaries and
providers and ensuring integrity of the program itself.
This legislation makes a number of wise improvements in the Medicare
program. It gives the Centers for Medicare and Medicaid Services, CMS,
additional flexibility with claims processors. It also strengthens the
independent standards for appeals. It entitles the beneficiaries and
the reviewers to ensure independent appeals are really independent, are
fair, and in fact take place.
I do wish again to commend my friend, the gentleman from Louisiana
(Mr. Tauzin), the gentleman from Florida (Mr. Bilirakis), the staff at
CMS, as well as my good friend the gentleman from Ohio, for their work
on this, and also our friends on the Committee on Ways and Means and
the majority and minority staff of both committees for the work they
have done.
In addition to strengthening the requirements for organizations that
will be reviewing appeals, we have improved upon notices that
beneficiaries receive when a service is denied, making this situation
more user friendly and understandable to beneficiaries who are most
often in their later years. More importantly, we have developed a
process where seniors can learn whether or not a particular item and
service is covered under Medicare before they are financially committed
to that service, something which is not presently the case and which
creates immense hardship either by denying benefits or imposing
unanticipated costs on senior citizens on fixed and limited incomes.
Currently the only way a senior can find out if Medicare covers an
item or a service is to potentially risk thousands of his or her
dollars by getting the service and then pray Medicare will pay the
claim. Obviously, this is unfair, and many seniors choose not to get a
service rather than take a chance that Medicare will not cover it. This
legislation fixes this, a situation which is clearly unjust. And while
the provision as it stands now is limited only to physician service in
order to meet scoring requirements, I hope, and I intend that in the
future we will give the beneficiaries this right for all Medicare
services.
{time} 1730
Mr. Speaker, I urge my colleagues to support the bill. Medicare is
the most socially successful and valuable program of this day. The
program works for beneficiaries and providers alike, but we must ensure
that it continues to be a success. The Medicare Regulatory and
Contracting Reform Act will do just that.
More remains to be done, and I look forward to working with the same
fine colleagues that I did to bring this about. The Medicare
legislation that we have before us ensures that Medicare fee for
services will continue to serve beneficiaries, and it will cause
further approval and satisfaction with one of our great legislative
accomplishments, Medicare.
Mr. TAUZIN. Mr. Speaker, I yield 2 minutes to the gentleman from
Pennsylvania (Mr. Toomey), the author of this legislation, who,
together with the gentlewoman from Nevada (Ms. Berkley), put together
240 co-sponsors.
(Mr. TOOMEY asked and was given permission to revise and extend his
remarks.)
Mr. TOOMEY. Mr. Speaker, I thank the gentleman from Louisiana (Mr.
Tauzin) for yielding me the time and also thank the gentleman for
recognizing my efforts in the area of Medicare regulatory reform and
for inviting me to join in with the Committee on Energy and Commerce in
developing this terrific compromise legislation.
Since my first term in Congress, I have been working on Medicare
regulatory reform to help alleviate some of the burdens that the health
care providers carry when dealing with Medicare's bureaucracy. We need
to give health care providers due process rights so they are not
treated like criminals when they make honest mistakes. We need to make
billing procedures easier for providers to understand and comply with
and reduce the huge volume of paperwork that staff have to contend
with.
This is important so health care providers can spend more time caring
for their patients and less time dealing with bureaucracy. This bill
addresses these problems. It is a step in the right direction, but it
is a modest step. We need to do more. For instance, we need profound
Medicare reform. As long as we have a Medicare bureaucracy that
enumerates, regulates, and prices every conceivable medical procedure,
we will continue to have enormous costs and inefficiencies in complying
with these staggering regulations. But we cannot wait until we fully
overhaul Medicare to provide the significant regulatory relief of this
bill.
Mr. Speaker, I thank my colleagues who made this bill possible: the
gentlewoman from Nevada (Ms. Berkley), the gentlewoman from Connecticut
(Mrs. Johnson), the gentleman from California (Mr. Stark), the
gentleman
[[Page H8798]]
from California (Chairman Thomas), the gentleman from New York (Mr.
Rangel), the gentleman from Michigan (Mr. Dingell), the gentleman from
Florida (Mr. Bilirakis), and the gentleman from Ohio (Mr. Brown).
I also thank some staff members, Gary Blank, formerly of my staff,
Kelly Weiss, currently with my staff, and Pat Morrisey of the commerce
staff, in particular.
Mr. Speaker, we take a big step forward today. I hope the same
combination of the bipartisan group that worked on this bill can come
back next year and do more work for health care providers and for their
patients; but in the meantime, I urge my colleagues to pass H.R. 3391
and give the health care community some of the regulatory relief that
they need and deserve.
Mr. BROWN of Ohio. Mr. Speaker, I yield 3 minutes to the gentleman
from Texas (Mr. Green).
Mr. GREEN of Texas. Mr. Speaker, I rise today in support of the
Medicare Regulatory and Contracting Reform Act. The legislation makes a
number of important changes to the way that Medicare does business, and
it comes not a second too late.
For years we have been hearing from doctors and providers who
complain that they are spending more time dealing with Medicare
paperwork than they are treating patients. They express frustration
where simple mistakes escalated into full-fledged investigations, where
well-intentioned providers were penalized and accused of defrauding the
system, and insufficient appeals process made it difficult for
providers to make their case. Many are ready to stop treating Medicare
patients altogether.
The Committee on Energy and Commerce passed legislation earlier this
year that addresses many of these issues and would have made
improvements in the Medicare system. Working with the Committee on Ways
and Means, we were able to come up with a consensus bill that addressed
the problem and makes the Medicare program more navigable for our
Medicare providers. This legislation streamlines key Medicare processes
so that providers are not trapped in a maze of confusing regulations.
It improves provider information and education so that doctors know
who to call and what to do when they have trouble with a claim. The
legislation also reforms the contracting system by giving the Secretary
greater flexibility in selecting contractors, assigning contractor
functions, and permitting competitive contracting.
There are many significant changes in the bill that will improve the
Medicare system for providers and beneficiaries alike, and I support
the legislation. I urge my colleagues to support this legislation.
Mr. TAUZIN. Mr. Speaker, I yield 2 minutes to the gentleman from
Georgia (Mr. Norwood).
Mr. NORWOOD. Mr. Speaker, I rise today in strong support of H.R.
3391. I commend it to all Members of this body, and I hope every Member
will vote for this bill. No doubt the outcome of this vote will be
noted by the body across the way, and it is important that we vote for
something that is needed so badly.
Mr. Speaker, I thank the gentleman from Louisiana (Mr. Tauzin) and
the gentleman from Florida (Mr. Bilirakis) and the gentleman from
Michigan (Mr. Dingell) and the gentleman from Ohio (Mr. Brown). And a
great deal of credit and thanks should go to the Committee on Ways and
Means, especially to the gentlewoman from Connecticut (Mrs. Johnson).
On the commerce staff, I thank Pat Morrisey. He put up with a lot to
get us here, and Erin Kuhls, Julie Corcoran, and Bridgett Taylor. They
worked so hard to get us to where we are today.
Many Members have mentioned the good things that are in this bill.
There are a lot of good things. I particularly would like to highlight
the benefit that will be made available to patients for them to
actually know if Medicare will cover a benefit that is a covered
benefit. That is called preauthorization or predetermination, and
probably in the end there is not much more in this bill that will be
more important to the quality of care for Medicare patients to actually
get treated.
But I note, as the gentlewoman from Connecticut (Mrs. Johnson) has
said, that this is a first step. I hope we will all recognize that, and
I would like to have a colloquy with the gentlewoman from Connecticut
(Mrs. Johnson) and the gentleman from Florida (Mr. Bilirakis); and I
will ask both the question at the same time.
Although many good things have been done in this bill, this is a
first step and I want to be part of working these two committees
together next year and I would like to hear from both Members. Can we
plan to move forward next year?
Mrs. JOHNSON of Connecticut. Mr. Speaker, will the gentleman yield?
Mr. NORWOOD. I yield to the gentlewoman from Connecticut.
Mrs. JOHNSON of Connecticut. Mr. Speaker, I can guarantee the
gentleman that we will work together next year. We learned a lot this
year. We solved some problems that we can understand. We laid aside
what we could not understand. There is lots more work to be done to
make Medicare a smart and efficient program.
Mr. BILIRAKIS. Mr. Speaker, will the gentleman yield?
Mr. NORWOOD. I yield to the gentleman from Florida.
Mr. BILIRAKIS. Mr. Speaker, as the gentleman knows because he was in
the room last week, I put my life on the line in terms of a question
that was asked, and the gentleman from Louisiana (Chairman Tauzin) did,
too; not the chairman's life, my life, on the line.
I will not go quite that far this time around, but I feel very
strongly that this is a first step. There is a tremendous amount of
work to be done.
Mr. BROWN of Ohio. Mr. Speaker, I reserve the balance of my time.
Mr. TAUZIN. Mr. Speaker, I yield 1 minute to the gentleman from Iowa
(Mr. Ganske).
Mr. GANSKE. Mr. Speaker, I thank the gentleman for yielding me this
time.
Mr. Speaker, there is a provision that many have spoken of already
that actually was something that I brought up and proved to be one of
the more difficult things to work out between the two committees and
that was on the predetermination of benefits.
As a physician in the earlier 1990s when I was taking care of
Medicare patients, sometimes we would do a procedure where it might or
might not be considered medically necessary by Medicare. All that we
wanted was to know whether Medicare would cover this or not. So at that
time the data could be gathered together, send in the physical exam and
tests, and Medicare would give their opinion. Then they stopped doing
that. I think it scared a lot of patients from not having medically
necessary procedures.
Mr. Speaker, that has been worked out in this bill. I thank the
members of both committees and both parties for working on this. I
think this will be a big improvement for patients.
Mr. TAUZIN. Mr. Speaker, I yield such time as he may consume to the
gentleman from Indiana (Mr. Buyer).
Mr. BUYER. Mr. Speaker, I rise in support of the Medicare Regulatory
and Contracting Reform Act. I would like to express my appreciation to
the gentleman from Louisiana (Mr. Tauzin), the gentleman from Florida
(Mr. Bilirakis), the gentlewoman from Connecticut (Mrs. Johnson), the
gentleman from Michigan (Mr. Dingell), and the gentleman from Ohio (Mr.
Brown) for their assistance in working on the concern of dentists who
often file Medicare claims even though the dental services are not
covered by Medicare.
The provision in the bill seeks to help reduce the paperwork burden
on dentists and expedite payment for services from appropriate sources
of that payment. In addition, I am grateful that language can be worked
out that will assist the medical device manufacturing community,
enhancing the communications and cooperation between the Food and Drug
Administration and the Centers for Medicare and Medicaid Services. This
is an excellent bill, and I urge its passage.
Mr. CRANE. Mr. Speaker, I rise today in support of the Medicare
Regulatory and Contracting Reform Act of 2001. This bipartisan
legislation is the product of months of negotiations with the Center
for Medicare and Medicaid Services (CMS), Medicare providers,
beneficiaries, and the House Committees on Ways and Means and Energy
and Commerce.
This legislation is a first step in ensuring that the Medicare
program delivers quality care to Medicare beneficiaries. Today, the
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Medicare program has more that 110,000 pages of regulations governing
it. This bill begins to finally address how to hold CMS accountable for
its regulations and the costs they impose.
The Medicare Regulatory and Contracting Reform Act creates a more
collaborative, less confrontational relationship between providers and
CMS. It takes steps to decrease the amount of complex and technical
paperwork that is currently required so that providers will be able to
spend more time delivering care to patients rather than filling out and
filing federal forms. Finally, H.R. 3391 streamlines the regulatory
process, enhances education and technical assistance for Medicare
providers.
I was also pleased to see inclusion of a provision to prohibit group
health plans from requiring a Medicare claims determination for dental
benefits that are specifically excluded from Medicare coverage as a
condition of making a determination for coverage under the group health
plan. This requirement to me does not serve any purpose other than the
filing of needless paperwork and further delay payment to the dental
provider. This provision ensures that dentists do not have to submit
claims to the Medicare program (and thus enroll in the Medicare
program) when the services they are providing are clearly those that
are categorically excluded from coverage.
I urge my colleagues to join me in support of this legislation.
Mrs. CHRISTENSEN. Mr. Speaker, I rise in support of H.R. 3391, the
Medicare Regulatory and Contracting Reform Act. As a physician in
private practice for more than 20 years, I wholeheartedly applaud the
work of the Ways and Means Committee and the Energy and Commerce
Committee in moving legislation which lifts many of the burdens placed
on physicians by the Medicare program and allow us to put our patients
first.
Mr. Speaker, I can't tell you the number of times over the four and a
half years that I have been a member of this body that I have heard
horror stories from providers in my district regarding the cumbersome
and burdensome Medicare billing process. They only serve to remind me
of my personal experience in over 21 years of practice. Whether it is
undue delays in receiving payments or repeatedly questioning
information that was already provided, the current Medicare system
treats physicians as suspects and requires that we spend nearly half of
our time on needless paper work. It further makes hard working
providers the first targets for fee reductions, repudiating their long
years of training and hard work.
I applaud the authors of this legislation, Congresswoman Nancy
Johnson and Pete Stark of the Ways and Means Committee, as well as
Representatives Bilirakis, Sherrod Brown, Billy Tauzin and my friend
John Dingell for their support of doctors and the patients that they
serve. Indeed, Mr. Speaker, no less than the General Accounting Office
documented the statements that I can personally attest to regarding the
difficulties of dealing with the Medicare program, pointing out that
Medicare is a complicated program requiring endless directives and long
explanations and articles which are necessary to explain facet after
facet.
I urge my colleagues to support this badly needed bill which is but a
first step in addressing what are myriad problems with this important
health insurance program.
Mr. SHADEGG. Mr. Speaker, I rise today to support the Medicare
Regulatory and Contracting Reform Act. Since I have been in Congress, I
have constantly heard from hospitals and physicians about the guessing
game they must play in order to be compliant with Medicare regulations.
The paperwork that providers must complete both for private insurance
and for Medicare is overwhelming them. Where twenty years ago, it was
uncommon to have more than one administrative person working in a
physician's office, today it seems to be the norm to have multiple
employees handling claims. Like a punch-drunk fighter, our nation's
health care providers are dizzy from the barrage of notices, guidance,
and issuances from Medicare describing ever-changing policies and
regulations. Worse yet, many of these providers approach the billing
process with trepidation. Fearful that they may be audited or have
payments withheld, many physicians downcode so as to reduce their
potential exposure even though they legitimately deserve reimbursement
for a higher code. Moreover, a simple, honest mistake, providers fear,
will result in harsh penalties and send them into a regulatory spiral,
thus taking them away from their patients. This is one of the reasons I
was a cosponsor of the Medicare Education and Regulatory Fairness Act
and support the bill on the floor today. H.R. 3391 provides important
reforms of the Medicare system to streamline Medicare's regulatory
process, ease paperwork burdens, and improve Medicare's responsiveness
to beneficiaries and health care providers.
I am particularly pleased that H.R. 3391 includes provisions aimed at
improving the functioning of the Emergency Medical Treatment and Active
Labor Act, better known as EMTALA. While a well-intended provision to
ensure that patients coming to hospital emergency departments are not
shipped from hospital to hospital or ``dumped,'' EMTALA is now serving
as an impediment to hospital emergency department access, the exact
opposite of what the original legislation was intended to do. The
provisions I included at the Full Committee markup include recreating
the EMTALA task force, something suggested not only in the January 2001
Inspector General's report, but also in the June 2001 GAO report.
Physicians and providers are crying out for clarification and guidance
on how to comply with the myriad, confusing EMTALA regulations and this
task force will be charged to work synergistically to make the
regulations manageable. In addition, the bill on the floor today
implements another suggestion from the Inspector General, mandatory
peer review organization. Under current law, a peer review organization
must review any EMTALA deficiency or violation involving medical
treatment before a civil monetary penalty can be levied, but the same
does not apply to those providers facing removal from the Medicare
program. The Medicare Regulatory and Contracting Reform Act will
restore equity by requiring PRO review in the Medicare conditions of
participation. Last, the bill will require the Centers for Medicare and
Medicaid Services to notify providers directly when an EMTALA
investigation is closed.
Mr. Speaker, these are important provisions to address a complex
situation--emergency department overcrowding--and I thank Chairman
Tauzin for working with me in Committee as well as members of the Ways
and Means Committee as we merged the two committee bills.
Mr. UPTON. Mr. Speaker, on behalf of all of the physicians and other
health professionals in my District who provide care to Medicare
beneficiaries and on behalf of the beneficiaries themselves, I rise to
express my strong support for H.R. 3391, the Medicare Regulatory and
Contracting Reform Act of 2001. I am honored to be an original
cosponsor of this bipartisan, common-sense bill that will provide much-
needed regulatory relief and greater program fairness, clarity, and
transparency.
From what I have been hearing for years now in my meetings with
Medicare beneficiaries and health care providers across my District,
the current program is simply not working well. Beneficiaries and
health professionals often don't know if services will be covered,
leading some beneficiaries to forgo needed care. It can take months--
and mounds of paperwork--just to get paid for health care services.
I've seen the inch-thick paperwork that can be required just to
document one claim.
Doctors and other health professionals feel that they are practicing
with a sword over their heads. The rules and regulations are so complex
that the Medicare intermediaries and carriers all too often give
conflicting advice and guidance. Regulations and guidance change so
frequently that it is difficult to know what the rules are at any one
time, and what they will be tomorrow. Making a simple mistake in coding
or misunderstanding a program requirement, health professionals fear,
could well open to a fraud charge. If a claim is denied, it can take
several years to go through the current process for appealing that
denial. Doctors are so frustrated with the program that they are
retiring early, and some beneficiaries are having a hard time finding
doctors willing to take them as patients once they turn 65.
The Medicare Regulatory and Contracting Reform Act will give the
Centers for Medicare and Medicaid Services the direction and
flexibility needed to streamline the regulatory and contracting
processes. It will provide strong incentives for intermediaries and
carriers to be responsive to beneficiaries and health professionals. It
will provide additional resources for provider education. One provision
that could be particularly helpful for both beneficiaries and providers
will test the effectiveness of placing Medicare experts in local Social
Security offices so that questions and concerns can be addressed in a
timely, accurate way. And when disputes do arise, Administrative Law
Judges specifically trained in Medicare law and regulation will hear
the cases.
These are just a few of the reforms in this comprehensive, much-
needed bill.
Mr. BENTSEN. Mr. Speaker, I rise today in strong support of the
Medicare Regulatory and Contracting Reform Act (H.R. 3391), legislation
which would reform our Medicare regulatory and contracting system. For
too long, Medicare providers have encountered problems in resolving
claims under the Medicare program. Today, many Medicare providers
submit claims to their Medicare contractor who do not provide timely
resolution for these claims. In addition, many Medicare providers face
lengthy appeals which result in delayed reimbursements. This
legislation would not only provide necessary regulatory relief to
Medicare providers, but it would also ensure
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that Medicare contracts are competitively bid so that taxpayers are
paying the lowest price for these services.
In order to help with better compliance by Medicare providers, this
legislation would require that Medicare regulations should be
promulgated only once a month. This bill requires the Department of
Health and Human Services (HHS) to develop time lines for Center for
Medicare and Medicaid Services (CMS) rules. As a result, Medicare
providers would know when to expect changes in the Medicare system and
would be able to plan for such changes. This measure prohibits
regulations from being applied retroactively and requires that any
substantive change in regulations from being applied retroactively and
requires that any substantive change in regulations should not become
effective until 30 days after the change has been announced. The bill
also protects providers by ensuring that they cannot be sanctioned if
they followed written guidance provide by HHS or by a contractor.
Providers would also be eligible to call a new Medicare Ombudsman to
assist Medicare providers with advice about Medicare regulations and
rules.
To ensure that contractors are more accountable to Medicare
providers, this bill encourages HHS to competitively bid contracts for
Medicare claims. This new procedure would eliminate the current system
where health care providers can nominate entities to become Medicare
contractors. We should eliminate this conflict of interest and would
ensure that taxpayers receive the best value for this program.
This bill allows providers to seek a hardship designation if they
have received overpayments. Under this program, Medicare providers and
suppliers could request to make repayments over a period of six months
to three years if their obligation exceeds 10 percent of their annual
payments from Medicare. In extreme circumstances, Medicare providers
could apply for a five-year repayment schedule. Many medical small
businesses which depend on Medicare for payments have requested this
flexibility so that they continue to provide services to Medicare
beneficiaries.
This measure also includes several provisions related to physician
payment fees. Under current law, these Medicare physician fees will be
reduced by 5.9 percent effective January 1, 2001. For many physicians,
this significant drop in Medicare payments will impose a financial
burden and may result in fewer physicians being willing to participate
in this program. This bill requires the General Accounting Office (GAO)
to report of Congress on the conversion factor used to calculate
physician payments and to make recommendations on how to reform it
within 12 months. This GAO report would also examine whether the
current sustainable growth formula for physician fees should be
reformed I have been contacted by many physicians in my district who
would be adversely impacted by this new fee schedule and I am committed
to working to change these payments in a timely manner so that Medicare
payments more accurately reflect the true cost of providing care for
Medicare patients.
As the representative for the Texas Medical Center, where many
Medicare providers work, I urge my colleagues to support H.R. 3391 that
will reform the Medicare program.
Mr. CARDIN. Mr. Speaker, I rise today in strong support of the
Medicare Regulatory and Contracting Reform Act of 2001. This bill is
the result of months of collaborative efforts between Democrats and
Republicans, between the ways and means and the Energy and Commerce
Committees. In other words, it was developed the way that responsible
Medicare legislation should be-in a bipartisan and deliberative manner.
For too long, Congress has ignored the valid concerns of one of
Medicare's most important assets--its health care providers. By easing
regulatory burdens on physicians and allied health professionals, and
by modifying the provider appeals process, this legislation speaks to
some of the foremost concerns that have been brought to Congress by the
dedicated health care professionals who participate in the Medicare
program.
This bill also provides important patient protections for
beneficiaries--it guarantees them access to a truly independent
external review process; it improves the advance beneficiary notice
(ABN) process so that seniors may know in advance of receiving care
whether the services will be reimbursed by Medicare; and it establishes
a Beneficiary Ombudsman to assist seniors in navigating the Medicare
program.
As the Medicare+Choice program enters its fifth year, and enrollees
across the country are witnessing their benefits reduced and their
premiums increased, this bill contains an important beneficiary
protection. It delays by one year the implementation of the enrollee
``lock-in'' period, which will enable many seniors to move between HMOs
as efforts are made to stabilize this program.
The 1997 Balanced Budget Act imposed $1500 caps on physical, speech-
language, and occupational therapy. I have long supported replacing
these caps with a rational payment mechanism. Congress has acted each
year to delay these caps, which discriminate against the most frail
beneficiaries. However, it is a waste of energy and resources for
providers to return to Congress annually to seek a one-year moratorium
on these caps. Medicare should implement a rational payment system that
provides seniors with the level of care they need. We passed a law
requiring the Secretary of Health and Human Services to establish a
mechanism for assuring appropriate use of services and to study use of
these services by last June. This bill directs the Secretary to produce
these overdue reports so that Congress can enact sound reimbursement
policy for outpatient therapy.
Mr. Speaker, H.R. 3391 is a shining example of how Congress can act
to greatly improve the Medicare program for beneficiaries and
providers. I am pleased to be an original cosponsor of this legislation
and I urge my colleagues to support it this evening.
Mr. ENGLISH. Mr. Speaker, I rise in strong support of H.R. 3391, The
Medicare Regulatory Reform Act of 2001. I urge my colleagues to vote in
favor of this important legislation.
The Occupational Safety and Health Administration (OSHA) estimates
that each year 5.6 million workers in the health care industry are
exposed to blood-borne diseases because of needlesticks. OSHA studies
have shown that nurses sustain the majority of these injuries and that
as many as one-third of all sharps injuries have been reported to be
related to the disposal process.
In addition, the Centers for Disease Control estimates that 62 to 88
percent of sharps injuries can potentially be prevented by the use of
safer medical devices. However, needlestick injuries and other sharps-
related injuries, that result in occupational blood-borne pathogens
exposure, continue to be an important public health concern.
H.R. 3391, The Medicare Regulatory Reform Act of 2001, includes a
provision that will reduce needlestick injuries. This provision
requires public hospitals, not otherwise covered by the OSHA rules, to
meet the administration's standards which require employers to
implement the use of safety-designed needles and sharps. The
requirements will be established under Medicare statute and enforced
through monetary fines similar to fines under OSHA. Violations would
not cause hospitals to lose Medicare their eligibility.
I also would like to take this opportunity to thank Subcommittee
Chairwoman Nancy Johnson for not only including this provision to
reduce needlestick injuries in the Medicare regulatory reform bill, but
also for her many years of hard work on this issue. She has long been a
champion of requiring public hospitals to use safety-designed needles
and sharps. I was pleased to join her and Mr. Stark in this important
effort.
We have the technology to provide better protections for our
healthcare workers. A vote in favor of this legislation ensures that
hospitals are using state-of-the-art equipment while significantly
reducing the risk to healthcare workers.
Mr. KLECZKA. Mr. Speaker, I am pleased that the House of
Representatives is considering the Medicare Regulatory and Contractor
Reform Act of 2001 (H.R. 3391) on the suspension calendar today.
This important, bipartisan legislation will address the very real and
practical regulatory concerns health care providers, contractors, and
beneficiaries are currently facing with the Medicare program. H.R. 3391
helps providers and beneficiaries better understand the complexities of
Medicare, while at the same time protecting the Federal Claims Act and
maintaining strong efforts to eliminate waste, fraud and abuse. It is
my hope that this legislation will allow providers to focus their
attention on patients, and not bureaucracy.
Of particular importance to me was the inclusion of language I
offered during the Ways and Means Health Subcommittee markup that would
establish a new Medicare Beneficiary Ombudsman. H.R. 2768, as
originally introduced by the Ways and Means Committee, had included
language requiring the U.S. Department of Health and Human Services
(HHS) Secretary to appoint a Medicare Provider Ombudsman to provide
confidential assistance to physicians and practitioners regarding
complaints and grievances. I believed this point-of-contact should be
extended to Medicare beneficiaries, who also have complex questions and
receive conflicting guidance. I am pleased that my suggestion to create
a comparable Beneficiary Ombudsman to serve as a voice for
beneficiaries within the Centers of Medicare and Medicaid Services
(CMS) was included. This provision should enable the Agency to better
anticipate and address beneficiary needs.
Furthermore, I requested language in Title II of the Act that would
eliminate the provider
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nomination provisions for contracting purposes. This provision
effectively waives the prime contracts that the Centers of Medicare and
Medicaid Services (CMS) currently has with national organizations and
permits CMS to contract directly with entities during the transition
period prior to the October 1, 2003 effective date without regard to
competitive bidding procedures.
I would like to express my sincere appreciation to both Ways and
Means Health Subcommittee Chairwoman Johnson and Ranking Member Stark,
and their respective staffs, for being so accommodating and working
together to create responsible, well-targeted regulatory legislation.
I urge my colleagues to support H.R. 3391, and I hope the Senate will
work quickly to pass this legislation prior to the end of this
Congressional Session.
Mr. BROWN of Ohio. Mr. Speaker, I yield back the balance of my time.
Mr. TAUZIN. Mr. Speaker, I yield back the balance of my time.
The SPEAKER pro tempore (Mr. Culberson). The question is on the
motion offered by the gentlewoman from Connecticut (Mrs. Johnson) that
the House suspend the rules and pass the bill, H.R. 3391.
The question was taken.
The SPEAKER pro tempore. In the opinion of the Chair, two-thirds of
those present have voted in the affirmative.
Mr. TAUZIN. Mr. Speaker, on that I demand the yeas and nays.
The yeas and nays were ordered.
The SPEAKER pro tempore. Pursuant to clause 8 of rule XX and the
Chair's prior announcement, further proceedings on this motion will be
postponed.
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