Sec. 234. Preventing and reducing improper Medicare and Medicaid expenditures

1,254 words·~6 min read·/bill/113/s/1871/pcs/section-234

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

Section 1860D–4(c) of the Social Security Act ( 42 U.S.C. 1395w–104(c) ) is amended by adding at the end the following new paragraph: For plan year 2015 and subsequent plan years, subject to subparagraph (B), the Secretary shall prohibit PDP sponsors of prescription drug plans from paying claims for prescription drugs under this part that do not include a valid prescriber National Provider Identifier. The Secretary shall establish procedures for determining the validity of prescriber National Provider Identifiers under subparagraph (A).

Not later than January 1, 2017, the Inspector General of the Department of Health and Human Services shall submit to Congress a report on the effectiveness of the procedures established under subparagraph (B). . Section 1893(h) of the Social Security Act ( 42 U.S.C. 1395ddd(h) ) is amended— in paragraph (8), as amended by section 231, by adding at the end the following new subparagraphs: For reports submitted under this paragraph for 2015 or a subsequent year, each such report shall include— a description of— the types and financial cost to the program under this title of improper payment vulnerabilities identified by recovery audit contractors under this subsection; and how the Secretary is addressing such improper payment vulnerabilities; and an assessment of the effectiveness of changes made to payment policies and procedures under this title in order to address the vulnerabilities so identified.

The Secretary shall ensure that each report submitted under subparagraph

(A)does not include information that the Secretary determines would be sensitive or would otherwise negatively impact program integrity. ; and by adding at the end the following new paragraph: The Secretary shall address improper payment vulnerabilities identified by recovery audit contractors under this subsection in a timely manner, prioritized based on the risk to the program under this title. . Section 1936 of the Social Security Act (42 U.S.C. 1396u–6) is amended— in subsection (a), by inserting , or otherwise, after entities ; and in subsection (e)— in paragraph (1), in the matter preceding subparagraph (A), by inserting (including the costs of equipment, salaries and benefits, and travel and training) after Program under this section ; and in paragraph (3), by striking by 100 and inserting by 100, or such number as determined necessary by the Secretary to carry out the Program under this section, . Section 453(j) of the Social Security Act ( 42 U.S.C. 653(j) ) is amended by adding at the end the following new paragraph: The Administrator of the Centers for Medicare & Medicaid shall have access to the information in the National Directory of New Hires for purposes of determining the eligibility of an applicant for, or enrollee in, the Medicare program under title XVIII or an applicable State health subsidy program (as defined in section 1413(e) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18083(e) ). If the Inspector General of the Department of Health and Human Services transmits to the Secretary the names and social security account numbers of individuals, the Secretary shall disclose to the Inspector General information on such individuals and their employers maintained in the National Directory of New Hires. The Inspector General of the Department of Health and Human Services may use information provided under clause

(i)only for purposes of — determining the eligibility of an applicant for, or enrollee in, the Medicare program under title XVIII or an applicable State health subsidy program (as defined in section 1413(e) of the Patient Protection and Affordable Care Act (42 U.S.C. 18083(e)); or evaluating the integrity of the Medicare program or an applicable State health subsidy program (as so defined). If, for purposes of determining the eligibility of an applicant for, or an enrollee in, an applicable State health subsidy program (as defined in section 1413(e) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18083(e) ), a State agency responsible for administering such program transmits to the Secretary the names, dates of birth, and social security account numbers of individuals, the Secretary shall disclose to such State agency information on such individuals and their employers maintained in the National Directory of New Hires, subject to this subparagraph. The Secretary shall make a disclosure under clause

(i)only to the extent that the Secretary determines that the disclosure would not interfere with the effective operation of the program under this part. A State agency may not use or disclose information provided under clause

(i)except for purposes of determining the eligibility of an applicant for, or an enrollee in, a program referred to in clause (i). The State agency shall have in effect data security and control policies that the Secretary finds adequate to ensure the security of information obtained under clause

(i)and to ensure that access to such information is restricted to authorized persons for purposes of authorized uses and disclosures. An officer or employee of the State agency who fails to comply with this clause shall be subject to the sanctions under subsection (l)(2) to the same extent as if such officer or employee were an officer or employee of the United States. State agencies requesting information under clause

(i)shall adhere to uniform procedures established by the Secretary governing information requests and data matching under this paragraph. The State agency shall reimburse the Secretary, in accordance with subsection (k)(3), for the costs incurred by the Secretary in furnishing the information requested under this subparagraph. . The Secretary of Health and Human Services (in this subsection referred to as the Secretary ) shall establish a plan to encourage and facilitate the participation of States in the Medicare-Medicaid Data Match Program (commonly referred to as the Medi-Medi Program ) under section 1893(g) of the Social Security Act (42 U.S.C. 1395ddd(g)). Section 1893(g)(1)(A) of the Social Security Act (42 U.S.C. 1395ddd(g)(1)(A)) is amended— in the matter preceding clause (i), by inserting or otherwise after eligible entities ; in clause (i)— by inserting to review claims data after algorithms ; and by striking service, time, or patient and inserting provider, service, time, or patient ; in clause (ii)— by inserting to investigate and recover amounts with respect to suspect claims after appropriate actions ; and by striking ; and and inserting a semicolon; in clause (iii), by striking the period and inserting ; and ; and by adding at end the following new clause: furthering the Secretary’s design, development, installation, or enhancement of an automated data system architecture— to collect, integrate, and assess data for purposes of program integrity, program oversight, and administration, including the Medi-Medi Program; and that improves the coordination of requests for data from States. . The Secretary shall develop and implement a plan that allows each State agency responsible for administering a State plan for medical assistance under title XIX of the Social Security Act access to relevant data on improper or fraudulent payments made under the Medicare program under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ) for health care items or services provided to dual eligible individuals. In this paragraph, the term dual eligible individual means an individual who is entitled to, or enrolled for, benefits under part A of title XVIII of the Social Security Act (42 U.S.C. 1395c et seq.), or enrolled for benefits under part B of title XVIII of such Act ( 42 U.S.C. 1395j et seq. ), and is eligible for medical assistance under a State plan under title XIX of such Act ( 42 U.S.C. 1396 et seq. ) or under a waiver of such plan.

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