Sec. 301. Reducing improper Medicare payments
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Section 1874A of the Social Security Act ( 42 U.S.C. 1395kk–1 ) is amended— in subsection (a)(4)— by redesignating subparagraph
(G)as subparagraph (H); and by inserting after subparagraph
(F)the following new subparagraph: Having in place an improper payment outreach and education program described in subsection (h). ; and by adding at the end the following new subsection: In order to reduce improper payments under this title, each medicare administrative contractor shall establish and have in place an improper payment outreach and education program under which the contractor, through outreach, education, training, and technical assistance activities, shall provide providers of services and suppliers located in the region covered by the contract under this section with the information described in paragraph (3). The activities described in the preceding sentence shall be conducted on a regular basis. The outreach, education, training, and technical assistance activities under a payment outreach and education program shall be carried out through any of the following: Emails and other electronic communications. Webinars. Telephone calls. In-person training. Other forms of communications determined appropriate by the Secretary. The information to be provided to providers of services and suppliers under a payment outreach and education program shall include all of the following information: A list of the provider’s or supplier's most frequent and expensive payment errors over the last quarter. Specific instructions regarding how to correct or avoid such errors in the future. A notice of all new topics that have been approved by the Secretary for audits conducted by recovery audit contractors under section 1893(h). Specific instructions to prevent future issues related to such new audits. Other information determined appropriate by the Secretary. The activities under a payment outreach and education program shall include error rate reduction training. The training described in subparagraph
(A)shall— be provided at least annually; and focus on reducing the improper payments described in paragraph (5). A medicare administrative contractor shall ensure that all providers of services and suppliers located in the region covered by the contract under this section are invited to attend the training described in subparagraph
(A)either in person or online. A medicare administrative contractor shall give priority to activities under the improper payment outreach and education program that will reduce improper payments for items and services that— have the highest rate of improper payment; have the greatest total dollar amount of improper payments; are due to clear misapplication or misinterpretation of Medicare policies; are clearly due to common and inadvertent clerical or administrative errors; or are due to other types of errors that the Secretary determines could be prevented through activities under the program. In order to assist medicare administrative contractors in carrying out improper payment outreach and education programs, the Secretary shall provide each contractor with a complete list of improper payments identified by recovery audit contractors under section 1893(h) with respect to providers of services and suppliers located in the region covered by the contract under this section. Such information shall be provided on a quarterly basis. The information described in subparagraph
(A)shall include the following information: The providers of services and suppliers that have the highest rate of improper payments. The providers of services and suppliers that have the greatest total dollar amounts of improper payments. The items and services furnished in the region that have the highest rates of improper payments. The items and services furnished in the region that are responsible for the greatest total dollar amount of improper payments. Other information the Secretary determines would assist the contractor in carrying out the improper payment outreach and education program. The information furnished to medicare administrative contractors by the Secretary under this paragraph shall be transmitted in a manner that permits the contractor to easily identify the areas of the Medicare program in which targeted outreach, education, training, and technical assistance would be most effective. In carrying out the preceding sentence, the Secretary shall ensure that— the information with respect to improper payments made to a provider of services or supplier clearly displays the name and address of the provider or supplier, the amount of the improper payment, and any other information the Secretary determines appropriate; and the information is in an electronic, easily searchable database. All communications with providers of services and suppliers under a payment outreach and education program are subject to the standards and requirements of subsection (g). After application of paragraph (1)(C) of section 1893(h), the Secretary shall retain a portion of the amounts recovered by recovery audit contractors under such section which shall be available to the program management account of the Centers for Medicare & Medicaid Services for purposes of carrying out this subsection and to implement corrective actions to help reduce the error rate of payments under this title. The amount retained under the preceding sentence shall not exceed an amount equal to 25 percent of the amounts recovered under section 1893(h). . Section 1893(h)(2) of the Social Security Act ( 42 U.S.C. 1395ddd(h)(2) ) is amended by inserting or section 1874(h)(8) after paragraph (1)(C) . The amendments made by this subsection take effect on January 1, 2015. Section 1893(h)(8) of the Social Security Act ( 42 U.S.C. 1395ddd(h)(8) ) is amended— by striking and inserting “ report .—The Secretary report .— The Secretary ; and by adding at the end the following new subparagraph: For reports submitted under this paragraph for 2015 or a subsequent year, each such report shall include the information described in clause
(ii)with respect to each of the following categories of audits carried out by recovery audit contractors under this subsection: Automated. Complex. Medical necessity review. Part A. Part B. Durable medical equipment. For purposes of clause (i), the information described in this clause, with respect to a category of audit described in clause (i), is the result of all appeals for each individual level of appeals in such category. . The Secretary shall conduct a demonstration project under title XVIII of the Social Security Act that— targets audits by recovery audit contractors under section 1893(h) of the Social Security Act (42 U.S.C. 1395ddd(h)) with respect to high error providers of services and suppliers identified under paragraph (3); and rewards low error providers of services and suppliers identified under such paragraph. The demonstration project shall be implemented not later than January 1, 2015, and shall be conducted for a period of three years. In determining the geographic area of the demonstration project, the Secretary shall consider the following: The total number of providers of services and suppliers in the region. The diversity of types of providers of services and suppliers in the region. The level and variation of improper payment rates of and among individual providers of services and suppliers in the region. The inclusion of a mix of both urban and rural areas. In conducting the demonstration project, the Secretary shall identify the following two groups of providers in accordance with this paragraph: Low error providers of services and suppliers. High error providers of services and suppliers. For purposes of identifying the groups under subparagraph (A), the Secretary shall analyze the following as they relate to the total number and amount of claims submitted in the area and by each provider: The improper payment rates of individual providers of services and suppliers. The amount of improper payments made to individual providers of services and suppliers. The frequency of errors made by the provider of services or supplier over time. Other information determined appropriate by the Secretary. The Secretary shall assign selected providers of services and suppliers under the demonstration program based on a composite score determined using the analysis under subparagraph
(B)as follows: Providers of services and suppliers with high, expensive, and frequent errors shall receive a high score and be identified as high error providers of services and suppliers under subparagraph (A). Providers of services and suppliers with few, inexpensive, and infrequent errors shall receive a low score and be identified as low error providers of services and suppliers under such subparagraph. Only a small proportion of the total providers of services and suppliers and individual types of providers of services and suppliers in the geographic area of the demonstration project shall be assigned to either group identified under such subparagraph. Any identification of a provider of services or a supplier under subparagraph
(A)shall be for a period of 12 months. The Secretary shall reevaluate each such identification at the end of such period. In carrying out the reevaluation under clause
(ii)with respect to a provider of services or supplier, the Secretary shall— consider the most current information available with respect to the provider of services or supplier under the analysis under subparagraph (B); and take into account improvement or regression of the provider of services or supplier. Under the demonstration project, the Secretary shall establish procedures to— increase the maximum record request made by recovery audit contractors to providers of services and suppliers identified as high error providers of services and suppliers under paragraph (3); and decrease the maximum record request made by recovery audit contractors to providers of services and suppliers identified as low error providers of services and supplier under such paragraph. Under the demonstration project, the Secretary may make additional adjustments to requirements for recovery audit contractors under section 1893(h) of the Social Security Act ( 42 U.S.C. 1395ddd(h) ) and the conduct of audits with respect to low error providers of services and suppliers identified under paragraph
(3)and high error providers of services and suppliers identified under such paragraph as the Secretary determines necessary in order to incentivize reductions in improper payment rates under title XVIII of such Act (42 U.S.C. 1395 et seq.). The Secretary shall not exempt any group of providers of services or suppliers in the demonstration project from being subject to audit by a recovery audit contractor under such section 1893(h). The Inspector General of the Department of Health and Human Services shall conduct an evaluation of the demonstration project under this subsection. The evaluation shall include an analysis of— the error rates of providers of services and suppliers— identified under paragraph
(3)as low error providers of services and suppliers; identified under such paragraph as high error providers of services and suppliers; and that are located in the geographic area of the demonstration project and are not identified as either a low error or high error provider of services or supplier under such paragraph; and any improvements in the error rates of those high error providers of services and suppliers identified under such paragraph. Not later than 12 months after completion of the demonstration project, the Inspector General shall submit to Congress a report containing the results of the evaluation conducted under subparagraph (A), together with recommendations on whether the demonstration project should be continued or expanded, including on a permanent or nationwide basis. For purposes of carrying out the demonstration project under this subsection (other than the evaluation and report under paragraph (6)), the Secretary shall provide for the transfer, from the Federal Hospital Insurance Trust Fund under section 1817 ( 42 U.S.C. 1395i ) and the Federal Supplementary Medical Insurance Trust Fund under section 1841 ( 42 U.S.C. 1395t ), in such proportion as the Secretary determines appropriate, of $10,000,000 to the Centers for Medicare & Medicaid Services Program Management Account. For purposes of carrying out the evaluation and report under paragraph (6), the Secretary shall provide for the transfer, from the Federal Hospital Insurance Trust Fund under such section 1817 and the Federal Supplementary Medical Insurance Trust Fund under such section 1841, in such proportion as the Secretary determines appropriate, of $245,000 to the Inspector General of the Department of Health and Human Services. Amounts transferred under subparagraph
(A)or
(B)shall remain available until expended. In this section: The term demonstration project means the demonstration project under this subsection. The term provider of services has the meaning given that term in section 1861(u). The term recovery audit contractor means an entity with a contract under section 1893(h) of the Social Security Act (42 U.S.C. 1395ddd(h)). The term Secretary means the Secretary of Health and Human Services. The term supplier has the meaning given that term in section 1861(d).
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- 42 USC 1395kk–1
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Sec. 301
Reducing improper Medicare payments
Cite42 USC 1395kk–1
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