Sec. 121. Prompt payment to providers

1,186 words·~5 min read·/bill/115/s/2184/is/section-121

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

Subchapter I of chapter 17 is amended by inserting after section 1703C, as added by section 103 of this Act, the following new section: Notwithstanding any other provision of this title or of any other provision of law, the Secretary shall pay for hospital care, medical services, or extended care services furnished by health care entities or providers under this chapter within 45 calendar days upon receipt of a clean paper claim or 30 calendar days upon receipt of a clean electronic claim.

If a claim is denied, the Secretary shall, within 45 calendar days of denial for a paper claim and 30 calendar days of denial for an electronic claim, notify the health care entity or provider of the reason for denying the claim and what, if any, additional information is required to process the claim. Upon the receipt of the additional information, the Secretary shall ensure that the claim is paid, denied, or otherwise adjudicated within 30 calendar days from the receipt of the requested information.

This section shall only apply to payments made on an invoice basis and shall not apply to capitation or other forms of periodic payment to entities or providers. A health care entity or provider that furnishes hospital care, medical services, or extended care services under this chapter shall submit to the Secretary a claim for payment for furnishing the care or services not later than 180 days after the date on which the entity or provider furnished the care or services. Sections 3729 through 3733 of title 31 shall apply to fraudulent claims for payment submitted to the Secretary by a health care entity or provider under this chapter.

Pursuant to regulations prescribed by the Secretary, the Secretary shall bar a health care entity or provider from furnishing hospital care, medical services, and extended care services under this chapter when the Secretary determines the entity or provider has submitted to the Secretary fraudulent health care claims for payment by the Secretary. Any claim that has not been denied with notice, made pending with notice, or paid to the health care entity or provider by the Secretary shall be overdue if the notice or payment is not received by the entity or provider within the time periods specified in subsection (a).

If a claim is overdue under this subsection, the Secretary may, under the requirements established by subsection

(a)and consistent with the provisions of chapter 39 of title 31 (commonly referred to as the Prompt Payment Act ), require that interest be paid on clean claims. Interest paid under subparagraph

(A)shall be computed at the rate of interest established by the Secretary of the Treasury under section 3902 of title 31 and published in the Federal Register. The Secretary shall deduct the amount of any overpayment from payments due a health care entity or provider under this chapter. Deductions may not be made under this subsection unless the Secretary has made reasonable efforts to notify a health care entity or provider of the right to dispute the existence or amount of such indebtedness and the right to request a compromise of such indebtedness. The Secretary shall make a determination with respect to any such dispute or request prior to deducting any overpayment unless the time required to make such a determination before making any deductions would jeopardize the Secretary’s ability to recover the full amount of such indebtedness. The Secretary shall provide to all health care entities and providers participating in a program to furnish hospital care, medical services, or extended care services under this chapter a list of information and documentation that is required to establish a clean claim under this section. The Secretary shall consult with entities in the health care industry, in the public and private sector, to determine the information and documentation to include in the list under paragraph (1). If the Secretary modifies the information and documentation included in the list under paragraph (1), the Secretary shall notify all health care entities and providers described in paragraph

(1)not later than 30 days before such modifications take effect. In processing a claim for compensation for hospital care, medical services, or extended care services furnished by a health care entity or provider under this chapter, the Secretary shall act through— a non-Department entity that is under contract or agreement for the program established under section 1703(a) of this title; or a non-Department entity that specializes in such processing for other Federal agency health care systems. Not later than 90 days after the date of the enactment of the Veterans Community Care and Access Act of 2017 , the Secretary shall submit to the appropriate committees of Congress a report on the feasibility and advisability of adopting a funding mechanism similar to what is utilized by other Federal agencies to allow a contracted entity to act as a fiscal intermediary for the Federal Government to distribute, or pass through, Federal Government funds for certain non-underwritten hospital care, medical services, or extended care services. The Secretary may coordinate with the Department of Defense, the Department of Health and Human Services, and the Department of the Treasury in developing the report required by paragraph (1). In this section: The term appropriate committees of Congress means— the Committee on Veterans’ Affairs and the Committee on Appropriations of the Senate; and the Committee on Veterans’ Affairs and the Committee on Appropriations of the House of Representatives. The term clean electronic claim means the transmission of data for purposes of payment of covered health care expenses that is submitted to the Secretary which contains substantially all of the required data elements necessary for accurate adjudication, without obtaining additional information from the entity or provider that furnished the care or service, submitted in such format as prescribed by the Secretary in regulations for the purpose of paying claims for care or services. The term clean paper claim means a paper claim for payment of covered health care expenses that is submitted to the Secretary which contains substantially all of the required data elements necessary for accurate adjudication, without obtaining additional information from the entity or provider that furnished the care or service, submitted in such format as prescribed by the Secretary in regulations for the purpose of paying claims for care or services. The term fraudulent claims means the intentional and deliberate misrepresentation of a material fact or facts by a health care entity or provider made to induce the Secretary to pay a claim that was not legally payable to that provider. This term, as used in this section, shall not include a good faith interpretation by a health care entity or provider of utilization, medical necessity, coding, and billing requirements of the Secretary. The term health care entity or provider includes any non-Department health care entity or provider, but does not include any Federal health care entity or provider. . The table of sections at the beginning of such chapter is amended by inserting after the item related to section 1703C, as added by section 103 of this Act, the following new item: 1703D. Prompt payment standard. .