Sec. 203. Addressing significant outlier billing patterns for telehealth services
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The Secretary shall, using national provider identifiers on claims for telehealth services furnished to individuals under section 1834(m) of the Social Security Act ( 42 U.S.C. 1395m(m) ), identify physicians and practitioners that demonstrate significant outlier billing patterns (such as coding of telehealth services for inappropriate length of time and inaccurate complexity and inappropriate or duplicate billing) for telehealth services or items or services ordered or prescribed concurrent to a telehealth service over a period of time specified by the Secretary.
For purposes of this subsection, the Secretary shall establish thresholds for outlier billing patterns to identify whether a physician or practitioner is a significant outlier biller for telehealth services or items or services ordered or prescribed concurrent to a telehealth service as compared to other physicians or practitioners within the same specialty and geographic area. The Secretary shall notify any physician or practitioner identified as a significant outlier biller for telehealth services or items or services ordered or prescribed concurrent to a telehealth service under subsection (a).
Each notification under the preceding sentence shall include the following: Information on how the physician or practitioner compares to physicians or practitioners within the same specialty and geographic area with respect to billing for telehealth services or items or services ordered or prescribed concurrent to a telehealth service under the Medicare program under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ). Information on telehealth billing guidelines under the Medicare program.
Other information determined appropriate by the Secretary. Nothing in this subsection or subsection
(a)shall be construed as directing the Centers for Medicare & Medicaid Services to pursue further audits of providers of services and suppliers outside of those permitted or required under titles XI or XVIII of the Social Security Act, or otherwise under applicable Federal law. The Secretary shall make aggregate information on outlier billing patterns identified under subsection
(a)available on the internet website of the Centers for Medicare & Medicaid Services. Such information shall be in a form and manner determined appropriate by the Secretary and shall not identify any specific physician or practitioner. Nothing in this section shall preclude the Secretary from conducting activities that provide physicians and practitioners with information as to how they compare to other physicians and practitioners that are in addition to the activities under this section. Section 330I(j)(2) of the Public Health Service Act ( 42 U.S.C. 254c–14(j)(2) ) is amended— in subparagraph (F), by striking and at the end; in subparagraph (G), by striking the period at the end and inserting ; and ; and by adding at the end the following new subparagraph: providing technical assistance and education to physicians and practitioners that the Secretary identifies pursuant to section 203(a) of the CONNECT for Health Act of 2023 as having significant levels of outlier billing patterns with respect to telehealth services or items or services ordered or prescribed concurrent to a telehealth service under the Medicare program under title XVIII of the Social Security Act, including— education on practices to ensure coding of telehealth services for appropriate length of time and accurate complexity; education on prevention of inappropriate or duplicate billing; and information on— services specified in paragraph (4)(F)(i) of section 1834(m) of the Social Security Act ( 42 U.S.C. 1395m(m) ) for authorized payment under paragraph
(1)of such section; and the process used to update such services under clauses
(ii)and
(iii)(as added by section 104) of paragraph (4)(F) of such section 1834(m); and referral to the appropriate medicare administrative contractor for specific questions that fall outside of the scope of broad best practices. . In this section: The term Secretary means the Secretary of Health and Human Services. The term telehealth service has the meaning given that term in section 1834(m)(4)(F) of the Social Security Act ( 42 U.S.C. 1395m(m)(4)(F) ). The terms physician and practitioner have the meaning given those terms for purposes of section 1834(m) of the Social Security Act ( 42 U.S.C. 1395m(m) ).
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- 42 USC 254c–14(j)(2)
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Sec. 203
Addressing significant outlier billing patterns for telehealth services
Cite42 USC 254c–14(j)(2)
Cites 3Cited by 0 across 0 sources