Sec. 6212. Enhancing certain program integrity requirements for DME under Medicare
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Section 1834(a) of the Social Security Act ( 42 U.S.C. 1395m(a) ) is amended by adding at the end the following new paragraph: Beginning January 1, 2029, for purposes of the Master List described in section 414.234(b) of title 42, Code of Federal Regulations (or any successor regulation), in determining which items have aberrant billing patterns (as such term is used for purposes of such section), the Secretary shall also treat an item for which payment may be made under this subsection as having such an aberrant billing pattern if the Secretary determines that, without explanatory contributing factors (such as furnishing emergent care services), a substantial number of claims for such items under this subsection are for such items ordered by a physician or practitioner who has not previously (during a period of not less than 24 months, as established by the Secretary) furnished to the individual involved any item or service for which payment may be made under this title.
With respect to items furnished on or after January 1, 2029, that are included on the Master List pursuant to subparagraph (A), if such an item is not subject to a determination of coverage in advance pursuant to paragraph (15)(C), the Secretary may conduct prepayment review of claims for payment for such item. . Section 1834(h)(3) of the Social Security Act ( 42 U.S.C. 1395m(h)(3) ) is amended by inserting , and paragraph
(23)of subsection
(a)shall apply to prosthetic devices, orthotics, and prosthetics in the same manner as such provision applies to items for which payment may be made under such subsection before the period at the end. Not later than January 1, 2028, the Inspector General of the Department of Health and Human Services shall submit to Congress a report assessing fraud risks relating to clinical diagnostic laboratory tests for which payment may be made under section 1834A of the Social Security Act ( 42 U.S.C. 1395m–1 ) and effective tools for reducing such fraudulent claims. The report may include, at the Inspector General's discretion— which, if any, clinical diagnostic laboratory tests are identified as being at high risk of fraudulent claims, and an analysis of the factors that contribute to such risk; with respect to a clinical diagnostic laboratory test identified under paragraph
(1)as being at high risk of fraudulent claims— the amount payable under such section 1834A with respect to such test; the number of such tests furnished to individuals enrolled under part B of title XVIII of the Social Security Act ( 42 U.S.C. 1395j et seq. ); whether an order for such a test was more likely to come from a provider with whom the individual involved did not have a prior relationship, as determined on the basis of prior payment experience; and the frequency with which a claim for payment under such section 1834A included the payment modifier identified by code 59 or 91; and suggested strategies for reducing the number of fraudulent claims made with respect to tests so identified as being at high risk, including— an analysis of whether the Centers for Medicare & Medicaid Services can detect aberrant billing patterns with respect to such tests in a timely manner; any strategies for identifying and monitoring the providers who are outliers with respect to the number of such tests that such providers order; and targeted education efforts to mitigate improper billing for such tests; and such other information as the Inspector General determines appropriate. In addition to amounts otherwise available, there is appropriated to the Inspector General of the Department of Health and Human Services, out of any money in the Treasury not otherwise appropriated, $1,200,000 for fiscal year 2026, to remain available until expended, to carry out this section.
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- 42 USC 1395m–1
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Sec. 6212
Enhancing certain program integrity requirements for DME under Medicare
Cite42 USC 1395m–1
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