Sec. 3. Identifying fraud in health care services

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The Secretary of Health and Human Services shall, not later than 60 days after making a determination described in paragraph (2), notify the Inspector General of the Department of Health and Human Services of such determination. A determination described in this paragraph is a determination that— the aggregate amount paid under the Medicare program under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ) for an item or service or items or services in a zip code and county or county equivalent increased by more than 100 percent in a single year; or the number of provider of services or suppliers (as those terms are defined under section 1861 of the Social Security Act ( 42 U.S.C. 1395x )) who received payment for items or services furnished under the Medicare program increased in a zip code and county or county equivalent by more than 100 percent in a single year.

The Secretary of Health and Human Services shall, not later than 60 days after making a determination described in paragraph (2), notify the Inspector General of the Department of Health and Human Services of such determination. A determination described in this paragraph is a determination that— the aggregate amount paid under all qualified health plans offered through the American Health Benefit Exchanges established under sections 1311 and 1321 of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18031 , 18041) for an item or service or items or services in a zip code and county or county equivalent increased by more than 100 percent in a single year; or the number of providers of services who received payment for items or services under such qualified health plans increased in a zip code and county or county equivalent by more than 100 percent in a single year.

Annually, each American Health Benefit Exchange established under section 1311 or 1321 of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18031 , 18041) shall collect from each qualified health plan offered through such an Exchange, and submit to the Secretary of Health and Human Services, the information necessary for the Secretary to make a determination described in paragraph (2). Section 1902 of the Social Security Act ( 42 U.S.C. 1396a ) is amended— in subsection (a)— in paragraph (88), by striking ; and and inserting a semicolon; in paragraph (89), by striking the period at the end and inserting ; and ; and by adding after paragraph

(89)the following new paragraph: provide that, not later than 60 days after making a determination described in subsection (yy), the State agency shall notify the Secretary and the Inspector General of the Department of Health and Human Services of such determination. ; and by adding at the end the following new subsection: For purposes of subsection (a)(90), a determination described in this subsection is a determination that— the aggregate amount paid under the State plan under this title, or under a waiver of such plan, for an item or service or items or services in a zip code and county or county equivalent increased by more than 100 percent in a single year; or the number of providers of items or services who received payments for items or services furnished in a zip code and county or county equivalent under such State plan or waiver increased by more than 100 percent in a single year. . Section 2107(e)(1) of the Social Security Act ( 42 U.S.C. 1397gg(e)(1) ) is amended by— redesignating subparagraphs

(I)through

(W)as subparagraphs

(J)through (X), respectively; and inserting after subparagraph

(H)the following subparagraph: Subsections (a)(90) and

(yy)of section 1902 (relating to determination of certain increased payments or providers in a single year and notification to the Secretary and the Inspector General of Health and Human Services). . Not later than 5 years after the date of enactment of this Act, and annually thereafter, the Inspector General of Health and Human Services shall— identify, based on the results of any notifications received under subsection

(a)or (b), or under section 1902(a)(90) of the Social Security Act ( 42 U.S.C. 1396a(a)(90) ) or section 2107(e)(1)(I) of such Act ( 42 U.S.C. 1397gg(e)(1)(I) ), any program or State plan or waiver (in the case of Medicaid and the State Children's Health Insurance Program) under which the aggregate amount paid for an item or service or items or services in a zip code and county or county equivalent or the number of providers of items or services or suppliers, as applicable, who received payments for items or services furnished in a zip code and county or county equivalent increased by at least 400 percent during the preceding 5-year period; and audit any such program, State plan, or waiver. Subsection

(a)shall take effect on the date that is 180 days after the date of enactment of this Act. Subsection

(b)shall take effect on the date that is 180 days after the date of enactment of this Act. Except as provided in subparagraph (B), the amendments made by subsection

(c)shall take effect on the date that is 180 days after the date of enactment of this Act. In the case of a State plan approved under title XIX of the Social Security Act ( 42 U.S.C. 1396 et seq. ) or title XXI of such Act ( 42 U.S.C. 1397aa et seq. ) which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirements imposed by the amendments made by subsection (c), the State plan shall not be regarded as failing to comply with the requirements of such title XIX or XXI (as applicable) solely on the basis of the failure of the plan to meet such additional requirements before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that ends after the 1-year period beginning with the date of the enactment of this section. For purposes of the preceding sentence, in the case of a State that has a 2-year legislative session, each year of the session is deemed to be a separate regular session of the State legislature.

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Sec. 3

Identifying fraud in health care services

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