,i #aacth ,,congress #ast ,session ,h4 ,r4 #bcje ,,in ,,the ,,house ,,of ,,representatives ,june #aj1 #bjac ,mr4 ,roskam 7for himself1 ,mr4 ,carney1 ,mr4 ,hultgren1 ,mr4 ,barber1 ,mr4 ,schrader1 and ,mr4 ,reed7 introduced the following bill2 which was referred to the ,committee on ,energy and ,commerce1 and in addition to the ,committee on ,ways and ,means1 for a period to be subsequently determined by the ,speaker1 in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned ,a ,,bill ,to amend titles ,,xviii and ,,xix of the ,social ,security ,act to curb waste1 fraud1 and abuse in the ,medicare and ,medicaid programs4 #a4 ,short title2 table of contents 7a7 ,short title ,this ,act may be cited as the ,preventing and ,reducing ,improper ,medicare and ,medicaid ,expenditures ,act of #bjac or the ,,prime ,act of #bjac 4 7b7 ,table of contents ,the table of contents of this ,act is as follows3 ,sec4 #a4 ,short title2 table of contents4 ,,title ,i--,curbing improper payments ,sec4 #aja4 ,requiring valid prescriber ,national ,provider ,identifiers on pharmacy claims4 ,sec4 #ajb4 ,reforming how ,,cms tracks and corrects the vulnerabilities identified by ,recovery ,audit ,contractors4 ,sec4 #ajc4 ,improving ,senior ,medicare ,patrol and fraud reporting rewards4 ,sec4 #ajd4 ,strengthening ,medicaid ,program integrity through flexibility4 ,sec4 #aje4 ,establishing ,medicare administrative contractor error reduction incentives4 ,sec4 #ajf4 ,strengthening penalties for the illegal distribution of a ,medicare1 ,medicaid1 or ,,chip beneficiary identification or billing privileges4 ,,title ,,ii--,improving data sharing ,sec4 #bja4 ,access to the ,national ,directory of ,new ,hires4 ,sec4 #bjb4 ,improving the sharing of data between the ,federal ,government and ,state ,medicaid programs4 ,sec4 #bjc4 ,improving claims processing and detection of fraud within the ,medicaid and ,,chip programs4 ,,title ,,iii--,report on implementation ,sec4 #cja4 ,report on implementation4 ,i ,curbing improper payments #aja4 ,requiring valid prescriber ,national ,provider ,identifiers on pharmacy claims ,section #ahfj;,d-#d7;c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ajd7;c77 is amended by adding at the end the following new paragraph3 7#d7 ,requiring valid prescriber ,national ,provider ,identifiers on pharmacy claims 7,a7 ,in general ,for plan year #bjae and subsequent plan years1 subject to subparagraph 7,b71 the ,secretary shall prohibit ,,pdp sponsors of prescription drug plans from paying claims for prescription drugs under this part that do not include a valid prescriber ,national ,provider ,identifier4 7,b7 ,procedures ,the ,secretary shall establish-- 7i7 procedures for determining the validity of prescriber ,national ,provider ,identifiers under subparagraph 7,a72 and 7ii7 procedures for transferring to the ,inspector ,general of the ,department of ,health and ,human ,services and appropriate law enforcement agencies and other oversight entities information on those ,national ,provider ,identifiers and pharmacy claims1 including records related to such claims1 that the ,secretary determines are invalid under clause 7i74 7,c7 ,report ,not later than ,january #a1 #bjag1 the ,inspector ,general of the ,department of ,health and ,human ,services shall submit to ,congress a report on the effectiveness of the procedures established under subparagraph 7,b74 4 #ajb4 ,reforming how ,,cms tracks and corrects the vulnerabilities identified by ,recovery ,audit ,contractors 7a7 ,in general ,section #ahic7;h7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd7h77 is amended-- 7#a7 in paragraph 7#h7-- 7,a7 by striking report4--,the ,secretary and inserting 8report4-- 7,a7 ,in general ,subject to subparagraph 7,c71 the ,secretary 2 and 7,b7 by adding after subparagraph 7,a71 as inserted by subparagraph 7,a71 the following new subparagraphs3 7,b7 ,inclusion of improper payment vulnerabilities identified ,each report submitted under subparagraph 7,a7 shall1 subject to subparagraph 7,c71 include-- 7i7 a description of-- 7,i7 the types and financial cost to the program under this title of improper payment vulnerabilities identified by recovery audit contractors under this subsection2 and 7,,ii7 how the ,secretary is addressing such improper payment vulnerabilities2 and 7ii7 an assessment of the effectiveness of changes made to payment policies and procedures under this title in order to address the vulnerabilities so identified4 7,c7 ,limitation ,the ,secretary shall ensure that each report submitted under subparagraph 7,a7 does not include information that the ,secretary determines would be sensitive or would otherwise negatively impact program integrity4 2 and 7#b7 by adding at the end the following new paragraph3 7#aj7 ,addressing improper payment vulnerabilities ,the ,secretary shall address improper payment vulnerabilities identified by recovery audit contractors under this subsection in a timely manner1 prioritized based on the risk to the program under this title4 4 7b7 ,use of ,medicare and ,medicaid recovery audit contractor recoveries for provider education and ,to prevent improper payments and fraud 7#a7 ,medicare ,,rac program ,section #ahic7;h77#a77;,c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd7h77#a77;,c77 is amended-- 7,a7 by striking the ,secretary shall retain and inserting 8the ,secretary-- 7i7 shall retain 2 7,b7 in clause 7i71 as added by subparagraph 7,a7-- 7i7 by inserting 1 in addition to any other funds that may be available1 after available2 7ii7 by inserting until expended after ,services2 and 7iii7 by striking the period at the end and inserting a semicolon2 and 7,c7 by adding at the end the following new clauses3 7ii7 may retain an additional portion of the amounts recovered 7not to exceed #be percent of such amounts recovered7 which shall be available1 in addition to any other funds that may be available1 to such program management account until expended for purposes of activities to address problems that contribute to improper payments and fraud under this title2 and 7iii7 shall retain an additional #e percent of such amounts recovered to be made available1 in addition to any other funds that may be available1 to the ,inspector ,general of the ,department of ,health and ,human ,services until expended for the ,inspector ,general to carry out activities of the ,inspector ,general relating to investigating improper payments or auditing internal controls associated with payments under this title4 4 7#b7 ,medicaid ,,rac program ,section #aicf of the ,social ,security ,act 7#db ,u4,s4,c4 #acifu-#f7 is amended by adding at the end the following new subsection3 7f7 ,amounts recovered through recovery audit contractors ,notwithstanding any other provision of law1 the ,secretary-- 7#a7 may retain a portion of the amounts recovered pursuant to the program established under section #aijb7;a77#db77;,b7 7not to exceed #be percent of the ,federal share of such amounts recovered7 which shall be available1 in addition to any other funds that may be available1 to the program management account of the ,centers for ,medicare ,medicaid ,services for purposes of activities to address problems that contribute to improper payments and fraud under this title2 and 7#b7 shall retain an additional #e percent of the ,federal share of such amounts recovered to be made available1 in addition to any other funds that may be available1 to the ,inspector ,general of the ,department of ,health and ,human ,services until expended for the ,inspector ,general to carry out activities of the ,inspector ,general relating to investigating improper payments or auditing internal controls associated with payments under this title4 4 7#c7 ,effective date ,the amendments made by this section shall take effect on ,january #a1 #bjad4 #ajc4 ,improving ,senior ,medicare ,patrol and fraud reporting rewards 7a7 ,in general ,the ,secretary of ,health and ,human ,services 7in this section referred to as the ,secretary7 shall develop a plan to revise the incentive program under section #bjc7;b7 of the ,health ,insurance ,portability and ,accountability ,act of #aiif 7#db ,u4,s4,c4 #acie;b-#e7;b77 to encourage greater participation by individuals to report fraud and abuse in the ,medicare program4 ,such plan shall include recommendations for-- 7#a7 ways to enhance rewards for individuals reporting under the incentive program1 including rewards based on information that leads to an administrative action2 and 7#b7 extending the incentive program to the ,medicaid program4 7b7 ,public awareness and education campaign ,the plan developed under subsection 7a7 shall also include recommendations for the use of the ,senior ,medicare ,patrols authorized under section #daa of the ,older ,americans ,act of #aife 7#db ,u4,s4,c4 #cjcb7 to conduct a public awareness and education campaign to encourage participation in the revised incentive program under subsection 7a74 7c7 ,submission of plan ,not later than #ahj days after the date of enactment of this ,act1 the ,secretary shall submit to ,congress the plan developed under subsection 7a74 #ajd4 ,strengthening ,medicaid ,program integrity through flexibility ,section #aicf of the ,social ,security ,act 7#db ,u4,s4,c4 #acifu-#f7 is amended-- 7#a7 in subsection 7a71 by inserting 1 or otherwise1 after entities2 and 7#b7 in subsection 7e7-- 7,a7 in paragraph 7#a71 in the matter preceding subparagraph 7,a71 by inserting 7including the costs of equipment1 salaries and benefits1 and travel and training7 after ,program under this section2 and 7,b7 in paragraph 7#c71 by striking by #ajj and inserting by #ajj1 or such number as determined necessary by the ,secretary to carry out the ,program14 #aje4 ,establishing ,medicare administrative contractor error reduction incentives 7a7 ,in general ,section #ahgd;,a7b77#a77;,d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciekk7b77#a77;,d77 is amended-- 7#a7 by striking quality4--,the ,secretary and inserting 8quality4-- 7i7 ,in general ,subject to clauses 7ii7 and 7iii71 the ,secretary 2 and 7#b7 by inserting after clause 7i71 as added by paragraph 7#a71 the following new clauses3 7ii7 ,improper payment error rate reduction incentives ,the ,secretary shall provide incentives for medicare administrative contractors to reduce the improper payment error rates in their jurisdictions4 7iii7 ,incentives ,the incentives provided for under clause 7ii7-- 7,i7 may include a sliding scale of bonus payments and additional incentives to medicare administrative contractors that reduce the improper payment error rates in their jurisdictions to certain benchmark levels1 as determined by the ,secretary2 and 7,,ii7 shall include substantial reductions in award fee payments under award fee contracts1 for any medicare administrative contractor that reaches an upper end error threshold or other threshold as determined by the ,secretary4 4 7b7 ,effective date 7#a7 ,in general ,the amendments made by subsection 7a7 shall apply to contracts entered into or renewed on or after the date that is #ab months after the date of enactment of this ,act4 7#b7 ,contracts entered into or renewed prior to effective date ,in the case of contracts in existence on or after the date of the enactment of this ,act and that are not subject to the effective date under paragraph 7#a71 the ,secretary of ,health and ,human ,services shall1 when appropriate and practicable1 seek to apply the incentives provided for in the amendments made by subsection 7a7 through contract modifications4 #ajf4 ,strengthening penalties for the illegal distribution of a ,medicare1 ,medicaid1 or ,,chip beneficiary identification or billing privileges ,section #aabh;,b7b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acbj;a-#g;b7b77 is amended by adding at the end the following3 7#d7 ,whoever knowingly1 intentionally1 and with the intent to defraud purchases1 sells or distributes1 or arranges for the purchase1 sale1 or distribution of a ,medicare1 ,medicaid1 or ,,chip beneficiary identification number or billing privileges under title ,,xviii1 title ,,xix1 or title ,,xxi shall be imprisoned for not more than #aj years or fined not more than #ejj1jjj 7#a1jjj1jjj in the case of a corporation71 or both4 4 ,,ii ,improving data sharing #bja4 ,access to the ,national ,directory of ,new ,hires ,section #dec7;j7 of the ,social ,security ,act 7#db ,u4,s4,c4 #fec 7j77 is amended by adding at the end of the following new paragraph3 7#ab7 ,information comparisons and disclosures to assist in administration of the ,medicare program and ,state health subsidy programs 7,a7 ,disclosure to the ,administrator of the ,centers for ,medicare ,medicaid ,services ,the ,administrator of the ,centers for ,medicare ,medicaid shall have access to the information in the ,national ,directory of ,new ,hires for purposes of determining the eligibility of an applicant for1 or enrollee in1 the ,medicare program under title ,,xviii or an applicable ,state health subsidy program 7as defined in section #adac7;e7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjhc7;e7774 7,b7 ,disclosure to the ,inspector ,general of the ,department of ,health and ,human ,services 7i7 ,in general ,if the ,inspector ,general of the ,department of ,health and ,human ,services transmits to the ,secretary the names and social security account numbers of individuals1 the ,secretary shall disclose to the ,inspector ,general information on such individuals and their employers maintained in the ,national ,directory of ,new ,hires4 7ii7 ,use of information ,the ,inspector ,general of the ,department of ,health and ,human ,services may use information provided under clause 7i7 only for purposes of-- 7,i7 determining the eligibility of an applicant for1 or enrollee in1 the ,medicare program under title ,,xviii or an applicable ,state health subsidy program 7as defined in section #adac7;e7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjhc7;e7772 or 7,,ii7 evaluating the integrity of the ,medicare program or an applicable ,state health subsidy program 7as so defined74 7,c7 ,disclosure to ,state agencies 7i7 ,in general ,if1 for purposes of administering an applicable ,state health subsidy program 7as defined in section #adac7;e7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjhc7;e7771 a ,state agency responsible for administering such program transmits to the ,secretary the names and social security account numbers of individuals1 the ,secretary shall disclose to such ,state agency information on such individuals and their employers maintained in the ,national ,directory of ,new ,hires1 subject to this subparagraph4 7ii7 ,condition on disclosure by the ,secretary ,the ,secretary shall make a disclosure under clause 7i7 only to the extent that the ,secretary determines that the disclosure would not interfere with the effective operation of the program under this part4 7iii7 ,use and disclosure of information by ,state agencies 7,i7 ,in general ,a ,state agency may not use or disclose information provided under clause 7i7 except for purposes of administering a program referred to in clause 7i74 7,,ii7 ,information security ,the ,state agency shall have in effect data security and control policies that the ,secretary finds adequate to ensure the security of information obtained under clause 7i7 and to ensure that access to such information is restricted to authorized persons for purposes of authorized uses and disclosures4 7,,iii7 ,penalty for misuse of information ,an officer or employee of the ,state agency who fails to comply with this clause shall be subject to the sanctions under subsection 7l77#b7 to the same extent as if such officer or employee were an officer or employee of the ,united ,states4 7iv7 ,procedural requirements ,state agencies requesting information under clause 7i7 shall adhere to uniform procedures established by the ,secretary governing information requests and data matching under this paragraph4 7v7 ,reimbursement of costs ,the ,state agency shall reimburse the ,secretary1 in accordance with subsection 7k77#c71 for the costs incurred by the ,secretary in furnishing the information requested under this subparagraph4 4 #bjb4 ,improving the sharing of data between the ,federal ,government and ,state ,medicaid programs 7a7 ,in general ,the ,secretary of ,health and ,human ,services 7in this section referred to as the ,secretary7 shall establish a plan to encourage and facilitate the participation of ,states in the ,medicare-,medicaid ,data ,match ,program 7commonly referred to as the ,medi-,medi ,program7 under section #ahic7;g7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd7g774 7b7 ,program revisions ,to improve ,medi-,medi ,data ,match ,program participation by ,states ,section #ahic7;g77#a77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd7g77#a77;,a77 is amended-- 7#a7 in the matter preceding clause 7i71 by inserting or otherwise after eligible entities2 7#b7 in clause 7i7-- 7,a7 by inserting to review claims data after algorithms2 and 7,b7 by striking service1 time1 or patient and inserting provider1 service1 time1 or patient2 7#c7 in clause 7ii7-- 7,a7 by inserting to investigate and recover amounts with respect to suspect claims after appropriate actions2 and 7,b7 by striking 2 and and inserting a semicolon2 7#d7 in clause 7iii71 by striking the period and inserting 2 and2 and 7#e7 by adding at end the following new clause3 7iv7 furthering the ,secretary's design1 development1 installation1 or enhancement of an automated data system architecture-- 7,i7 to collect1 integrate1 and assess data for purposes of program integrity1 program oversight1 and administration1 including the ,medi-,medi ,program2 and 7,,ii7 that improves the coordination of requests for data from ,states4 4 7c7 ,providing states with data on improper payments made for items or services provided to dual eligible individuals 7#a7 ,in general ,the ,secretary shall develop and implement a plan that allows each ,state agency responsible for administering a ,state plan for medical assistance under title ,,xix of the ,social ,security ,act access to relevant data on improper or fraudulent payments made under the ,medicare program under title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq47 for health care items or services provided to dual eligible individuals4 7#b7 ,dual eligible individual defined ,in this section1 the term dual eligible individual means an individual who is entitled to1 or enrolled for1 benefits under part ,a of title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;c et seq471 or enrolled for benefits under part ,b of title ,,xviii of such ,act 7#db ,u4,s4,c4 #acie;j et seq471 and is eligible for medical assistance under a ,state plan under title ,,xix of such ,act 7#db ,u4,s4,c4 #acif et seq47 or under a waiver of such plan4 #bjc4 ,improving claims processing and detection of fraud within the ,medicaid and ,,chip programs 7a7 ,medicaid ,section #aijc7;i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;b7i771 as amended by section #bjja7;a77#b77;,b7 of the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh71 is amended-- 7#a7 in paragraph 7#be71 by striking or at the end2 7#b7 in paragraph 7#bf71 by striking the period and inserting 2 or2 and 7#c7 by adding after paragraph 7#bf71 the following new paragraph3 7#bg7 with respect to amounts expended for an item or service for which medical assistance is provided under the ,state plan or under a waiver of such plan unless the claim for payment for such item or service contains a valid beneficiary identification number that1 for purposes of the individual who received such item or service1 has been determined by the ,state agency to correspond to an individual who is eligible to receive benefits under the ,state plan or waiver4 4 7b7 ,,chip ,section #bajg7;e77#a77;,i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acig;gg7e77#a77;,i77 is amended by striking and 7#ag7 and inserting 7#ag71 and 7#bg74 ,,iii ,report on implementation #cja4 ,report on implementation ,not later than #bgj days after the date of the enactment of this ,act1 the ,secretary of ,health and ,human ,services shall submit to ,congress a report on the implementation of the provisions of1 and the amendments made by1 this ,act4