,i #aacth ,,congress #b;d ,session ,h4 ,r4 #ejhc ,,in ,,the ,,house ,,of ,,representatives ,july #aa1 #bjad ,mrs4 ,ellmers 7for herself1 ,mr4 ,barrow of ,georgia1 ,mr4 ,braley of ,iowa1 ,mr4 ,duncan of ,tennessee1 and ,mr4 ,thompson of ,pennsylvania7 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 title ,,xviii of the ,social ,security ,act to improve audit effectiveness and efficiency in paying for durable medical equipment1 prosthetics1 orthotics1 and supplies 7,,dmepos7 under the ,medicare program1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,medicare ,,dmepos ,audit ,improvement and ,reform 7,,air7 ,act of #bjad4 #b4 ,improving ,medicare audit effectiveness and efficiency for durable medical equipment1 prosthetics1 orthotics1 and supplies 7,,dmepos7 7a7 ,medicare administrative contractor payment outreach and education program for ,,dmepos suppliers 7#a7 ,in general ,section #ahgd;,a of the ,social ,security ,act 7#db ,u4,s4,c4 #aciekk-#a7 is amended-- 7,a7 in subsection 7a77#d7-- 7i7 by redesignating subparagraph 7,g7 as subparagraph 7,h72 and 7ii7 by inserting after subparagraph 7,f7 the following new subparagraph3 7,g7 ,payment outreach and education program for suppliers of durable medical equipment1 prosthetics1 orthotics1 and supplies 7,,dmepos7 ,implementing a payment outreach and education program for ,,dmepos suppliers under subsection 7h74 2 and 7,b7 by adding at the end the following new subsection3 7h7 ,payment outreach and education program for ,,dmepos suppliers 7#a7 ,in general ,in order to reduce improper payments under part ,b for durable medical equipment1 prosthetics1 orthotics1 and supplies1 each medicare administrative contractor that has responsibility for payment under such part for durable medical equipment1 prosthetics1 orthotics1 and supplies furnished in an area 7in this subsection referred to as a ,medicare ,,dmepos contractor7 shall carry out a program 7in this subsection referred to as the ,,dmepos payment outreach and education program7 under which the contractor1 through outreach1 education1 training1 and technical assistance activities conducted on a quarterly basis1 provides ,,dmepos suppliers1 physicians and practitioners who prescribe ,,dmepos1 and discharge planners and case managers who coordinate ,,dmepos for individuals in such area with the information described in paragraph 7#c7 and with error reduction training under paragraph 7#d74 7#b7 ,forms of activities ,the activities under a ,,dmepos payment outreach and education program shall include the following3 7,a7 ,emails and other electronic communications4 7,b7 ,webinars4 7,c7 ,telephone calls4 7,d7 ,in-person training4 7,e7 ,other forms of communications and assistance determined appropriate by the ,secretary4 7#c7 ,information to be provided through activities ,the information to be provided under a ,,dmepos payment outreach and education program1 with respect to payment for ,,dmepos under part ,b1 shall include all of the following information3 7,a7 ,a list of suppliers' most frequent payment errors and most expensive payment errors over the last quarter4 7,b7 ,specific instructions regarding how to correct or avoid such errors in the future4 7,c7 ,a notice of all new topics that have been approved by the ,secretary for audits conducted by ,medicare contractors in relation to payment for ,,dmepos under part ,b4 7,d7 ,specific instructions to prevent future issues related to such new audits4 7,e7 ,other information determined appropriate by the ,secretary4 7#d7 ,error rate reduction training 7,a7 ,in general ,the activities under a ,,dmepos payment outreach and education program shall include error rate reduction training4 7,b7 ,requirements ,such training shall-- 7i7 be provided at least annually2 and 7ii7 focus on reducing improper ,medicare payments for ,,dmepos4 7,c7 ,invitation ,a ,medicare ,,dmepos contractor with responsibility for payment for ,,dmepos in an area shall ensure that all ,,dmepos suppliers1 physicians and practitioners who prescribe ,,dmepos1 and discharge planners and case managers who coordinate ,,dmepos for individuals in the area are invited to attend the training described in subparagraph 7,a7 either in person or online4 7#e7 ,priority ,a ,medicare ,,dmepos contractor shall give priority to activities under the ,,dmepos payment outreach and education program that will reduce improper ,medicare payments based on technical errors1 medical necessity1 and fraud for ,,dmepos that-- 7,a7 have the highest rate of improper payment under part ,b2 7,b7 have the greatest total dollar amount of such improper payments2 7,c7 are due to clear misapplication or misinterpretation of policies under this title2 7,d7 are clearly due to common and inadvertent clerical or administrative errors2 or 7,e7 are due to other types of errors that the ,secretary determines could be prevented through activities under the program4 7#f7 ,information on improper payments from medicare contractors 7,a7 ,in general ,in order to assist ,medicare ,,dmepos contractors in carrying out ,,dmepos payment outreach and education programs1 the ,secretary shall provide each such contractor with a complete list of improper payments for ,,dmepos identified by recovery audit contractors 7and other contractors performing audit activities relating to payment for ,,dmepos7 with respect to suppliers located in the area being serviced by the ,medicare ,,dmepos contractor4 ,such list shall not include claims for payments that have been denied and are being appealed by the supplier under section #ahfi4 ,such information shall be provided on a quarterly basis4 7,b7 ,information ,the information described in subparagraph 7,a7 shall include the following information3 7i7 ,the suppliers of ,,dmepos that have the highest rate of improper payments under part ,b for ,,dmepos4 7ii7 ,the suppliers of ,,dmepos that have the greatest total dollar amounts of such improper payments4 7iii7 ,the ,,dmepos furnished in the area that has the highest rates of such improper payments4 7iv7 ,the ,,dmepos furnished in the area that is responsible for the greatest total dollar amount of such improper payments4 7v7 ,other information the ,secretary determines would assist ,medicare ,,dmepos contractors in carrying out the ,,dmepos payment outreach and education program4 7,c7 ,format of information ,the information furnished to ,medicare ,,dmepos contractors by the ,secretary under this paragraph shall be transmitted in a manner that permits such contractors to easily identify the ,,dmepos suppliers for which targeted outreach1 education1 training1 and technical assistance would be most effective4 ,in carrying out the preceding sentence1 the ,secretary shall ensure that-- 7i7 the information with respect to improper payments made to such a supplier clearly displays the ,,npi or other identifier of the supplier1 the amount of the improper payment1 and any other information the ,secretary determines appropriate2 and 7ii7 the information is in an electronic1 easily searchable database4 7#g7 ,communications ,all communications with a supplier under a ,,dmepos payment outreach and education program are subject to the standards and requirements of subsection 7g74 7#h7 ,advance notice for policy changes and clarifications ,the ,secretary shall not implement a policy change or clarification for ,,dmepos audit requirements earlier than #f months after the date of publication of such change or clarification in the ,federal ,register4 7#i7 ,funding ,after application of paragraph 7#a77;,c7 of section #ahic7;h71 the ,secretary shall retain a portion of the amounts recovered by ,medicare ,,dmepos contractors under this title with respect to ,,dmepos which shall be available to the ,centers for ,medicare ,medicaid ,services ,program ,management ,account for purposes of carrying out this subsection and to implement corrective actions to help reduce the error rate of payments for ,,dmepos under part ,b4 ,the amount retained under the preceding sentence shall not exceed an amount equal to #be percent of the amounts recovered under section #ahic7;h7 with respect to ,,dmepos4 7#aj7 ,durable medical equipment1 prosthetics1 orthotics1 and supplies and ,,dmepos defined ,in this subsection1 the terms durable medical equipment1 prosthetics1 orthotics1 and supplies and ,,dmepos mean-- 7,a7 durable medical equipment 7as defined in section #ahfa7n77 and supplies used with such equipment1 other than implantable items for which payment may be made under section #ahcc7t72 7,b7 prosthetic devices 7as described in section #ahfa7s77#h771 including items described in section #ahdb7s77#b77;,d72 7,c7 orthotics and prosthetics 7as described in section #ahfa7s77#i772 7,d7 surgical dressings 7as described in section #ahfa7s77#e772 7,e7 home dialysis supplies and equipment 7as described in section #ahfa7s77#b77;,f772 and 7,f7 therapeutic shoes for diabetics 7as described in section #ahfa7s77#ab774 4 7#b7 ,funding conforming amendment ,section #ahic7;h77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd7h77#b77 is amended by inserting or section #ahgd;,a7h77#i7 after paragraph 7#a77;,c74 7#c7 ,transparency ,section #ahic7;h77#h7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd7h77#h77 is amended-- 7,a7 in the first sentence1 by inserting before the period at the end the following3 1 on the use of medicare administrative contractors in conducting audits with respect to durable medical equipment1 prosthetics1 orthotics1 and supplies under section #ahgd;,a1 and on the overturn rates for each level of appeal2 7,b7 by striking ,report4--,the ,secretary and inserting ,report4-- 7,a7 ,in general ,the ,secretary 2 and 7,c7 by adding at the end the following new subparagraph3 7,b7 ,inclusion of certain information 7i7 ,in general ,for reports submitted under this paragraph for #bjae or a subsequent year1 each such report shall include1 with respect to each recovery audit contractor 7and each medicare administrative contractor7 that is responsible for audits relating to payment for durable medical equipment1 prosthetics1 orthotics1 and supplies1 information on the result of all appeals relating to audits for durable medical equipment1 prosthetics1 orthotics1 and supplies for each individual level of appeals with respect to each of the categories of audits described in clause 7ii7 carried out by recovery audit contractors under this subsection or by medicare administrative contractors under section #ahgd;,a4 ,for purposes of such reports and public reporting regarding such reports1 such information relating to audits for orthotics and prosthetics shall be grouped separately from the information relating to audits for durable medical equipment and supplies4 7ii7 ,categories of audits ,for purposes of clause 7i71 each of the following is a separate category of audit3 7,i7 ,automated4 7,,ii7 ,complex4 7,,iii7 ,medical necessity review4 7,,iv7 ,part ,b4 4 7b7 ,adjustment of record request maximum based on error rates ,section #ahic of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd7 is amended by adding at the end the following new subsection3 7j7 ,adjustment of maximum record request threshold for audits for payment for durable medical equipment1 prosthetics1 orthotics1 and supplies 7,,dmepos7 based on supplier error rates 7#a7 ,identification of error rates ,the ,secretary shall determine the audited claims error rates for payment for durable medical equipment1 prosthetics1 orthotics1 and supplies and identify-- 7,a7 those ,,dmepos suppliers with a relatively high error rate with respect to claims for ,,dmepos2 and 7,b7 those ,,dmepos suppliers with a relatively low error rate with respect to such claims or with a steadily decreasing error rate for such claims4 7#b7 ,factors in identification 7,a7 ,analysis ,for purposes of identifying the groups of ,,dmepos suppliers under paragraph 7#a71 the ,secretary shall analyze the following as they relate to the total number and amount of claims submitted by product category and by each ,,dmepos supplier3 7i7 ,the improper payment rates of the supplier4 7ii7 ,the amount of improper payments made to the supplier4 7iii7 ,the frequency of errors made by the supplier over time4 7iv7 ,other information determined appropriate by the ,secretary4 ,in performing such analysis1 the ,secretary shall exclude claims for payment that have been denied and are being appealed by a ,,dmepos supplier under section #ahfi4 7,b7 ,assignment based on composite score ,using a statistically valid sample1 the ,secretary shall assign ,,dmepos suppliers under paragraph 7#a7 based on a composite score determined using the analysis under subparagraph 7,a7 as follows3 7i7 ,suppliers with high1 expensive1 and frequent errors shall receive a high score and be identified as high error suppliers under paragraph 7#a77;,a74 7ii7 ,suppliers with few1 inexpensive1 and infrequent errors shall receive a low score and be identified as low error suppliers under paragraph 7#a77;,b74 7iii7 ,only a small proportion of the total suppliers in any area shall be assigned to either group identified under either such paragraph4 7,c7 ,timeframe of identification 7i7 ,in general ,any identification of a ,,dmepos supplier under paragraph 7#a7 shall be for a period of #ab months4 7ii7 ,reevaluation ,the ,secretary shall reevaluate each such identification at the end of such period4 7iii7 ,use of most current information ,in carrying out the reevaluation under clause 7ii7 with respect to a supplier1 the ,secretary shall-- 7,i7 consider the most current information available with respect to the supplier under the analysis under subparagraph 7,a72 and 7,,ii7 take into account improvement or regression of the supplier4 7#c7 ,adjustment of maximum record requests based on error rate performance ,the ,secretary shall establish procedures under which1 for those ,,dmepos suppliers that are identified-- 7,a7 under paragraph 7#a77;,a7 7relating to a relatively high error rate71 the ,secretary shall increase the maximum record request made by ,medicare ,,dmepos contractors in auditing claims of such suppliers for ,,dmepos2 and 7,b7 under paragraph 7#a77;,b7 7relating to a relatively low or decreasing error rate71 the ,secretary shall decrease the maximum record request made by ,medicare ,,dmepos contractors of such suppliers4 7#d7 ,best performing suppliers have reduced random audits ,in the case of a ,,dmepos supplier that the ,secretary identifies under paragraph 7#a77;,b7 for a year as having an audited claims error rate that is less than #ae percent for a category of ,,dmepos1 the ,secretary shall not conduct more than #a random audit of a claim per product category for the year for such category4 7#e7 ,restoration of clinical inference and judgment ,with respect to the conduct of payment audits of ,,dmepos suppliers respecting ,,dmepos under part ,b1 the ,secretary shall use clinical inference and clinical judgment in the evaluation of medical records and orders when conducting such audits in the same manner as the ,secretary interpreted and applied such clinical judgment to claim reviews before #bjji pursuant to the ,secretary's instruction to contractors4 7#f7 ,treatment of certain documentation created by orthotists and prosthetists ,for purposes of determining under this title the reasonableness and medical necessity of prosthetic devices and orthotics and prosthetics1 documentation created by orthotists and prosthetists relating to the need for such devices1 orthotics1 and prosthetics shall be considered part of the medical record4 7#g7 ,definitions ,in this subsection3 7,a7 ,durable medical equipment1 prosthetics1 orthotics1 and supplies and ,,dmepos ,the terms durable medical equipment1 prosthetics1 orthotics1 and supplies and ,,dmepos have the meaning given such terms in section #ahgd;,a7h77#aj74 7,b7 ,,dmepos supplier ,the term ,,dmepos supplier means an entity that furnishes ,,dmepos to individuals for which payment may be made under part ,b4 7,c7 ,medicare ,,dmepos contractor ,the term ,medicare ,,dmepos contractor means a recovery audit contractor and any other contractor 7including a medicare administrative contractor7 that performs pre-pay or post-pay audits with respect to claims for payment for ,,dmepos under part ,b4 4 7c7 ,application of timely filing limits to reoccurring ,,dmepos claims subject to payment audits ,section #ahdb7;b77#c77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieu7b77#c77;,b77 is amended by inserting before the semicolon at the end the following3 1 except that the reopening of a claim by a ,medicare ,,dmepos contractor 7as defined in section #ahic7;j77#g77 in a post-payment audit or a claim denial in a prepayment audit for ,,dmepos 7as defined in such section7 shall toll the timely claim filing limits under this part such that the ,secretary may not prohibit a ,,dmepos supplier 7as defined in such section7 from taking an appeal from the determination of a claim in a pre- or post-payment audit1 or the submission or resubmission for payment of any claims that follow sequentially from the audited claim on the basis that the timely claim filing limits have expired4 7d7 ,maximum audit documentation review period of #c years for ,medicare contractors 7#a7 ,r,a,cs ,section #ahic7;h77#d77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd7h77#d77;,b77 is amended by striking #d fiscal years and inserting #c fiscal years4 7#b7 ,in overpayment of claims ,the last sentences of subsections 7b7 and 7c7 of section #ahgj of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;gg7 are each amended by striking fifth year and five-year and inserting third year and three-year1 respectively4 7#c7 ,limitation on audit documentation review period ,section #ahgd;,a7a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciekk-#a7;a77 is amended by adding at the end the following new paragraph3 7#g7 ,limitation on audit documentation review period ,the ,secretary shall limit the audit documentation review period for medicare administrative contractors to #c years4 4 7#d7 ,effective date ,the amendments made by this subsection shall apply with respect to payments made for items and services furnished on or after the date of the enactment of this ,act4