,i #aadth ,,congress #ast ,session ,h4 ,r4 #baef ,,in ,,the ,,house ,,of ,,representatives ,april #cj1 #bjae ,mr4 ,graves of ,missouri 7for himself1 ,mr4 ,schiff1 ,mr4 ,bost1 ,mrs4 ,wagner1 and ,mr4 ,crawford7 introduced the following bill2 which was referred to the ,committee on ,ways and ,means1 and in addition to the ,committee on ,energy and ,commerce1 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 reform the practices of recovery audit contractors under the ,medicare program1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,medicare ,audit ,improvement ,act of #bjae4 #b4 ,reforming the practices of recovery audit contractors under the ,medicare program 7a7 ,elimination of contingency fee payment system ,section #ahic7;h7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd7h77 is amended-- 7#a7 in paragraph 7#a71 by inserting 1 for recovery activities conducted during a fiscal year before fiscal year #bjae after ,under the contracts2 and 7#b7 by adding at the end the following new paragraph3 7#aa7 ,payment for recovery activities performed after fiscal year #bjad 7,a7 ,in general ,under the contracts1 subject to paragraphs 7,b7 and 7,c71 payment shall be made to recovery audit contractors for recovery activities conducted during fiscal year #bjae and each fiscal year thereafter in the same manner1 and from the same amounts1 as payment is made to eligible entities under contracts entered into for recovery activities conducted during fiscal year #bjad under subsection 7a74 7,b7 ,prohibition on incentive payments ,under the contracts1 payment made to a recovery audit contractor for recovery activities conducted during fiscal year #bjae or any fiscal year thereafter may not include any incentive payments4 7,c7 ,performance accountability 7i7 ,in general ,under the contracts1 payment made to a recovery audit contractor for recovery activities conducted during fiscal year #bjae or any fiscal year thereafter shall1 in the case that the contractor has a complex audit denial overturn rate at the end of such fiscal year 7as calculated under the methodology described in clause 7iv77 that is 4#a or greater1 be reduced in an amount determined in accordance with clause 7ii74 7ii7 ,payment reductions 7,i7 ,sliding scale of amount of reductions ,the ,secretary shall establish1 for purposes of determining the amount of a reduction in payment to a recovery audit contractor under clause 7i7 for recovery activities conducted during fiscal year1 a linear sliding scale of payment reductions for recovery audit contractors for such fiscal year4 ,under such linear sliding scale1 the amount of such a reduction in payment to a recovery audit contractor for a fiscal year shall be calculated in a manner that provides for such reduction to be greater than the reduction for such fiscal year for recovery audit contractors that have complex audit denial overturn rates at the end of such fiscal year 7as calculated under the methodology described in clause 7iv77 that are lower than the complex audit denial overturn rate of the contractor at the end of such fiscal year 7as so calculated74 7,,ii7 ,manner of collecting reduction ,the ,secretary may assess and collect the reductions in payment to recovery audit contractors under clause 7i7 in such manner as the ,secretary may specify 7such as by reducing the amount paid to the contractor for recovery activities conducted during a fiscal year or by assessing the reduction as a separate penalty payment to be paid to the ,secretary by the contractor with respect to each complex audit denial issued by the contractor that is overturned on appeal74 7iii7 ,timing of determinations of payment reductions ,the ,secretary shall1 with respect to a recovery audit contractor1 determine not later than six months after the end of a fiscal year-- 7,i7 whether to reduce payment to the recovery audit contractor under clause 7i7 for recovery activities conducted during such fiscal year2 and 7,,ii7 in the case that the ,secretary determines to so reduce payment to the contractor1 the amount of such payment reduction4 7iv7 ,methodology for calculation of overturned complex audit denial overturn rate 7,i7 ,calculation of overturn rate ,the ,secretary shall calculate a complex audit denial overturn rate for a recovery audit contractor for a fiscal year by-- 7aa7 determining1 with respect to the contract entered into under paragraph 7#a7 by the contractor1 the number of complex audit denials issued by the contractor under the contract 7including denials issued before such fiscal year and during such fiscal year7 that are overturned on appeal2 and 7bb7 dividing the number determined under item 7aa7 by the number of complex audit denials issued by the contractor under such contract 7including denials issued before such fiscal year and during such fiscal year74 7,,ii7 ,fairness and transparency ,the ,secretary shall calculate the percentage described in subclause 7,i7 in a fair and transparent manner4 7,,iii7 ,accounting for subsequently overturned appeals ,the ,secretary shall calculate the percentage described in subclause 7,i7 in a manner that accounts for the likelihood that complex audit denials issued by the contractor for such fiscal year will be overturned on appeal in a subsequent fiscal year4 7,,iv7 ,complex audit denial defined ,in this subparagraph1 the term complex audit denial means a denial by a recovery audit contractor of a claim for payment under this title submitted by a hospital1 psychiatric hospital1 or critical access hospital that is so denied by the contractor after the contractor has-- 7aa7 requested that the hospital1 psychiatric hospital1 or critical access hospital1 in order to support such claim for payment1 provide supporting medical records to the contractor2 and 7bb7 reviewed such medical records in order to determine whether an improper payment has been made to the hospital1 psychiatric hospital1 or critical access hospital for such claim4 7,v7 ,overturned on appeal defined ,in this subparagraph1 the term overturned on appeal means1 with respect to a complex audit denial1 a denial that is overturned on appeal at the reconsideration level1 the redetermination level1 or the administrative law judge hearing level4 7,d7 ,application to existing contracts ,not later than #fj days after the date of the enactment of this paragraph1 the ,secretary shall modify1 as necessary1 each contract under paragraph 7#a7 that the ,secretary entered into prior to such date of enactment in order to ensure that payment with respect to recovery activities conducted under such contract is made in accordance with the requirements described in this paragraph4 4 7b7 ,elimination of one-,year timely filing limit ,to rebill part ,b claims 7#a7 ,in general ,section #ahdb7;b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieu7b77 is amended by adding at the end the following new paragraph3 7#bj7 ,exception to the one-year timely filing limit for certain rebilled claims 7,a7 ,in general ,in the case of a claim submitted under this part by a hospital 7as defined in subparagraph 7,b77i77 for hospital services with respect to which there was a previous claim submitted under part ,a as inpatient hospital services or inpatient critical access hospital services that was denied by a ,medicare contractor 7as defined in subparagraph 7,b77ii77 because of a determination that the inpatient admission was not medically reasonable and necessary under section #ahfb7;a77#a77;,a71 the deadline described in this paragraph is #ahj days from the date of the final denial of such claim under part ,a4 7,b7 ,definitions ,in this paragraph3 7i7 ,hospital ,the term hospital has the meaning given such term in section #ahfa7;e71 and includes a psychiatric hospital 7as defined in section #ahfa7;f77 and a critical access hospital 7as defined in section #ahfa7mm77#a774 7ii7 ,medicare contractor ,the term ,medicare contractor has the meaning given such term under section #ahhi7;g71 and includes a recovery audit contractor with a contract under section #ahic7;h74 7iii7 ,final denial ,the term final denial means-- 7,i7 in the case that a hospital elects not to appeal a denial described in subparagraph 7,a7 by a ,medicare contractor1 the date of such denial2 or 7,,ii7 in the case that a hospital elects to appeal a such a denial1 the date on which such appeal is exhausted4 4 7#b7 ,conforming amendments 7,a7 ,section #ahce7;a77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acien7a77#a77 is amended by inserting or1 in the case of a claim described in section #ahdb7;b77#bj71 the no later than the deadline described in such paragraph after the date of service4 7,b7 ,section #ahdb7;b77#c77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieu7b77#c77;,b77 is amended in the flush language following clause 7ii7 by inserting or1 in the case of a claim described in section #ahdb7;b77#bj71 the no later than the deadline described in such paragraph after the date of service4 7#c7 ,effective date ,the amendments made by this subsection shall take effect on the date of the enactment of this ,act and shall apply to claims submitted under part ,b of title ,,xviii of the ,social ,security ,act for hospital services for which there was a previous claim submitted under part ,a as inpatient hospital services or inpatient critical access hospital services that was subject to a final denial 7as defined in paragraph 7#bj77;,b77iii7 of section #ahdb7;b7 of such ,act 7#db ,u4,s4,c4 #acieu7b77 on or after such date of enactment4 7c7 ,medical documentation considered for medical necessity reviews of claims for inpatient hospital services ,section #ahfb7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciey7a77 is amended by adding at the end the following new sentence3 ,a determination under paragraph 7#a7 of whether inpatient hospital services or inpatient critical access hospital services furnished to an individual on or after the date of the enactment of this sentence are reasonable and necessary shall be based solely upon information available to the admitting physician at the time of the inpatient admission of the individual for such inpatient services1 as documented in the medical record4