,,ii ,calendar ,no4 #cag #aadth ,,congress #ast ,session ,s4 #bcfh ,report ,no4 #aad-agg ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,december #h1 #bjae ,mr4 ,hatch1 from the ,committee on ,finance1 reported the following original bill2 which was read twice and placed on the calendar ,a ,,bill ,to amend title ,,xviii of the ,social ,security ,act to improve the efficiency of the ,medicare appeals process1 and for other purposes4 #a4 ,short title2 table of contents 7a7 ,short title ,this ,act may be cited as the ,audit ,appeals ,fairness1 ,integrity1 and ,reforms in ,medicare ,act of #bjae or the ,,afirm ,act4 7b7 ,table of contents ,the table of contents for this ,act is as follows3 ,sec4 #a4 ,short title2 table of contents4 ,sec4 #b4 ,increased resources for the ,office of ,medicare ,hearings and ,appeals and the ,departmental ,appeals ,board4 ,sec4 #c4 ,establishment of ,medicare magistrate review and revision of amount in controversy thresholds4 ,sec4 #d4 ,remanding appeals to the redetermination level with the introduction of new evidence4 ,sec4 #e4 ,expedited access to appeals4 ,sec4 #f4 ,authority to use sampling and extrapolation methodologies and to consolidate appeals for administrative efficiency4 ,sec4 #g4 ,identification and referral of fraud4 ,sec4 #h4 ,study to assess hearing participation4 ,sec4 #i4 ,improvements to the ,office of ,medicare ,hearings and ,appeals4 ,sec4 #aj4 ,review program improvements4 ,sec4 #aa4 ,creation of ,medicare ,provider and ,supplier ,ombudsman for ,reviews and ,appeals4 ,sec4 #ab4 ,limiting the audit and recovery period for patient status reviews4 ,sec4 #ac4 ,incentives and disincentives for ,medicare contractors1 providers1 and suppliers4 #b4 ,increased resources for the ,office of ,medicare ,hearings and ,appeals and the ,departmental ,appeals ,board 7a7 ,in general ,for fiscal year #bjaf and for each fiscal year thereafter1 for purposes of conducting reviews1 hearings1 and appeals under title ,,xviii of the ,social ,security ,act1 the ,secretary of ,health and ,human ,services shall provide for the transfer from the ,federal ,hospital ,insurance ,trust ,fund under section #ahag of such ,act 7#db ,u4,s4,c4 #acie;i7 and the ,federal ,supplementary ,insurance ,trust ,fund under section #ahda of such ,act 7#db ,u4,s4,c4 #aciet71 in such proportion as the ,secretary may determine1 of-- 7#a7 #abe1jjj1jjj to the ,office of ,medicare ,hearings and ,appeals2 and 7#b7 #b1jjj1jjj to the ,departmental ,appeals ,board of the ,department of ,health and ,human ,services4 ,amounts transferred under the preceding sentence shall be in addition to any other amounts that may be available for such purposes and shall remain available until expended4 7b7 ,,gao study and report 7#a7 ,study ,the ,comptroller ,general of the ,united ,states shall conduct a study of the use of the amount made available to the ,office of ,medicare ,hearings and ,appeals under subsection 7a7 to determine whether the availability of such amounts led to any improvements in the ,medicare appeals program1 such as an increased number of appeals processed or a decrease in the time required to process an appeal4 7#b7 ,report ,not later than ,december #ca1 #bjah1 the ,comptroller ,general of the ,united ,states shall submit a report to ,congress on the study required under paragraph 7#a71 together with recommendations for such legislative and administrative actions as the ,comptroller ,general determines appropriate4 #c4 ,establishment of ,medicare magistrate review and revision of amount in controversy thresholds 7a7 ,establishment of ,medicare magistrate program 7#a7 ,in general ,section #ahfi7;b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7b77 is amended by adding at the end the following new paragraph3 7#d7 ,conduct of reviews by ,medicare magistrates 7,a7 ,in general ,the ,secretary shall establish within the ,office of ,medicare ,hearings and ,appeals decision-making officials to be known as ,medicare magistrates4 7,b7 ,medicare magistrate defined ,for purposes of this section1 the term ,medicare magistrate means an attorney who is licensed by a ,state1 has expertise in this title 7including regulations and policies promulgated thereunder71 meets such other qualifications as the ,secretary shall require1 and who performs reviews and renders decisions in appeals described in paragraph 7#a77;,e77i77,,ii74 7,c7 ,requirements for reviews conducted by magistrates ,the provisions of this subsection and subsection 7d7 that govern hearings and decisions by administrative law judges 7including provisions related to reviews of decisions by administrative law judges by the ,departmental ,appeals ,board of the ,department of ,health and ,human ,services7 shall apply to reviews and decisions by ,medicare magistrates in the same manner and to the same extent as such provisions apply to hearings and decisions by an administrative law judge4 ,the ,secretary may establish by regulation such other requirements and procedures as may be necessary so that reviews by ,medicare magistrates are resolved fairly1 efficiently1 and expeditiously4 4 7#b7 ,conforming amendment ,section #ahfi7;b77#a77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7b77#a77;,a77 is amended by inserting and paragraph 7#d7 after subject to subparagraphs 7,d7 and 7,e74 7b7 ,amount in controversy thresholds 7#a7 ,in general ,section #ahfi7;b77#a77;,e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7b77#a77;,e77 is amended-- 7,a7 by striking clause 7i7 and inserting the following3 7i7 ,in general ,except as otherwise provided in this section1 subject to clause 7iii7-- 7,i7 a review by a ,medicare magistrate under paragraph 7#d71 or a hearing by an administrative law judge under this subsection or subsection 7d71 shall not be available to an individual if the amount in controversy is less than #aej2 7,,ii7 a review by a ,medicare magistrate under paragraph 7#d7 shall be available to an individual if the amount in controversy is equal to or greater than the amount specified in subclause 7,i7 but less than the amount specified in subclause 7,,iii72 and 7,,iii7 a hearing by an administrative law judge shall be available to an individual under this subsection or subsection 7d7 if the amount in controversy is equal to or greater than #a1ejj4 2 7,b7 in clause 7iii7-- 7i7 by striking ,for requests for hearings and inserting ,for requests for ,medicare magistrate reviews1 hearings12 7ii7 by striking #bjjd and inserting #bjag2 and 7iii7 by striking #bjjc and inserting #bjaf2 and 7,c7 by adding at the end the following new clause3 7iv7 ,judicial review ,judicial review shall not be available to an individual under this section if the amount in controversy is less than the amount specified in clause 7i77,,iii74 4 7#b7 ,conforming amendments 7,a7 ,section #aaee of the ,social ,security ,act 7#db ,u4,s4,c4 #acbj;c-#d7 is amended-- 7i7 in the second sentence1 by striking #bjj or more and inserting equal to or greater than the amount specified in section #ahfi7;b77#a77;,e77i77,,iii72 7ii7 in the fourth sentence1 by striking #b1jjj or more and inserting equal to or greater than the amount specified in section #ahfi7;b77#a77;,e77i77,,iii72 and 7iii7 by adding at the end the following new sentences3 ,where the amount in controversy is equal to or greater than the amount specified in subclause 7,i7 of section #ahfi7;b77#a77;,e77i7 but less than the amount specified in subclause 7,,iii7 of such section1 such beneficiary shall be entitled to a review by a ,medicare magistrate in accordance with procedures established by the ,secretary pursuant to section #ahfi4 ,the provisions of section #ahfi7;b77#a77;,e77iii7 shall apply with respect to the dollar amounts referred to in this section in the same manner as they apply to the dollar amounts specified in section #ahfi7;b77#a77;,e77i744 7,b7 ,section #aheb7;g77#e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7;g77#e77 is amended-- 7i7 in the first sentence1 by striking #ajj or more and inserting equal to or greater than the amount specified in section #ahfi7;b77#a77;,e77i77,,iii72 7ii7 in the second sentence1 by striking #a1jjj or more and inserting equal to or greater than the amount specified in section #ahfi7;b77#a77;,e77i77,,iii72 7iii7 by inserting after the second sentence the following new sentence3 ,if the amount in controversy is equal to or greater than the amount specified in subclause 7,i7 of section #ahfi7;b77#a77;,e77i7 but less than the amount specified in subclause 7,,iii7 of such section1 such enrollee shall be entitled to review by a ,medicare magistrate in accordance with procedures established by the ,secretary pursuant to section #ahfi42 and 7iv7 in the last sentence1 by striking the first #b sentences of4 7,c7 ,section #ahgf7;c77#e77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciemm7c77#e77;,b77 is amended-- 7i7 in the first sentence1 by striking #ajj or more and inserting equal to or greater than the amount specified in section #ahfi7;b77#a77;,e77i77,,iii72 7ii7 in the second sentence1 by striking #a1jjj or more and inserting equal to or greater than the amount specified in section #ahfi7;b77#a77;,e77i77,,iii72 7iii7 by inserting after the second sentence the following new sentence3 ,if the amount in controversy is equal to or greater than the amount specified in subclause 7,i7 of section #ahfi7;b77#a77;,e77i7 but less than the amount specified in subclause 7,,iii7 of such section1 such member shall be entitled to review by a ,medicare magistrate in accordance with procedures established by the ,secretary pursuant to section #ahfi42 and 7iv7 in the last sentence1 by striking the first #b sentences of4 7c7 ,calculation of amount in controversy for the aggregation of claims ,section #ahfi7;b77#a77;,e77ii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7b77#a77;,e77ii77 is amended-- 7#a7 by redesignating subclauses 7,i7 and 7,,ii7 as items 7aa7 and 7bb71 respectively1 and indenting appropriately2 7#b7 in the matter preceding item 7aa71 as so redesignated1 by striking if the appeals involve and inserting the following3 8if-- 7,i7 the appeals involve-- 2 7#c7 in item 7bb71 as so redesignated1 by striking the period at the end and inserting 2 and2 and 7#d7 by adding at the end the following new subclause3 7,,ii7 all claims that an individual seeks to aggregate are included in the same request for an aggregated appeal4 4 7d7 ,effective date ,the amendments made by this section shall take effect on ,january #a1 #bjag4 #d4 ,remanding appeals to the redetermination level with the introduction of new evidence 7a7 ,in general ,section #ahfi7;b77#c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7b77#c77 is amended by striking ,a provider of services and all that follows through the period and inserting the following new subparagraphs3 7,a7 ,remand upon submission of new evidence 7i7 ,in general ,except as provided in subparagraph 7,b71 when a party to an appeal1 other than an individual entitled to1 or enrolled for1 benefits under part ,a or enrolled under part ,b or the ,centers for ,medicare ,medicaid ,services or its contractors1 introduces new evidence into the administrative record at a reconsideration conducted by a qualified independent contractor under subsection 7c7 or at any subsequent1 higher level of appeal1 the appeal shall be remanded for a de novo redetermination under subsection 7a77#c71 and any prior decisions 7other than the initial determination made by the ,secretary pursuant to subsection 7a77#a77 on this appeal shall be vacated4 7ii7 ,requirements ,for purposes of clause 7i71 except to the extent otherwise provided by the ,secretary in regulations1 the provisions that apply to redeterminations under subsection 7a7 and this subsection shall apply to redeterminations of appeals that are remanded4 7,b7 ,exceptions ,the provisions of subparagraph 7,a7 shall not apply in instances where an adjudicator determines that introduction of new evidence is justified due to-- 7i7 an inadvertent omission or erroneous decision by a lower-level adjudicator to omit the evidence from the administrative record when that evidence was timely submitted to the lower-level adjudicator by a party to the appeal2 7ii7 a decision by a lower-level adjudicator to issue an unfavorable decision based on new or different grounds than were previously adjudicated2 or 7iii7 such other circumstances for good cause as the ,secretary may establish4 7,c7 ,no appeal ,a decision to remand an appeal under this paragraph shall not be subject to appeal4 4 7b7 ,effective date ,the amendments made by this section shall take effect on ,january #a1 #bjag4 #e4 ,expedited access to appeals 7a7 ,in general ,section #ahfi7;b77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7b77#a77 is amended by adding at the end the following new subparagraph3 7,h7 ,expedited access to appeals 7i7 ,decision on the record ,not later than ,january #a1 #bjag1 the ,secretary shall establish by regulation and implement a process authorizing an administrative law judge reviewing a decision pursuant to this subsection or subsection 7d7 to issue a decision on the record in cases where1 based on the evidence of record1 there are no material issues of fact in dispute and the administrative law judge determines that there is a binding authority that controls the decision in the matter under review4 7ii7 ,expedited access to judicial review not requested by appellant ,the ,secretary shall by regulation establish a process authorizing an administrative law judge reviewing a decision pursuant to this subsection or subsection 7d7 to certify the appeal for expedited access to judicial review where-- 7,i7 the appellant does not request expedited access to judicial review pursuant to paragraph 7#b72 7,,ii7 there are no material issues of fact in dispute2 and 7,,iii7 neither the administrative law judge nor the ,departmental ,appeals ,board has authority to decide the questions of law or regulation relevant to the matters in controversy4 7iii7 ,application of hearing rules to decisions on the record ,the provisions of subsection 7d7 that govern hearings by administrative law judges shall apply to a decision issued by an administrative law judge without a hearing pursuant to clause 7i7 in the same manner and to the same extent as such provisions apply to a hearing by an administrative law judge4 7iv7 ,effect of certification for judicial review ,notwithstanding subsection 7d77#b71 a decision to certify an appeal pursuant to clause 7ii7 shall not be subject to further review by the ,secretary and shall be deemed a final decision by the ,secretary as provided in section #bje7;g7 7as applied to this section7 for purposes of determining an individual's entitlement to judicial review4 4 7b7 ,conforming amendments 7#a7 ,section #aaee of the ,social ,security ,act 7#db ,u4,s4,c4 #acbj;c-#d71 as amended by section #c7;b77#b77;,a71 is amended-- 7,a7 in the second sentence1 by striking ,where and inserting ,subject to the succeeding sentences of this section1 where2 and 7,b7 by adding at the end the following new sentence3 ,the provisions of subparagraph 7,h7 of section #ahfi7;b77#a7 shall apply with respect to decisions by an administrative law judge under this section in the same manner as they apply to decisions by an administrative law judge under such subparagraph 7,h744 7#b7 ,section #aheb7;g77#e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7;g77#e771 as amended by section #c7;b77#b77;,b71 is amended-- 7,a7 in the first sentence1 by striking ,an enrollee and inserting ,subject to the succeeding sentences of this paragraph1 an enrollee2 and 7,b7 by adding at the end the following new sentence3 ,the provisions of subparagraph 7,h7 of section #ahfi7;b77#a7 shall apply with respect to decisions by an administrative law judge under this paragraph in the same manner as they apply to decisions by an administrative law judge under such subparagraph 7,h744 7#c7 ,section #ahfi7;b77#a77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7b77#a77;,a771 as amended by section #c7;a77#b71 is amended by striking subparagraphs 7,d7 and 7,e7 and inserting subparagraphs 7,d71 7,e71 and 7,h74 7#d7 ,section #ahgf7;c77#e77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciemm7c77#e77;,b771 as amended by section #c7;b77#b77;,c71 is amended-- 7,a7 in the first sentence1 by striking ,a member and inserting ,subject to the succeeding sentences of this subparagraph1 a member2 and 7,b7 by adding at the end the following new sentence3 ,the provisions of subparagraph 7,h7 of section #ahfi7;b77#a7 shall apply with respect to decisions by an administrative law judge under this subparagraph in the same manner as they apply to decisions by an administrative law judge under such subparagraph 7,h744 7c7 ,effective date ,the amendments made by subsections 7a7 and 7b7 shall take effect on the date of the enactment of this ,act and shall apply to cases that are pending as of such date4 #f4 ,authority to use sampling and extrapolation methodologies and to consolidate appeals for administrative efficiency 7a7 ,in general ,section #ahfi of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7 is amended by adding at the end the following new subsection3 7j7 ,authorities ,to promote administrative efficiencies 7#a7 ,authority to consolidate appeals 7,a7 ,in general ,any individual or entity conducting redeterminations1 reconsiderations1 reviews1 or hearings under subsection 7a77#c71 7b71 7c71 or 7d7 7in this section1 referred to as an adjudicator7 may consolidate pending requests for review into a single action1 and may issue a single decision1 or separate decisions1 with respect to such review requests-- 7i7 if such requests involve one or more common questions of fact or law for similar claims submitted by the same individual or entity2 7ii7 if such requests involve claims that were included within a statistical sample during the initial determination or any previous level of appeal2 7iii7 if the appellant requests aggregation of two or more claims under subsection 7b77#a77;,e77ii72 or 7iv7 in any other case in which the adjudicator determines that consolidation would promote administrative efficiency1 consistent with such standards as the ,secretary shall establish by regulation4 7,b7 ,deadlines ,the ,secretary may establish the applicable timeframe for requesting consolidations and for issuing decisions on appeals that have been consolidated4 7#b7 ,requirements for claims that were included in an extrapolated overpayment or previously consolidated ,an individual or entity requesting a redetermination1 reconsideration1 review or hearing under subsection 7a77#c71 7b71 7c71 or 7d7 with respect to two or more claims that were included in an extrapolated overpayment1 or claims that were consolidated into a single appeal at a lower-level adjudication under this section1 must submit a single request for review or hearing with respect to such claims in order to be entitled to a review or hearing4 7#c7 ,authority to use statistical sampling and extrapolation methodologies in adjudications ,with the consent of the appellant1 an adjudicator may use statistical sampling and extrapolation methodologies in reaching a decision with respect to a claim or claims for benefits for items or services furnished under part ,a or ,b4 ,when an appeal involves a decision that was based on a statistical sample at the lower level1 the adjudicator's decision shall be based on the same statistical sample4 4 7b7 ,effective date ,the amendments made by this section shall apply to requests for review that are pending at any level of appeal as of the date of the enactment of this ,act and to those filed after such date4 #g4 ,identification and referral of fraud ,not later than ,january #a1 #bjag1 the ,secretary of ,health and ,human ,services1 in consultation with the ,inspector ,general of the ,department of ,health and ,human ,services and the ,attorney ,general of the ,united ,states1 shall establish and implement a process under which the ,office of ,medicare ,hearings and ,appeals and the ,departmental ,appeals ,board of the ,department of ,health and ,human ,services shall refer cases in which there is a credible suspicion of fraudulent activity to appropriate law enforcement agencies and to the ,centers for ,medicare ,medicaid ,services4 #h4 ,study to assess hearing participation 7a7 ,study ,not later than ,january #a1 #bjag1 the ,secretary of ,health and ,human ,services shall conduct a study to determine whether it would be feasible to increase the participation1 with respect to hearings conducted by the ,office of ,medicare ,hearings and ,appeals1 of-- 7#a7 the ,centers for ,medicare ,medicaid ,services2 7#b7 entities serving as qualified independent contractors under section #ahfi7;c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7c772 7#c7 entities serving as medicare administrative contractors under section #ahgd;,a of such ,act 7#db ,u4,s4,c4 #aciekk-#a72 7#d7 entities services as recovery audit contractors under section #ahic7;h7 of such ,act 7#db ,u4,s4,c4 #acie;ddd7h772 and 7#e7 other ,medicare claims review entities determined appropriate by the ,secretary4 7b7 ,report ,not later than #a year after the date of the enactment of this ,act1 the ,secretary of ,health and ,human ,services shall publish a report containing the results of the study required under subsection 7a7 on the ,internet website of the ,department of ,health and ,human ,services4 #i4 ,improvements to the ,office of ,medicare ,hearings and ,appeals 7a7 ,training for ,a,l,js and ,medicare magistrates ,section #ahfi7;e77#c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7e77#c77 is amended-- 7#a7 in the paragraph heading1 by striking and administrative law judges and inserting 1 administrative law judges1 and ,medicare magistrates2 ,annual training for administrative law judges and ,medicare magistrates2 7#b7 by striking ,the ,secretary and inserting the following3 7,a7 ,continuing education requirement ,the ,secretary 2 7#c7 by inserting and1 beginning in #bjag1 to ,medicare magistrates after administrative law judges the first place it appears2 7#d7 by striking and administrative law judges and inserting 1 administrative law judges1 and ,medicare magistrates2 and 7#e7 by adding at the end the following new subparagraph3 7,b7 ,annual training ,beginning with #bjag1 each year the ,secretary shall provide to each administrative law judge and ,medicare magistrate within the ,office of ,medicare ,hearings and ,appeals training on ,medicare policies1 including any policies that were changed or instituted in the previous year4 4 7b7 ,treatment of ,,qic decisions ,section #ahfi7;d77#d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7d77#d77 is amended-- 7#a7 in subparagraph 7,b71 by striking and at the end2 7#b7 in subparagraph 7,c71 by striking the period at the end and inserting 2 and2 and 7#c7 by adding at the end the following new subparagraph3 7,d7 in the case of a review conducted on or after ,january #a1 #bjag1 of a decision by a qualified independent contractor in which the administrative law judge reaches a different decision than the qualified independent contractor1 the reasons why the decision of the administrative law judge differs from the decision of the qualified independent contractor4 4 7c7 ,publication of appeals information ,section #ahfi7;e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7e77 is amended by adding at the end the following new paragraph3 7#e7 ,publication of appeals information ,not later than ,january #a1 #bjag1 and annually thereafter1 the ,secretary of ,health and ,human ,services shall publish and maintain on the ,internet website of the ,department of ,health and ,human ,services the following information1 which may be effectuated through the use of statistical sampling1 regarding appeals heard by the ,office of ,medicare ,hearings and ,appeals for each fiscal year3 7,a7 ,the percentage of appeals that received fully favorable1 partially favorable1 and unfavorable decisions4 7,b7 ,for each administrative law judge1 the percentage of appeals that received fully favorable1 partially favorable1 and unfavorable decisions4 7,c7 ,for each type of service1 the percentage of appeals that received fully favorable1 partially favorable1 and unfavorable decisions4 7,d7 ,the average length of time elapsed between the initial request for review and a final decision4 7,e7 ,such other information as the ,secretary determines necessary to ensure greater transparency for the ,office of ,medicare ,hearings and ,appeals4 4 7d7 ,,gao review of consistency of ,,omha decisions 7#a7 ,study 7,a7 ,in general ,the ,comptroller ,general of the ,united ,states shall conduct a study of decisions rendered by the ,office of ,medicare ,hearings and ,appeals to determine the frequency with which decisions by administrative law judges or ,medicare magistrates-- 7i7 diverge from the interpretation of ,medicare policy and program instruction of the ,centers for ,medicare ,medicaid ,services2 7ii7 demonstrate significant variation in the interpretation of similar ,medicare policies or instructions2 and 7iii7 fail to apply applicable ,medicare law1 regulation1 policy1 or instruction4 7,b7 ,methodology ,in conducting the study required under this paragraph1 the ,comptroller ,general of the ,united ,states shall focus on decisions rendered by the ,office of ,medicare ,hearings and ,appeals not less than #a year after the date of the enactment of this ,act and1 if the ,comptroller so chooses1 may use sampling to identify decisions to evaluate4 7#b7 ,report ,not later than ,january #a1 #bjah1 the ,comptroller ,general of the ,united ,states shall submit a report to ,congress on the study required under paragraph 7#a71 together with recommendations for such legislative and administrative actions as the ,comptroller ,general determines appropriate4 7e7 ,identification of inconsistent interpretations of policies across review entities ,not later than ,january #a1 #bjag1 the ,secretary of ,health and ,human ,services shall establish and implement a process for identifying policies or coverage determinations relating to title ,,xviii of the ,social ,security ,act that are most frequently interpreted and applied differently by review entities1 ,medicare magistrates1 administrative law judges1 or the ,department ,appeals ,board of the ,department of ,health and ,human ,services4 ,as a part of such process1 the ,secretary shall1 where appropriate1 issue guidance or take other administrative action to clarify how a policy or coverage decision should be interpreted in order to prevent future conflicting interpretations4 7f7 ,study and report on administrative law judge specialization 7#a7 ,study ,the ,secretary of ,health and ,human ,services shall conduct a study to determine if the specialization of administrative law judges within the ,office of ,medicare ,hearings and ,appeals by type of appeal would lead to more consistent decisions by administrative law judges determining cases with similar facts4 7#b7 ,report ,not later than ,january #a1 #bjah1 the ,secretary of ,health and ,human services shall submit to ,congress a report containing the results of the study required under paragraph 7#a71 together with recommendations for such legislative and administrative action as the ,secretary determines appropriate4 7g7 ,alternative dispute resolution 7#a7 ,in general ,section #ahfi7;b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7b771 as amended by section #c7;a71 is amended by adding at the end the following new paragraph3 7#e7 ,alternative dispute resolution 7,a7 ,in general 7i7 ,redetermination and reconsideration ,,adr process ,the ,secretary shall establish one or more alternative dispute resolution processes whereby1 at the ,secretary's discretion1 an individual or entity entitled to a redetermination under subsection 7a77#c7 by a medicare administrative contractor or a reconsideration under subsection 7c7 by a qualified independent contractor may have the option to enter into alternative dispute resolution with the ,centers for ,medicare ,medicaid ,services1 consistent with the following3 7,i7 ,during the alternative dispute resolution process1 the request for review with respect to the claims covered by the alternative dispute resolution shall be suspended4 7,,ii7 ,in the event that an alternative dispute resolution does not result in a settlement1 the request for review with respect to the claims covered by the alternative dispute resolution shall resume under subsection 7a77#c7 or subsection 7c71 as applicable4 7ii7 ,hearing and review mediation ,the ,secretary shall establish an alternative dispute resolution process whereby1 at the ,secretary's discretion1 an individual or entity entitled to a review or hearing on a decision of a qualified independent contractor by a ,medicare magistrate or an administrative law judge may have the option to enter into an alternative dispute resolution process mediated by staff members of the ,office of ,medicare ,hearings and ,appeals selected for the purpose of mediating alternative dispute resolutions under this paragraph4 7,b7 ,effect of alternative dispute resolution 7i7 ,in general ,as part of any alternative dispute resolution settlement under this paragraph1 an appellant shall be required to-- 7,i7 forego the right to such redetermination1 reconsideration1 review1 or hearing1 as applicable2 and 7,,ii7 withdraw all requests for review with respect to the claims covered by the settlement4 7ii7 ,no judicial review ,there shall be no administrative or judicial review under section #ahfi1 #ahgh1 or otherwise of the alternative dispute resolution settlement and the claims covered by the settlement4 7,c7 ,coordination with law enforcement and ,,cms ,the ,secretary shall establish a process under which the officers responsible for conducting an alternative dispute resolution process shall coordinate with appropriate law enforcement agencies and the ,centers for ,medicare ,medicaid ,services to avoid the inadvertent settlement of cases that involve fraud or other criminal activity4 7,d7 ,no entitlement to alternative dispute resolution ,nothing in this paragraph shall be construed as creating an entitlement to alternative dispute resolution4 4 7#b7 ,conforming amendments 7,a7 ,section #ahfi7;a77#c77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7a77#c77;,a77 is amended by inserting 81 subject to subsection 7b77#e710 after regulations shall4 7,b7 ,section #ahfi7;b77#a77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7b77#a77;,a771 as amended by section #c7;a77#b71 is amended-- 7i7 by inserting and paragraph 7#e7 after 8,subject to subparagraph 7,d702 and 7ii7 by striking and paragraph 7#d7 and inserting and paragraphs 7#d7 and 7#e74 #aj4 ,review program improvements 7a7 ,in general ,section #ahic of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd7 is amended-- 7#a7 in subsection 7b71 by adding at the end the following new paragraph3 7#g7 ,the review program improvements described in subsection 7j74 2 7#b7 by redesignating subsection 7i7 as subsection 7j72 and 7#c7 by inserting after subsection 7h7 the following new subsection3 7i7 ,review program improvements 7#a7 ,in general 4 7,a7 ,guidelines 7i7 ,in general ,to ensure uniformity and consistency in initial determinations and appeals decisions relating to the appropriateness of payment with respect to items or services furnished under this title1 the ,secretary shall ensure that claim review guidelines are established for reviewing claims for payment submitted by providers of services and suppliers4 7ii7 ,requirements ,prior to the implementation of the claim review guidelines described in subparagraph 7,a77i71 the ,secretary shall-- 7,i7 approve the claim review guidelines2 7,,ii7 make the claim review guidelines publicly available as described in subparagraph 7,b72 7,,iii7 ensure that review contractors apply the claim review guidelines consistently1 as appropriate2 and 7,,iv7 ensure that ,medicare magistrates1 administrative law judges1 and the ,departmental ,appeals ,board are trained in the application of the claim review guidelines4 7iii7 ,transition period ,the ,secretary may provide for or establish one or more transition periods1 during which the use of existing claim review guidelines for reviewing claims submitted by providers of services and suppliers shall be permitted to continue until such time as the ,secretary is able to review and approve the claim review guidelines established under this subparagraph4 7,b7 ,transparency 7i7 ,in general ,the ,secretary shall ensure that the information described in clause 7iii7-- 7,i7 is published on the ,internet website of the ,department of ,health and ,human ,services for not less than #cj days prior to its implementation2 7,,ii7 remains available on such ,internet website after such publication2 and 7,,iii7 is updated at least annually4 7ii7 ,expedited process ,the ,secretary of ,health and ,human ,services may expedite the process described in clause 7i7 for claims review guidelines that are expected to impact the improper payment rate1 frequency of denials of payment1 or costs to the ,medicare program4 7iii7 ,information described ,the information described in this clause is the following3 7,i7 ,subject to clause 7ii7 and subparagraph 7,a71 any new claim review guideline approved for use under this paragraph4 7,,ii7 ,any updates or revisions to existing claim review guidelines4 7,c7 ,limitation ,nothing in this section is intended to-- 7i7 delineate sample size or how claims are to be selected for review2 7ii7 require the publication of algorithms or methodologies used for claim selection2 or 7iii7 require the publication of information that could promote fraud or potential gaming4 7,d7 ,review contractor defined ,in this subsection1 the term review contractor means-- 7i7 a medicare administrative contractor 7as defined in section #ahgd;,a7a77#c77;,a77 with a contract to conduct prepayment or post-payment reviews of claims for payment by providers of services or suppliers2 7ii7 a recovery audit contractor with a contract under subsection 7h72 or 7iii7 any other contractor the ,secretary determines appropriate4 7#b7 ,program integrity initiatives ,to improve existing and future ,medicare program integrity initiatives1 and to limit unnecessary burdens on providers of services and suppliers1 the ,secretary shall designate a point of contact to oversee and undertake the following3 7,a7 ,develop a comprehensive strategy for claim review determinations made on a prepayment1 post-payment1 or prior-authorization basis that-- 7i7 focuses on identifying and reducing those claim errors that have the largest impact on the improper payment rate1 pose the greatest risk to the ,federal ,hospital ,insurance ,trust ,fund under section #ahag of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i7 or the ,federal ,supplementary ,medical ,insurance ,trust ,fund under section #ahda of such ,act 7#db ,u4,s4,c4 #aciet71 or are likely to negatively affect quality of care2 7ii7 reduces unnecessary burden on providers of services and suppliers and minimizes any negative effects on ,medicare beneficiaries2 and 7iii7 utilizes data and other sources1 including claims data1 improper payment rate data1 and reports from the ,office of the ,inspector ,general of the ,department of ,health and ,human ,services1 the ,general ,accountability ,office1 the ,medicare ,payment ,advisory ,commission1 and the media4 7,b7 ,develop methods to ensure1 using all available data1 that review contractors do not unnecessarily conduct duplicate reviews of specific individual claims4 7,c7 ,to the extent possible given the specific mission of each entity that has contracted with the ,secretary1 work with all review contractors to develop a uniform1 consistent1 and transparent review process to reduce the burden on providers of services and suppliers to the greatest extent possible1 including a uniform approach for such entities to notify parties of pending reviews and to request medical documentation1 improved communication with providers of services and suppliers1 better refinement of audits to target claims that are at the highest risk for improper payments or other errors1 and any other areas in which the ,secretary determines that the burden on providers of services and suppliers may be decreased4 7,d7 ,identify local coverage determinations1 national coverage determinations1 regulations1 and program instructions issued by the ,centers for ,medicare ,medicaid ,services for the ,medicare program that need updating or that inappropriately conflict with other ,medicare policies and make modifications where appropriate1 and1 if necessary1 establish new policies or claim review guidelines with input from stakeholders as appropriate4 7,e7 ,publish on the ,internet website of the ,department of ,health and ,human ,services the volume and type of prepayment and post-payment claim reviews performed by medicare administrative contractors under section #ahgd;,a of the ,social ,security ,act 7#db ,u4,s4,c4 #aciekk-#a7 and recovery audit contractors under section #ahic7;h7 of such ,act 7#db ,u4,s4,c4 #acie;ddd7h774 7,f7 ,coordinate with the ,office of ,medicare ,hearings and ,appeals and the ,departmental ,appeals ,board of the ,department of ,health and ,human ,services to ensure that the improved claim review guidelines and evidentiary standards established by the provisions of1 and the amendments made by1 this ,act1 such as the decision to remand an appeal1 are properly implemented4 7,g7 ,ensure that providers of services and suppliers subject to post-payment review by a medicare administrative contractor are granted a discussion period with the contractor of at least #cj days from the letter from the contractor regarding the result of the review4 7,h7 ,develop qualification standards for review contractors that require prepayment and post-payment reviews of claims for payment submitted by providers of services or suppliers to be conducted or approved by medical doctors with knowledge of relevant ,medicare laws1 regulations1 and program instruction1 as appropriate4 7,i7 ,verify1 through the use of sampling if the ,secretary so chooses1 that decisions by review contractors are consistent with ,medicare laws1 regulations1 and program instruction 7taking into account geographical variations that are a result of local coverage determinations74 7,j7 ,determine whether additional punitive actions against ineffective review contractors could be taken and what1 if any1 financial incentives or disincentives could be used to promote the accuracy of a review contractor's reviews4 7#c7 ,medicare provider claim audit ,internet portal 7,a7 ,in general ,the ,secretary shall establish a secure1 ,internet-based system 7which may be based on the existing database system of claims under review used by review contractors or a similar existing system7 through which a provider of services1 a supplier1 or other appropriate entity may track the status of any claim for payment submitted by such provider or supplier that is being audited or processed as an appeal by-- 7i7 a medicare administrative contractor under section #ahgd;,a2 or 7ii7 a qualified independent contractor1 ,medicare magistrate1 administrative law judge1 or the ,departmental ,appeals ,board of the ,department of ,health and ,human ,services under section #ahfi4 7,b7 ,fraud prevention ,the ,secretary shall ensure that the system established under paragraph 7#a7 does not impede any ongoing investigations of potential fraud4 7,c7 ,progress report ,not later than #ahj days after the date of the enactment of this ,act1 the ,secretary shall submit a report to ,congress describing the plan to establish and operate the system described in paragraph 7#a74 4 7b7 ,annual ,,rac report ,section #ahic7;h77#h7 is amended by inserting 1 and1 with respect to reports submitted after the date of the enactment of the ,audit ,appeals ,fairness1 ,integrity1 and ,reforms in ,medicare ,act of #bjae1 the number of claims corrected in the discussion period1 the percentage of appeals of determinations by recovery audit contractors that were ultimately successful1 a careful description of the denominator of total audits and appeals 7given the likelihood that many appeals in a given year will not have a decision in that year71 and separate reports on complex ,medicare part ,a1 complex ,medicare part ,b1 semiautomated1 and automated reviews before the period at the end4 7c7 ,independence of adjudicators ,nothing in this section or the amendments made thereby shall be construed as authorizing the ,secretary to limit the authority or decisional independence of ,medicare magistrates1 administrative law judges1 or the ,departmental ,appeals ,board of the ,department of ,health and ,human ,services4 #aa4 ,creation of ,medicare ,provider and ,supplier ,ombudsman for ,reviews and ,appeals ,section #ahjh of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;b-#i7 is amended by adding at the end the following new subsection3 7d7 ,medicare ,reviews and ,appeals ,ombudsman 7#a7 ,in general ,not later than #a year after the date of the enactment of this subsection1 the ,secretary shall appoint within the ,centers for ,medicare ,medicaid ,services a ,medicare ,reviews and ,appeals ,ombudsman4 7#b7 ,duties ,the ,medicare ,reviews and ,appeals ,ombudsman shall-- 7,a7 identify1 investigate1 and assist in the resolution of complaints and inquiries related to the ,medicare audits and appeals process from providers of services or suppliers with respect to benefits under part ,a or ,b2 7,b7 identify trends in complaints and inquiries regarding the current ,medicare review and appeals systems to provide recommendations for improvements to the ,secretary that would improve the efficacy and efficiency of claim review and appeals systems1 as well as communication to beneficiaries1 providers of services1 and suppliers2 7,c7 design a system by which to objectively measure and evaluate reviewer responsiveness to addressing inquiries from providers of services and suppliers and inquiries from the ,ombudsman2 7,d7 provide administrative and technical assistance to appellants and those considering an appeal2 7,e7 publish data regarding the number of review determinations appealed1 each appeal's outcome1 and aggregate appeal statistics-- 7i7 for each medicare administrative contractor conducting redeterminations under section #ahfi7;a77#c72 7ii7 for each qualified independent contractor conducting reconsiderations under section #ahfi7;c72 7iii7 for each recovery audit contractor conducting reviews under section #ahic7;h72 7iv7 by type of provider of services2 and 7v7 by type of supplier2 7,f7 assist in education and training efforts for providers of services1 suppliers1 and review contractors 7as defined in section #ahic7;i77#a77;,d772 7,g7 communicate with the ,medicare ,beneficiary ,ombudsman to assist with the identification1 investigation1 and resolution of beneficiary-related complaints1 including those that overlap with requests for review and appeals submitted by providers of services or suppliers2 and 7,h7 perform such other duties as determined appropriate by the ,secretary4 4 #ab4 ,limiting the audit and recovery period for patient status reviews 7a7 ,in general ,section #ahic7;h77#d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd7h77#d7 is amended-- 7#a7 by redesignating subparagraphs 7,a7 and 7,b7 as clauses 7i7 and 7ii71 respectively1 and moving such clauses #b ems to the right2 7#b7 by striking ,each such and inserting the following3 7,a7 ,in general ,except as provided in subparagraph 7,b71 each such 2 and 7#c7 by adding at the end the following new subparagraph3 7,b7 ,limitation 7i7 ,in general ,with respect to the classification of an individual entitled to1 or enrolled for1 benefits under part ,a or enrolled under part ,b1 or both1 as an inpatient or an outpatient for purposes of hospital claims for payment for items or services furnished to such individual under this title1 such contracts shall provide that a recovery audit contractor shall only send additional documentation requests related to the appropriateness of such classification in the first #f months after the date on which such items or services were furnished4 7ii7 ,exception ,the limitation described in clause 7i7 shall not apply where a claim for payment is submitted more than #c months after the date on which such items or services were furnished4 4 7b7 ,study on shortening the audit and recovery period for other reviews 7#a7 ,study ,the ,secretary of ,health and ,human ,services shall conduct a study to assess-- 7,a7 the potential burden on providers of services 7as defined in subsection 7u7 of section #ahfa of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex77 and suppliers 7as defined in subsection 7d7 of such section #ahfa7 under the ,medicare program of the audit and recovery period applicable to audit and recovery activities conducted by recovery audit contractors under section #ahic7;h77#d7 of such ,act 7#db ,u4,s4,c4 #acie;ddd7h77#d772 and 7,b7 the impact of shortening such period with respect to different types of reviews4 7#b7 ,report ,not later than #a year after the date of the enactment of this ,act1 the ,secretary of ,health and ,human ,services shall publish a report containing the results of the study required under paragraph 7#a7 on the ,internet website of the ,department of ,health and ,human ,services4 7c7 ,authority ,to implement shorter audit and recovery period ,section #ahic7;h77#d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd7h77#d771 as amended by subsection 7a71 is further amended-- 7#a7 in subparagraph 7,a71 by striking subparagraph 7,b7 and inserting subparagraphs 7,b7 and 7,c72 and 7#b7 by adding at the end the following new subparagraph3 7,c7 ,authority to implement shorter audit and recovery period ,notwithstanding subparagraph 7,a77ii71 with respect to payments made under this title for specific categories of services1 the ,secretary may enter into contracts under paragraph 7#a7 that provide for a retrospective period during which audit and recovery activities may be conducted of not more than #c years4 4 7d7 ,report on ,,rac payment structure ,not later than #f months after the date of the enactment of this ,act1 the ,secretary of ,health and ,human ,services shall submit to ,congress a report on ways to change1 in a budget neutral manner1 the payment structure for recovery audit contractors under section #ahic7;h77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd7h77#a77 from an incentive-based model to a non-incentive based approach that does not impose additional financial burdens on providers4 7e7 ,effective date ,the amendments made by this section shall take effect on ,january #a1 #bjag1 and shall apply to contracts between the ,secretary and recovery audit contractors entered into on or after such date4 #ac4 ,incentives and disincentives for ,medicare contractors1 providers1 and suppliers ,section #ahic of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd71 as amended by section #aj1 is further amended-- 7#a7 by redesignating subsection 7j7 as subsection 7k72 and 7#b7 by inserting after subsection 7i7 the following new subsection3 7j7 ,compliance incentive program 7#a7 ,in general ,not later than ,january #a1 #bjag1 the ,secretary shall establish a compliance incentive program1 consisting of the components described in paragraphs 7#b7 and 7#c71 to encourage-- 7,a7 providers of services and suppliers to submit accurate claims that comply with this title and the policies1 regulations1 and program instructions promulgated thereunder1 as well as any applicable national or local coverage determinations2 and 7,b7 entities that have entered into contracts with the ,secretary under subsection 7h7 or section #ahgd;,a 7referred to in this subsection as review contractors7 to conduct reviews under this section or section #ahgd;,a1 as applicable1 in a manner that is consistent with the provisions of this title and the claim review guidelines1 regulations1 and program instructions promulgated thereunder1 as well as any applicable national or local coverage determinations4 7#b7 ,compliance with claim procedures by providers of services and suppliers 7,a7 ,in general ,not later than ,january #a1 #bjag1 the ,secretary shall establish a system through which a provider of services or supplier that has achieved a low rate of denials of claims for payment subject to additional documentation requests over a #b year period1 as determined by the ,secretary1 shall be exempt for a period of #a year from any post-payment review of claims for payment conducted by review contractors4 7,b7 ,limitation ,the ,secretary shall not exempt or shall rescind an exemption granted to a provider of services or supplier under subparagraph 7,a7 if the ,secretary determines that there is evidence of systematic gaming1 fraud1 abuse1 or delay in the provision of services or items by such provider or services or supplier4 7#c7 ,compliance with review procedures by ,medicare contractors 7,a7 ,in general ,not later than ,january #a1 #bjag1 the ,secretary shall establish a process1 which may include the use of sampling1 for determining the frequency with which the decisions made by a review contractor with respect to reviews conducted under this section or section #ahgd;,a are consistent with the provisions of this title and the policies1 regulations1 and program instructions promulgated thereunder1 as well as any applicable national or local coverage determinations4 ,the results of this process shall be made available to the public on the ,internet website of the ,department of ,health and ,human ,services4 7,b7 ,access to medical records by review contractors 7i7 ,access to records based on performance review ,not later than ,january #a1 #bjag1 the ,secretary shall establish a system under which1 for any incentive period-- 7,i7 the number of medical records that a review contractor that was a high-performing review contractor in the performance review period associated with such incentive period may request from a provider of services or supplier in carrying out activities under this section or section #ahgd1 as applicable1 may be increased 7on a sliding scale72 and 7,,ii7 the number of medical records that a review contractor that was a low-performing review contractor in the performance review period associated with such incentive period may request from a provider of services or supplier in carrying out activities under this section or section #ahgd;,a1 as applicable1 may be decreased 7on a sliding scale74 7ii7 ,definitions ,in this subparagraph3 7,i7 ,high-performing review contractor ,the term high-performing review contractor means a review contractor that1 for a given performance review period1 makes decisions with respect to reviews conducted under this section or section #ahgd;,a1 as applicable1 of the activities of providers of services and suppliers that are consistent with the provisions of this title and the policies1 regulations1 and program instructions promulgated thereunder1 as well as any applicable national or local coverage determinations1 at a rate that is equal to or greater than #ie percent4 7,,ii7 ,incentive period ,the term incentive period means1 with respect to a performance review period1 a period of time 7to be determined by the ,secretary7 following such performance review period during which the number of medical records that a review contractor may request from a provider of services or supplier may be increased or decreased based on such contractor's status as a high-performing review contractor or a low-performing review contractor for such performance review period4 7,,iii7 ,low-performing review contractor ,the term low-performing review contractor means a review contractor that1 for a given performance review period1 is not described in subclause 7,i74 7,,iv7 ,performance review period ,the term performance review period means a period of time 7to be determined by the ,secretary7 during which a review contractor's decisions with respect to reviews conducted under this section or section #ahgd;,a1 as applicable1 are evaluated to determine if such review contractor is a high-performing contractor or a low-performing contractor for such period4 4 ,december #h1 #bjae,read twice and placed on the calendar