,,ii #aaith ,,congress #ast ,session ,s4 #bjff ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,june #ab1 #bjbe,mr4 ,sheehy 7for himself1 ,ms4 ,hassan1 ,mr4 ,schmitt1 and ,mr4 ,cassidy7 introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to amend title ,,xi of the ,social ,security ,act to establish a pilot program for testing the use of a predictive risk-scoring algorithm to provide oversight of payments for durable medical equipment and clinical diagnostic laboratory tests under the ,medicare program4 #a4 ,short title ,this ,act may be cited as the ,medicare ,transaction ,fraud ,prevention ,act4 #b4 ,pilot program testing use of predictive risk-scoring algorithm to provide oversight of payments for durable medical equipment and clinical diagnostic laboratory tests under the ,medicare program ,section #aabh,k of the ,social ,security ,act 7#db ,u4,s4,c4 #acbj;a-#gn7 is amended-- 7#a7 in the section heading by inserting 2 pilot program testing use of predictive risk-scoring algorithm to provide oversight of payments for durable medical equipment and clinical diagnostic laboratory tests under the ,medicare program after abuse2 and 7#b7 by adding at the end the following new subsection3 7d7 ,pilot program testing use of predictive risk-,scoring algorithm ,to provide oversight of payments for durable medical equipment and clinical diagnostic laboratory tests under the ,medicare program 7#a7 ,in general ,the ,secretary shall establish a pilot program to test the use of predictive risk-scoring algorithms to provide oversight of relevant transactions 7as defined in paragraph 7#h77;,b774 7#b7 ,duration ,the pilot program shall be conducted for a period of #b years1 beginning not later than ,january #a1 #bjbf4 7#c7 ,scope 7,a7 ,in general ,the ,secretary shall limit the implementation of the pilot program to relevant transactions involving applicable items or services furnished to applicable beneficiaries 7as defined in subparagraph 7,b774 7,b7 ,applicable beneficiary defined ,in this subsection1 the term applicable beneficiary means an individual who has opted in to-- 7i7 receive electronic ,medicare ,summary ,notices2 and 7ii7 participate in the pilot program in accordance with subparagraph 7,c74 7,c7 ,voluntary participation ,an applicable beneficiary may participate in the pilot program on a voluntary basis and may terminate participation at any time4 7#d7 ,considerations ,the ,secretary may1 for purposes of identifying and calculating the risks of relevant transactions under the pilot program1 consider the following factors3 7,a7 ,the absence of a prior relationship between the beneficiary and a provider of services 7as defined in section #ahfa7u77 or supplier 7as defined in section #ahfa7;d774 7,b7 ,aberrant billing patterns for a provider of services or supplier with regards to volume of claims in one particular area4 7,c7 ,electronic fund transfer 7,,eft7 changes4 7,d7 ,changes in ownership of a provider of services or supplier4 7#e7 ,collaboration ,the ,secretary shall work with industry representatives 7including suppliers of durable medical equipment7 on the development and implementation of the pilot program4 7#f7 ,requirements ,under the pilot program1 the ,secretary shall-- 7,a7 adopt a predictive risk-scoring algorithm that would learn from beneficiary data to score relevant transactions from #a 7least risky7 to #ii 7most risky72 7,b7 prior to implementation of any predictive risk-scoring algorithm adopted under subparagraph 7,a7 under the pilot program-- 7i7 require sufficient testing1 evaluation1 and review of such algorithm1 taking into consideration ,executive ,order #adagi 7#ij ,fed4 ,reg4 #hgda2 relating to removing barriers to ,american leadership in artificial intelligence72 7ii7 establish methods for notifying applicable beneficiaries and providers of services and suppliers impacted by the use of the algorithm regarding such usage 7including information regarding how beneficiary data is collected and processed under the pilot program to produce a risk score for relevant transactions and the possible implications associated with the use of the algorithm72 and 7iii7 establish methods of communication with the ,office of the ,inspector ,general of the ,department of ,health and ,human ,service1 and the ability to waive or forgo notice to an applicable beneficiary or a provider of services or supplier if appropriate2 7,c7 for any relevant transaction involving an item or service furnished to an applicable beneficiary identified by a predictive risk-scoring algorithm adopted under subparagraph 7,a7 and implemented under subparagraph 7,b7 as having a risk score that exceeds a level of risk specified by the ,secretary-- 7i7 review the relevant transaction to determine whether it should be suspended pending the applicable beneficiary's response under clause 7ii72 7ii7 provide the applicable beneficiary the opportunity1 by email or phone call response-- 7,i7 to cure a high-risk score or suspended transaction that the beneficiary believes is based on inaccurate underlying data2 and 7,,ii7 confirm the relevant transaction2 and 7iii7 if1 based on the results of the review1 the relevant transaction is suspended-- 7,i7 trigger an automatic alert to the applicable beneficiary by electronically sending a ,medicare ,summary ,notice that includes the relevant transaction2 7,,ii7 require that all subsequent ,medicare ,summary ,notices involving the relevant transaction be sent electronically and in two week intervals for #c months after the first alert is sent under subclause 7,i72 and 7,,iii7 include on such ,medicare ,summary ,notices1 as determined appropriate by the ,secretary1 information explaining how the beneficiary may report suspected fraud to relevant law enforcement agencies2 and 7,d7 have the authority to determine when a ,medicare card must be terminated or a new card issued to prevent fraud and abuse4 7#g7 ,clarification ,any suspension of an account or transaction under the pilot program shall be based on a human review process1 informed through the implementation of the predictive risk-scoring algorithm4 7#h7 ,definitions ,in this subsection3 7,a7 ,applicable item or service ,the term applicable item or service means-- 7i7 an item of durable medical equipment 7as defined in section #ahfa7n772 and 7ii7 a clinical diagnostic laboratory test4 7,b7 ,relevant transaction ,the term relevant transaction means a claim for payment for an applicable item or service furnished to an applicable beneficiary1 as determined by the ,secretary4 4