,,ii #aai? ,,congress #a/ ,session ,s4 #bjff ,,9 ,,! ,,s5ate ,,( ,,! ,,unit$ ,,/ates ,june #ab1 #bjbe,mr4 ,%eehy 7= himself1 ,ms4 ,hassan1 ,mr4 ,s*mitt1 & ,mr4 ,cassidy7 introduc$ ! foll[+ bill2 :i* 0 read twice & ref]r$ to ! ,committee on ,f9ance ,a ,,bill ,to am5d title ,,xi ( ! ,social ,security ,act to e/abli% a pilot program = te/+ ! use ( a pr$ictive risk-scor+ algori?m to provide ov]sight ( paym5ts = durable m$ical equipm5t & cl9ical diagno/ic laboratory te/s "u ! ,m$ic>e program4 #a4 ,%ort title ,?is ,act may be cit$ z ! ,m$ic>e ,transaction ,fraud ,prev5tion ,act4 #b4 ,pilot program te/+ use ( pr$ictive risk-scor+ algori?m to provide ov]sight ( paym5ts = durable m$ical equipm5t & cl9ical diagno/ic laboratory te/s "u ! ,m$ic>e program ,section #aabh,k ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;a-#gn7 is am5d$-- 7#a7 9 ! section head+ by ins]t+ 2 pilot program te/+ use ( pr$ictive risk-scor+ algori?m to provide ov]sight ( paym5ts = durable m$ical equipm5t & cl9ical diagno/ic laboratory te/s "u ! ,m$ic>e program aft] abuse2 & 7#b7 by add+ at ! end ! foll[+ new subsection3 7d7 ,pilot program te/+ use ( pr$ictive risk-,scor+ algori?m ,to provide ov]sight ( paym5ts = durable m$ical equipm5t & cl9ical diagno/ic laboratory te/s "u ! ,m$ic>e program 7#a7 ,9 g5]al ,! ,secret>y %all e/abli% a pilot program to te/ ! use ( pr$ictive risk-scor+ algori?ms to provide ov]sight ( relevant transactions 7z def9$ 9 p>agraph 7#h77;,b774 7#b7 ,duration ,! pilot program %all be conduct$ = a p]iod ( #b ye>s1 beg9n+ n lat] ?an ,janu>y #a1 #bjbf4 7#c7 ,scope 7,a7 ,9 g5]al ,! ,secret>y %all limit ! implem5tation ( ! pilot program to relevant transactions involv+ applicable items or s]vices furni%$ to applicable b5efici>ies 7z def9$ 9 subp>agraph 7,b774 7,b7 ,applicable b5efici>y def9$ ,9 ?is subsection1 ! t]m applicable b5efici>y means an individual :o has opt$ 9 to-- 7i7 receive electronic ,m$ic>e ,summ>y ,notices2 & 7ii7 p>ticipate 9 ! pilot program 9 accordance ) subp>agraph 7,c74 7,c7 ,volunt>y p>ticipation ,an applicable b5efici>y may p>ticipate 9 ! pilot program on a volunt>y basis & may t]m9ate p>ticipation at any "t4 7#d7 ,consid]ations ,! ,secret>y may1 = purposes ( id5tify+ & calculat+ ! risks ( relevant transactions "u ! pilot program1 consid] ! foll[+ factors3 7,a7 ,! abs5ce ( a prior relation%ip betwe5 ! b5efici>y & a provid] ( s]vices 7z def9$ 9 section #ahfa7u77 or suppli] 7z def9$ 9 section #ahfa7;d774 7,b7 ,ab]rant bill+ patt]ns = a provid] ( s]vices or suppli] ) reg>ds to volume ( claims 9 "o p>ticul> area4 7,c7 ,electronic fund transf] 7,,eft7 *anges4 7,d7 ,*anges 9 own]%ip ( a provid] ( s]vices or suppli]4 7#e7 ,collaboration ,! ,secret>y %all "w ) indu/ry repres5tatives 7includ+ suppli]s ( durable m$ical equipm5t7 on ! developm5t & implem5tation ( ! pilot program4 7#f7 ,requirem5ts ,"u ! pilot program1 ! ,secret>y %all-- 7,a7 adopt a pr$ictive risk-scor+ algori?m t w\ld le>n f b5efici>y data to score relevant transactions f #a 7lea/ risky7 to #ii 7mo/ risky72 7,b7 prior to implem5tation ( any pr$ictive risk-scor+ algori?m adopt$ "u subp>agraph 7,a7 "u ! pilot program-- 7i7 require suffici5t te/+1 evaluation1 & review ( su* algori?m1 tak+ into consid]ation ,executive ,ord] #adagi 7#ij ,f$4 ,reg4 #hgda2 relat+ to remov+ b>ri]s to ,am]ican lead]%ip 9 artificial intellig5ce72 7ii7 e/abli% me?ods = notify+ applicable b5efici>ies & provid]s ( s]vices & suppli]s impact$ by ! use ( ! algori?m reg>d+ su* usage 7includ+ in=mation reg>d+ h[ b5efici>y data is collect$ & process$ "u ! pilot program to produce a risk score = relevant transactions & ! possible implications associat$ ) ! use ( ! algori?m72 & 7iii7 e/abli% me?ods ( communication ) ! ,(fice ( ! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vice1 & ! ability to waive or =go notice to an applicable b5efici>y or a provid] ( s]vices or suppli] if appropriate2 7,c7 = any relevant transaction involv+ an item or s]vice furni%$ to an applicable b5efici>y id5tifi$ by a pr$ictive risk-scor+ algori?m adopt$ "u subp>agraph 7,a7 & implem5t$ "u subp>agraph 7,b7 z hav+ a risk score t exce$s a level ( risk specifi$ by ! ,secret>y-- 7i7 review ! relevant transaction to det]m9e :e!r x %\ld be susp5d$ p5d+ ! applicable b5efici>y's response "u clause 7ii72 7ii7 provide ! applicable b5efici>y ! opportunity1 by email or phone call response-- 7,i7 to cure a high-risk score or susp5d$ transaction t ! b5efici>y believes is bas$ on inaccurate und]ly+ data2 & 7,,ii7 confirm ! relevant transaction2 & 7iii7 if1 bas$ on ! results ( ! review1 ! relevant transaction is susp5d$-- 7,i7 trigg] an automatic al]t to ! applicable b5efici>y by electronically s5d+ a ,m$ic>e ,summ>y ,notice t includes ! relevant transaction2 7,,ii7 require t all subsequ5t ,m$ic>e ,summ>y ,notices involv+ ! relevant transaction be s5t electronically & 9 two week int]vals = #c mon?s aft] ! fir/ al]t is s5t "u subclause 7,i72 & 7,,iii7 include on su* ,m$ic>e ,summ>y ,notices1 z det]m9$ appropriate by ! ,secret>y1 in=mation expla9+ h[ ! b5efici>y may report suspect$ fraud to relevant law en=cem5t ag5cies2 & 7,d7 h ! au?ority to det]m9e :5 a ,m$ic>e c>d mu/ be t]m9at$ or a new c>d issu$ to prev5t fraud & abuse4 7#g7 ,cl>ification ,any susp5sion ( an acc\nt or transaction "u ! pilot program %all be bas$ on a human review process1 in=m$ ?r\gh ! implem5tation ( ! pr$ictive risk-scor+ algori?m4 7#h7 ,def9itions ,9 ?is subsection3 7,a7 ,applicable item or s]vice ,! t]m applicable item or s]vice means-- 7i7 an item ( durable m$ical equipm5t 7z def9$ 9 section #ahfa7n772 & 7ii7 a cl9ical diagno/ic laboratory te/4 7,b7 ,relevant transaction ,! t]m relevant transaction means a claim = paym5t = an applicable item or s]vice furni%$ to an applicable b5efici>y1 z det]m9$ by ! ,secret>y4 4