Anti-fraud provisions in White House proposal


Note:  The provisions discussed below were not included in the final legislation.

The White House summary of  new proposed measures to “crack down on waste, fraud and abuse” include a number of provisions from H.R. 3970, the “Medical Rights and Reform Act” sponsored by Representative Mark Kirk (R-IL) and 12 Republican co-sponsors.

One of these  proposals is  already included in the House and Senate bills; it would establish provider screening and other enrollment requirements.

Provisions of H.R. 3970 not already included in the bills already adopted by one or both houses would:

  • Impose regulation and oversight of billing agencies and agents who submit claims to Medicare, who will be required to register with HHS and may be denied registration for various reasons.  They would also become subject to exclusion from Medicare for submitting a Medicare claim that the biller knew or should have known was false or fraudulent.
  • Define as criminal healthcare fraud the purchase, sale, or distribution of Medicare or Medicaid beneficiary identification numbers or billing privileges, if done knowingly, intentionally, and with intent to defraud.
  • Broaden access to the healthcare integrity databank to quality control and peer review organizations as well as to private plans that are involved in furnishing items or services reimbursed by a Federal healthcare program.
  • Establish criminal penalties for the misuse of information maintained in the healthcare integrity data bank.
  • Prevent a provider or supplier’s obligation to pay civil monetary penalties or to refund Medicare overpayments to CMS from being discharged in bankruptcy.
  • Require that CMS contracts with Medicare Administrative Contractors include a provision that mandates that the contractor reimburse Medicare for payments erroneously made to excluded providers.
  • Require a site inspection before a community mental health center can enroll as a Medicare provider.
  • Require HHS to study and report to Congress on the costs and benefits of assigning universal product numbers (UPNs) to selected items and services reimbursed under Medicare.  The report must examine whether UPNs could help improve the efficient operation of Medicare and its ability to detect fraud and abuse.

Other program integrity provisions included in the White House proposal come from other Republican proposals or the President’s proposed federal budget for 2011.

From the conservative Republican Study Committee, there is a proposal to establish a comprehensive Medicare and Medicaid sanctions database, overseen by the HHS Inspector General, that will provide a central storage location, allowing for law enforcement access to information related to past sanctions on health care providers, suppliers and related entities.

Proposals from the 2011 budget proposal are summarized on the White House’s website; however, proposed statutory language does not appear to be available, so I can’t add any further details here.  The same is true for the “Roskam Amendment offered in House Ways & Means Committee markup,” cited as the source for a provision concerning “use of technology for real-time data review.” I was unable to find the language of Congressman Roskam’s proposal on the internet.

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