42 U.S.C. § 1395ddd : US Code - Section 1395DDD: Medicare Integrity Program

Search 42 U.S.C. § 1395ddd : US Code - Section 1395DDD: Medicare Integrity Program

(a) Establishment of Program
There is hereby established the Medicare Integrity Program (in
this section referred to as the "Program") under which the
Secretary shall promote the integrity of the medicare program by
entering into contracts in accordance with this section with
eligible entities to carry out the activities described in
subsection (b) of this section.
(b) Activities described
The activities described in this subsection are as follows:
(1) Review of activities of providers of services or other
individuals and entities furnishing items and services for which
payment may be made under this subchapter (including skilled
nursing facilities and home health agencies), including medical
and utilization review and fraud review (employing similar
standards, processes, and technologies used by private health
plans, including equipment and software technologies which
surpass the capability of the equipment and technologies used in
the review of claims under this subchapter as of August 21,
1996).
(2) Audit of cost reports.
(3) Determinations as to whether payment should not be, or
should not have been, made under this subchapter by reason of
section 1395y(b) of this title, and recovery of payments that
should not have been made.
(4) Education of providers of services, beneficiaries, and
other persons with respect to payment integrity and benefit
quality assurance issues.
(5) Developing (and periodically updating) a list of items of
durable medical equipment in accordance with section 1395m(a)(15)
of this title which are subject to prior authorization under such
section.
(c) Eligibility of entities
An entity is eligible to enter into a contract under the Program
to carry out any of the activities described in subsection (b) of
this section if -
(1) the entity has demonstrated capability to carry out such
activities;
(2) in carrying out such activities, the entity agrees to
cooperate with the Inspector General of the Department of Health
and Human Services, the Attorney General, and other law
enforcement agencies, as appropriate, in the investigation and
deterrence of fraud and abuse in relation to this subchapter and
in other cases arising out of such activities;
(3) the entity complies with such conflict of interest
standards as are generally applicable to Federal acquisition and
procurement; and
(4) the entity meets such other requirements as the Secretary
may impose.
In the case of the activity described in subsection (b)(5) of this
section, an entity shall be deemed to be eligible to enter into a
contract under the Program to carry out the activity if the entity
is a carrier with a contract in effect under section 1395u of this
title.
(d) Process for entering into contracts
The Secretary shall enter into contracts under the Program in
accordance with such procedures as the Secretary shall by
regulation establish, except that such procedures shall include the
following:
(1) Procedures for identifying, evaluating, and resolving
organizational conflicts of interest that are generally
applicable to Federal acquisition and procurement.
(2) Competitive procedures to be used -
(A) when entering into new contracts under this section;
(B) when entering into contracts that may result in the
elimination of responsibilities of an individual fiscal
intermediary or carrier under section 202(b) of the Health
Insurance Portability and Accountability Act of 1996; and
(C) at any other time considered appropriate by the
Secretary,
except that the Secretary may continue to contract with entities
that are carrying out the activities described in this section
pursuant to agreements under section 1395h of this title or
contracts under section 1395u of this title in effect on August
21, 1996.
(3) Procedures under which a contract under this section may be
renewed without regard to any provision of law requiring
competition if the contractor has met or exceeded the performance
requirements established in the current contract.
The Secretary may enter into such contracts without regard to final
rules having been promulgated.
(e) Limitation on contractor liability
The Secretary shall by regulation provide for the limitation of a
contractor's liability for actions taken to carry out a contract
under the Program, and such regulation shall, to the extent the
Secretary finds appropriate, employ the same or comparable
standards and other substantive and procedural provisions as are
contained in section 1320c-6 of this title.
(f) Recovery of overpayments
(1) Use of repayment plans
(A) In general
If the repayment, within 30 days by a provider of services or
supplier, of an overpayment under this subchapter would
constitute a hardship (as described in subparagraph (B)),
subject to subparagraph (C), upon request of the provider of
services or supplier the Secretary shall enter into a plan with
the provider of services or supplier for the repayment (through
offset or otherwise) of such overpayment over a period of at
least 6 months but not longer than 3 years (or not longer than
5 years in the case of extreme hardship, as determined by the
Secretary). Interest shall accrue on the balance through the
period of repayment. Such plan shall meet terms and conditions
determined to be appropriate by the Secretary.
(B) Hardship
(i) In general
For purposes of subparagraph (A), the repayment of an
overpayment (or overpayments) within 30 days is deemed to
constitute a hardship if -
(I) in the case of a provider of services that files cost
reports, the aggregate amount of the overpayments exceeds
10 percent of the amount paid under this subchapter to the
provider of services for the cost reporting period covered
by the most recently submitted cost report; or
(II) in the case of another provider of services or
supplier, the aggregate amount of the overpayments exceeds
10 percent of the amount paid under this subchapter to the
provider of services or supplier for the previous calendar
year.
(ii) Rule of application
The Secretary shall establish rules for the application of
this subparagraph in the case of a provider of services or
supplier that was not paid under this subchapter during the
previous year or was paid under this subchapter only during a
portion of that year.
(iii) Treatment of previous overpayments
If a provider of services or supplier has entered into a
repayment plan under subparagraph (A) with respect to a
specific overpayment amount, such payment amount under the
repayment plan shall not be taken into account under clause
(i) with respect to subsequent overpayment amounts.
(C) Exceptions
Subparagraph (A) shall not apply if -
(i) the Secretary has reason to suspect that the provider
of services or supplier may file for bankruptcy or otherwise
cease to do business or discontinue participation in the
program under this subchapter; or
(ii) there is an indication of fraud or abuse committed
against the program.
(D) Immediate collection if violation of repayment plan
If a provider of services or supplier fails to make a payment
in accordance with a repayment plan under this paragraph, the
Secretary may immediately seek to offset or otherwise recover
the total balance outstanding (including applicable interest)
under the repayment plan.
(E) Relation to no fault provision
Nothing in this paragraph shall be construed as affecting the
application of section 1395gg(c) of this title (relating to no
adjustment in the cases of certain overpayments).
(2) Limitation on recoupment
(A) In general
In the case of a provider of services or supplier that is
determined to have received an overpayment under this
subchapter and that seeks a reconsideration by a qualified
independent contractor on such determination under section
1395ff(b)(1) of this title, the Secretary may not take any
action (or authorize any other person, including any medicare
contractor, as defined in subparagraph (C)) to recoup the
overpayment until the date the decision on the reconsideration
has been rendered. If the provisions of section 1395ff(b)(1) of
this title (providing for such a reconsideration by a qualified
independent contractor) are not in effect, in applying the
previous sentence any reference to such a reconsideration shall
be treated as a reference to a redetermination by the fiscal
intermediary or carrier involved.
(B) Collection with interest
Insofar as the determination on such appeal is against the
provider of services or supplier, interest on the overpayment
shall accrue on and after the date of the original notice of
overpayment. Insofar as such determination against the provider
of services or supplier is later reversed, the Secretary shall
provide for repayment of the amount recouped plus interest at
the same rate as would apply under the previous sentence for
the period in which the amount was recouped.
(C) Medicare contractor defined
For purposes of this subsection, the term "medicare
contractor" has the meaning given such term in section
1395zz(g) of this title.
(3) Limitation on use of extrapolation
A medicare contractor may not use extrapolation to determine
overpayment amounts to be recovered by recoupment, offset, or
otherwise unless the Secretary determines that -
(A) there is a sustained or high level of payment error; or
(B) documented educational intervention has failed to correct
the payment error.
There shall be no administrative or judicial review under section
1395ff of this title, section 1395oo of this title, or otherwise,
of determinations by the Secretary of sustained or high levels of
payment errors under this paragraph.
(4) Provision of supporting documentation
In the case of a provider of services or supplier with respect
to which amounts were previously overpaid, a medicare contractor
may request the periodic production of records or supporting
documentation for a limited sample of submitted claims to ensure
that the previous practice is not continuing.
(5) Consent settlement reforms
(A) In general
The Secretary may use a consent settlement (as defined in
subparagraph (D)) to settle a projected overpayment.
(B) Opportunity to submit additional information before consent
settlement offer
Before offering a provider of services or supplier a consent
settlement, the Secretary shall -
(i) communicate to the provider of services or supplier -
(I) that, based on a review of the medical records
requested by the Secretary, a preliminary evaluation of
those records indicates that there would be an overpayment;
(II) the nature of the problems identified in such
evaluation; and
(III) the steps that the provider of services or supplier
should take to address the problems; and
(ii) provide for a 45-day period during which the provider
of services or supplier may furnish additional information
concerning the medical records for the claims that had been
reviewed.
(C) Consent settlement offer
The Secretary shall review any additional information
furnished by the provider of services or supplier under
subparagraph (B)(ii). Taking into consideration such
information, the Secretary shall determine if there still
appears to be an overpayment. If so, the Secretary -
(i) shall provide notice of such determination to the
provider of services or supplier, including an explanation of
the reason for such determination; and
(ii) in order to resolve the overpayment, may offer the
provider of services or supplier -
(I) the opportunity for a statistically valid random
sample; or
(II) a consent settlement.
The opportunity provided under clause (ii)(I) does not waive
any appeal rights with respect to the alleged overpayment
involved.
(D) Consent settlement defined
For purposes of this paragraph, the term "consent settlement"
means an agreement between the Secretary and a provider of
services or supplier whereby both parties agree to settle a
projected overpayment based on less than a statistically valid
sample of claims and the provider of services or supplier
agrees not to appeal the claims involved.
(6) Notice of over-utilization of codes
The Secretary shall establish, in consultation with
organizations representing the classes of providers of services
and suppliers, a process under which the Secretary provides for
notice to classes of providers of services and suppliers served
by the contractor in cases in which the contractor has identified
that particular billing codes may be overutilized by that class
of providers of services or suppliers under the programs under
this subchapter (or provisions of subchapter XI of this chapter
insofar as they relate to such programs).
(7) Payment audits
(A) Written notice for post-payment audits
Subject to subparagraph (C), if a medicare contractor decides
to conduct a post-payment audit of a provider of services or
supplier under this subchapter, the contractor shall provide
the provider of services or supplier with written notice (which
may be in electronic form) of the intent to conduct such an
audit.
(B) Explanation of findings for all audits
Subject to subparagraph (C), if a medicare contractor audits
a provider of services or supplier under this subchapter, the
contractor shall -
(i) give the provider of services or supplier a full review
and explanation of the findings of the audit in a manner that
is understandable to the provider of services or supplier and
permits the development of an appropriate corrective action
plan;
(ii) inform the provider of services or supplier of the
appeal rights under this subchapter as well as consent
settlement options (which are at the discretion of the
Secretary);
(iii) give the provider of services or supplier an
opportunity to provide additional information to the
contractor; and
(iv) take into account information provided, on a timely
basis, by the provider of services or supplier under clause
(iii).
(C) Exception
Subparagraphs (A) and (B) shall not apply if the provision of
notice or findings would compromise pending law enforcement
activities, whether civil or criminal, or reveal findings of
law enforcement-related audits.
(8) Standard methodology for probe sampling
The Secretary shall establish a standard methodology for
medicare contractors to use in selecting a sample of claims for
review in the case of an abnormal billing pattern.