Stop Schemes and Crimes Against Medicare and Seniors (Stop SCAMS) Act

Summary: Stop Schemes and Crimes Against Medicare and Seniors (Stop SCAMS) Act - Amends title XI of the Social Security Act with respect to standards for financial and administrative transactions and their data elements to enable the electronic exchange of health information. Requires the Secretary of Health and Human Services (HHS) to adopt standards that: (1) ensure that any entity producing and transmitting valid transactions that include code sets for appropriate data elements is subject to a consistent, industry-wide framework that supports a seamless transition to new and modified code sets; and (2) establish an end-to-end testing procedure for new and modified code sets that shall require the participation of any entity producing and transmitting valid transactions that use the new or modified code set. Prohibits the Secretary from adopting a new or modified code set unless the Secretary: (1) assesses its impact on fraud prevention and pre-payment review, determines that anti-fraud edits work as intended, and confirms that a plan is in place to ensure continuing effective detection of fraud following the adoption of the code set; (2) ensures that the end-to-end testing procedure established has been completed; and (3) completes end-to-end testing with any federal government entity that produces and transmits valid transactions that include the code set with private sector tracking partners. Exempts routine, regularly scheduled updates to existing code sets from such prohibition. Directs the Secretary, with respect to information supplied to it by a disclosing entity about those with an ownership or control interest in the entity, to verify such information in a specified manner and confirm the accuracy of any Social Security account number or employer identification number. Holds immune from civil liability (in a safe harbor) any non-governmental entity participating in a Healthcare Fraud Prevention Partnership, including private insurers, for sharing information about potentially fraudulent providers with each other, HHS, the Department of Justice (DOJ), any other federal or state law enforcement agency, any federal or state agency contractor, and another Partnership participant. Directs the Medicare Payment Advisory Commission (MEDPAC) to study administrative efforts to strengthen program integrity in the Medicare program. Amends the Small Business Jobs Act of 2010, with respect to the use of predictive modeling and other analytics technologies to identify and prevent waste, fraud, and abuse in the Medicare fee-for-service program, to require predictive analytics technologies to capture outcome information on civil recoveries, administrative actions, and criminal convictions for fraud. 

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Stop Schemes and Crimes Against 
Medicare and Seniors (Stop SCAMS) Act''.

SEC. 2. ENSURING THAT NEW MEDICAL CODING SYSTEMS DO NOT COMPROMISE 
              FRAUD PREVENTION EFFORTS.

    (a) In General.--Section 1173(c) of the Social Security Act (42 
U.S.C. 1320d-2(c)) is amended--
            (1) in paragraph (1)--
                    (A) in subparagraph (A), by striking ``; or'' and 
                inserting ``or, if no code sets for such data elements 
                have been developed, establish code sets for the data 
                elements;''; and
                    (B) by striking subparagraph (B) and adding the 
                following new subparagraphs:
                    ``(B) ensure that any entity producing and 
                transmitting valid transactions that include code sets 
                are subject to a consistent, industry-wide framework 
                that supports a seamless transition to new and modified 
                code sets; and
                    ``(C) establish, by a rule promulgated after notice 
                and an opportunity for a hearing on the record, an end-
                to-end testing procedure for new and modified code sets 
                that shall require the participation of any entity 
                producing and transmitting valid transactions that use 
                such new or modified code set.''; and
            (2) by adding at the end the following paragraphs:
            ``(3) Adopting new and modified code sets.--The Secretary 
        shall not adopt a new or modified code set unless the 
        Secretary--
                    ``(A) assesses the impact of the code set on fraud 
                prevention and pre-payment review, determines that 
                anti-fraud edits work as intended, and confirms that a 
                plan is in place to ensure continuing effective 
                detection of fraud following the adoption of the code 
                set;
                    ``(B) ensures that the end-to-end testing procedure 
                established by the Secretary under paragraph (1) has 
                been completed; and
                    ``(C) completes end-to-end testing with any Federal 
                Government entity that produces and transmits valid 
                transactions that include the code set with private 
                sector tracking partners.
            ``(4) Routine updates to existing code sets.--Paragraph (3) 
        shall not apply to routine, regularly scheduled updates to 
        existing code sets.''.
    (b) Effective Date.--The amendments made by this section shall be 
effective as of October 1, 2015.

SEC. 3. VERIFICATION OF PROVIDER OWNERSHIP INTERESTS.

    (a) In General.--Section 1124(c) of the Social Security Act (42 
U.S.C. 1320a-3(c)) is amended--
            (1) by redesignating paragraph (5) as paragraph (6); and
            (2) by inserting after paragraph (4) the following 
        paragraph:
            ``(5) Verification of information.--
                    ``(A) In general.--With respect to information 
                supplied by a disclosing entity under subsections (a) 
                and (b), the Secretary shall--
                            ``(i) verify such information by comparing 
                        it to available data on the provider collected 
                        through disclosures made to the Secretary under 
                        section 1128G(a)(2), or, in the case of a 
                        disclosing entity to which section 1128G(a)(2) 
                        does not apply, verify such information through 
                        comparison with at least one other public or 
                        private database which contains information as 
                        to the identity of each person with an 
                        ownership or control interest in the entity; 
                        and
                            ``(ii) confirm the accuracy of any social 
                        security account number or employer 
                        identification number supplied under subsection 
                        (a) by verifying--
                                    ``(I) each social security account 
                                number with the Commissioner of Social 
                                Security; and
                                    ``(II) each employer identification 
                                number with the Secretary of the 
                                Treasury.
                    ``(B) Discrepancies.--If the comparison described 
                in subparagraph (A)(i) reveals a discrepancy between 
                information supplied by a disclosing entity under 
                subsections (a) and (b) and available data on the 
                provider collected through disclosures made to the 
                Secretary under section 1128G(a)(2), the Secretary 
                shall independently verify the accuracy of such data 
                collected under section 1128G(a)(2) before taking any 
                action against a provider based on such discrepancy.''.
    (b) Effective Date.--The amendments made by this section shall be 
effective as of the date that is 1 year after the date of enactment of 
this Act.

SEC. 4. SUPPORTING PUBLIC AND PRIVATE INFORMATION SHARING TO PREVENT 
              HEALTH CARE FRAUD.

    (a) Definitions.--In this section:
            (1) Healthcare fraud prevention partnership; partnership.--
        The terms ``Healthcare Fraud Prevention Partnership'' and 
        ``Partnership'' mean the information sharing partnership 
        established between the Department of Health and Human 
        Services, the Department of Justice, and other public and 
        private stakeholders, including private insurers, under the 
        authority of section 1128C(a)(2) of the Social Security Act (42 
        U.S.C. 1320a-7c(a)(2)) for the purpose of detecting and 
        preventing health care fraud.
            (2) Private insurer.--The term ``private insurer'' has the 
        meaning given the term ``health insurance issuer'' under 
        section 2791(b)(2) of the Public Health Service Act (42 U.S.C. 
        300GG-91(b)(2)).
    (b) Safe Harbor for the Sharing of Information.--
            (1) General immunity.--
                    (A) In general.--A non-governmental entity 
                participating in the Partnership (including a private 
                insurer) that--
                            (i) provides data or information described 
                        in clause (i) or (ii) of subparagraph (B) to 
                        the Department of Health and Human Services, 
                        the Department of Justice, any other Federal or 
                        State law enforcement agency, any contractor of 
                        such Department or agency, or another entity 
                        participating in the Partnership (including a 
                        private insurer); or
                            (ii) uses such data or information as 
                        permitted by this subsection,
                shall be immune from civil liability with respect to 
                the provision or authorized use of such data or 
                information.
                    (B) Data or information.--
                            (i) Data.--The data described in this 
                        clause is aggregated claims data or other 
                        information described in clause (ii) that does 
                        not include individually identifiable 
                        information with respect to any health care 
                        provider, supplier, or beneficiary, whether or 
                        not analysis of such information results in the 
                        identification of a health care provider, 
                        supplier, or other person or organization as 
                        having committed fraud or having committed acts 
                        suspected of being fraudulent.
                            (ii) Information.--The information 
                        described in this clause is information 
                        concerning fraud or suspected fraudulent acts 
                        that identifies a specific health care 
                        provider, supplier, or other person or 
                        organization if the provider, supplier, or 
                        other person or organization so identified--
                                    (I) is the subject of a bona fide 
                                fraud investigation conducted by the 
                                entity participating in the 
                                Partnership, including a private 
                                insurer, that is providing the 
                                information;
                                    (II) is the subject of a fraud-
                                related allegation that has been filed 
                                by or received by the entity 
                                participating in the Partnership, 
                                including a private insurer, that is 
                                providing the information; or
                                    (III) has been convicted of a 
                                fraud-related offense.
            (2) Limitation.--The immunity described in paragraph (1) 
        shall apply only where--
                    (A) the data or information involved was provided 
                in good faith and without malice; and
                    (B) the data or information provided is true, based 
                on a reasonable belief, to the knowledge of the person 
                providing the information, or if false, the information 
                is provided without knowledge of, and without reckless 
                disregard for, its falsity.
            (3) Use of partnership data or information.--For purposes 
        of this subsection, data or information relating to a specific 
        provider or supplier received by a private insurer solely 
        through the Partnership shall be used, with respect to such 
        provider or supplier, only for the purpose of informing 
        decisionmaking by the private insurer related to fraud 
        investigations, including whether to conduct such an 
        investigation. Nothing in the preceding sentence shall prevent 
        a private insurer or other entity participating in the 
        Partnership from taking other actions, not specific to such 
        provider or supplier, based on such data or information.
    (c) Report.--Not later than October 1 of each calendar year that 
begins after the date of enactment of this Act, the Secretary of Health 
and Human Services shall submit to the Special Committee on Aging, the 
Committee on Finance, and the Committee on Homeland Security and 
Governmental Affairs of the Senate, and the Committee on Ways and Means 
and the Committee on Energy and Commerce of the House of 
Representatives, a report that describes the activities of the 
Healthcare Fraud Prevention Partnership. Such report shall include--
            (1) a description of how input was obtained from private 
        insurers regarding the appropriate usage of data shared through 
        the Healthcare Fraud Prevention Partnership; and
            (2) plans for the Partnership to be expanded to encompass a 
        representative sample of national private insurers and to 
        include health care provider organizations.

SEC. 5. MEDPAC STUDY AND REPORT.

    (a) Study.--The Medicare Payment Advisory Commission shall conduct 
a study on administrative efforts to strengthen program integrity in 
the Medicare program. Such study may include--
            (1) an evaluation of ways to detect fraudulent claims 
        before payment is made;
            (2) a review of the efficiency and effectiveness of post-
        payment recovery methods;
            (3) analysis by the Centers for Medicare & Medicaid 
        Services and public reporting of claims and spending patterns; 
        and
            (4) a review of the organizational structure and resources 
        of the Centers for Medicare & Medicaid Services as they relate 
        to program integrity.
    (b) Report.--Not later than June 15, 2016, the Medicare Payment 
Advisory Commission shall submit to Congress a report on the study 
conducted under subsection (a), together with recommendations for such 
legislative and administrative action as the Commission determines 
appropriate.

SEC. 6. ABILITY TO MEASURE FRAUD PREVENTION EFFORTS.

    Section 4241 of the Small Business Jobs Act of 2010 (42 U.S.C. 
1320a-7m) is amended--
            (1) in subsection (b)(4), by inserting ``and on civil 
        recoveries, administrative actions, and criminal convictions 
        for fraud'' after ``reimbursement''; and
            (2) in subsection (c), by adding at the end the following 
        paragraph:
            ``(7) Implementation of amendments.--The Secretary shall 
        implement amendments made to this subsection by the Stop 
        Schemes and Crimes Against Medicare and Seniors (Stop SCAMS) 
        Act not later than 6 months after the date of enactment of such 
        Act. If the Secretary determines that new technology or data 
        processing systems are required to carry out such amendments, 
        the Secretary shall issue a request for proposals to carry out 
        such amendments not later than 6 months after the enactment of 
        such Act, and the contractors selected under such request for 
        proposal shall implement such amendments not later than 12 
        months after the date of enactment of such Act.''.