I 

114TH CONGRESS 

1ST SESSION H. R. 3718 

To amend titles XVIII and XIX of the Social Security Act to curb waste, 

fraud, and abuse in the Medicare and Medicaid programs. 

IN THE HOUSE OF REPRESENTATIVES 

OCTOBER 8, 2015 

Mr. ROSKAM (for himself and Mr. CARNEY) introduced the following bill; 

which was referred to the Committee on Energy and Commerce, and in 

addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such 

provisions as fall within the jurisdiction of the committee concerned 

A BILL 

To amend titles XVIII and XIX of the Social Security Act 

to curb waste, fraud, and abuse in the Medicare and 

Medicaid programs. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Preventing and Reduc5 ing Improper Medicare and Medicaid Expenditures to Re6 store Integrity to Benefits Act of 2015’’. 


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1 SEC. 2. STRENGTHENING MEDICAID PROGRAM INTEGRITY 

2 THROUGH FLEXIBILITY. 

3 Section 1936 of the Social Security Act (42 U.S.C. 

4 1396u–6) is amended— 

5 (1) in subsection (a), by inserting ‘‘, or other6 wise,’’ after ‘‘entities’’; and 

7 (2) in subsection (e)— 

8 (A) in paragraph (1), in the matter pre9 ceding subparagraph (A), by inserting ‘‘(includ10 ing the costs of equipment, salaries and bene11 fits, and travel and training)’’ after ‘‘Program 

12 under this section’’; and 

13 (B) in paragraph (3), by striking ‘‘by 100’’ 

14 and inserting ‘‘by 100, or such number as de15 termined necessary by the Secretary to carry 

16 out the Program,’’. 

17 SEC. 3. ESTABLISHING MEDICARE ADMINISTRATIVE CON18 TRACTOR ERROR REDUCTION INCENTIVES. 

19 (a) IN GENERAL.—Section 1874A(b)(1)(D) of the 

20 Social Security Act (42 U.S.C. 1395kk–1(b)(1)(D)) is 

21 amended— 

22 (1) by striking ‘‘QUALITY.—The Secretary’’ and 

23 inserting ‘‘QUALITY.— 

24 ‘‘(i) IN GENERAL.—Subject to clauses 

25 (ii) and (iii), the Secretary’’; and 


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1 (2) by inserting after clause (i), as added by 

2 paragraph (1), the following new clauses: 

3 ‘‘(ii) IMPROPER PAYMENT RATE RE4 DUCTION INCENTIVES.—The Secretary 

5 shall provide incentives for medicare ad6 ministrative contractors to reduce the im7 proper payment error rates in their juris8 dictions. 

9 ‘‘(iii) INCENTIVES.—The incentives 

10 provided for under clause (ii)— 

11 ‘‘(I) may include a sliding scale 

12 of award fee payments and additional 

13 incentives to medicare administrative 

14 contractors that either reduce the im15 proper payment rates in their jurisdic16 tions to certain thresholds, as deter17 mined by the Secretary, or accomplish 

18 tasks, as determined by the Secretary, 

19 that further improve payment accu20 racy; and 

21 ‘‘(II) may include substantial re22 ductions in award fee payments under 

23 cost-plus-award-fee contracts, for 

24 medicare administrative contractors 

25 that reach an upper end improper 


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1 payment rate threshold or other 

2 threshold as determined by the Sec3 retary, or fail to accomplish tasks, as 

4 determined by the Secretary, that fur5 ther improve payment accuracy.’’. 

6 (b) EFFECTIVE DATE.— 

7 (1) IN GENERAL.—The amendments made by 

8 subsection (a) shall apply to contracts entered into 

9 or renewed on or after the date that is 3 years after 

10 the date of enactment of this Act. 

11 (2) APPLICATION TO EXISTING CONTRACTS.— 

12 In the case of contracts in existence on or after the 

13 date of the enactment of this Act and that are not 

14 subject to the effective date under paragraph (1), 

15 the Secretary of Health and Human Services shall, 

16 when appropriate and practicable, seek to apply the 

17 incentives provided for in the amendments made by 

18 subsection (a) through contract modifications. 

19 SEC. 4. STRENGTHENING PENALTIES FOR THE ILLEGAL 

20 DISTRIBUTION OF A MEDICARE, MEDICAID, 

21 OR CHIP BENEFICIARY IDENTIFICATION OR 

22 BILLING PRIVILEGES. 

23 Section 1128B(b) of the Social Security Act (42 

24 U.S.C. 1320a–7b(b)) is amended by adding at the end the 

25 following: 


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1 ‘‘(4) Whoever without lawful authority know2 ingly and willfully purchases, sells or distributes, or 

3 arranges for the purchase, sale, or distribution of a 

4 beneficiary identification number or unique health 

5 identifier for a health care provider under title 

6 XVIII, title XIX, or title XXI shall be imprisoned 

7 for not more than 10 years or fined not more than 

8 $500,000 ($1,000,000 in the case of a corporation), 

9 or both.’’. 

10 SEC. 5. IMPROVING THE SHARING OF DATA BETWEEN THE 

11 FEDERAL GOVERNMENT AND STATE MED12 ICAID PROGRAMS. 

13 (a) IN GENERAL.—The Secretary of Health and 

14 Human Services (in this section referred to as the ‘‘Sec15 retary’’) shall establish a plan to encourage and facilitate 

16 the participation of States in the Medicare-Medicaid Data 

17 Match Program (commonly referred to as the ‘‘Medi-Medi 

18 Program’’) under section 1893(g) of the Social Security 

19 Act (42 U.S.C. 1395ddd(g)). 

20 (b) PROGRAM REVISIONS TO IMPROVE MEDI-MEDI

21 DATA MATCH PROGRAM PARTICIPATION BY STATES.— 

22 Section 1893(g)(1)(A) of the Social Security Act (42 

23 U.S.C. 1395ddd(g)(1)(A)) is amended— 

24 (1) in the matter preceding clause (i), by insert25 ing ‘‘or otherwise’’ after ‘‘eligible entities’’; 


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1 (2) in clause (i)— 

2 (A) by inserting ‘‘to review claims data’’ 

3 after ‘‘algorithms’’; and 

4 (B) by striking ‘‘service, time, or patient’’ 

5 and inserting ‘‘provider, service, time, or pa6 tient’’; 

7 (3) in clause (ii)— 

8 (A) by inserting ‘‘to investigate and re9 cover amounts with respect to suspect claims’’ 

10 after ‘‘appropriate actions’’; and 

11 (B) by striking ‘‘; and’’ and inserting a 

12 semicolon; 

13 (4) in clause (iii), by striking the period and in14 serting ‘‘; and’’; and 

15 (5) by adding at the end the following new 

16 clause: 

17 ‘‘(iv) furthering the Secretary’s de18 sign, development, installation, or enhance19 ment of an automated data system archi20 tecture— 

21 ‘‘(I) to collect, integrate, and as22 sess data for purposes of program in23 tegrity, program oversight, and ad24 ministration, including the Medi-Medi 

25 Program; and 


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1 ‘‘(II) that improves the coordina2 tion of requests for data from 

3 States.’’. 

4 (c) PROVIDING STATES WITH DATA ON IMPROPER

5 PAYMENTS MADE FOR ITEMS OR SERVICES PROVIDED TO

6 DUAL ELIGIBLE INDIVIDUALS.— 

7 (1) IN GENERAL.—The Secretary shall develop 

8 and implement a plan that allows each State agency 

9 responsible for administering a State plan for med10 ical assistance under title XIX of the Social Security 

11 Act access to relevant data on improper or fraudu12 lent payments made under the Medicare program 

13 under title XVIII of the Social Security Act (42 

14 U.S.C. 1395 et seq.) for health care items or serv15 ices provided to dual eligible individuals. 

16 (2) DUAL ELIGIBLE INDIVIDUAL DEFINED.—In 

17 this section, the term ‘‘dual eligible individual’’ 

18 means an individual who is entitled to, or enrolled 

19 for, benefits under part A of title XVIII of the So20 cial Security Act (42 U.S.C. 1395c et seq.), or en21 rolled for benefits under part B of title XVIII of 

22 such Act (42 U.S.C. 1395j et seq.), and is eligible 

23 for medical assistance under a State plan under title 

24 XIX of such Act (42 U.S.C. 1396 et seq.) or under 

25 a waiver of such plan. 


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1 SEC. 6. REPORT ON IMPLEMENTATION. 

2 Not later than 18 months after the date of the enact3 ment of this Act, the Secretary of Health and Human 

4 Services shall submit to Congress a report on the imple5 mentation of the provisions of, and the amendments made 

6 by— 

7 (1) this Act; and 

8 (2) sections 506 and 507 of the Medicare Ac9 cess and CHIP Reauthorization Act of 2015 (Public 

10 Law 114–10). 

Æ 


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