I 

114TH CONGRESS 

1ST SESSION H. R. 4077 

To amend title XVIII of the Social Security Act to provide for a Medicare 

established provider system under which providers of services and suppliers representing a low risk for submitting fraudulent Medicare claims 

are provided certain claim review protections. 

IN THE HOUSE OF REPRESENTATIVES 

NOVEMBER 18, 2015 

Mr. WILLIAMS (for himself, Mr. FLORES, Ms. GRANGER, Mr. THORNBERRY, 

Mr. NEUGEBAUER, Mr. OLSON, and Mr. AUSTIN SCOTT of Georgia) introduced the following bill; which was referred to the Committee on Ways 

and Means, and in addition to the Committee on Energy and Commerce, 

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 title XVIII of the Social Security Act to provide 

for a Medicare established provider system under which 

providers of services and suppliers representing a low 

risk for submitting fraudulent Medicare claims are provided certain claim review protections. 

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 ‘‘Medicare Established 

5 Provider Act of 2015’’. 


tkelley on DSK3SPTVN1PROD with BILLS
2 

•HR 4077 IH

1 SEC. 2. MEDICARE ESTABLISHED PROVIDER SYSTEM. 

2 Title XVIII of the Social Security Act is amended by 

3 inserting after section 1893 of such Act (42 U.S.C. 

4 1395ddd) the following new section: 

5 ‘‘SEC. 1893A. MEDICARE ESTABLISHED PROVIDER SYSTEM. 

6 ‘‘(a) IN GENERAL.—The Secretary shall develop and 

7 implement a system (in this section referred to as the 

8 ‘Medicare Established Provider System’) to designate pro9 viders of services and suppliers who represent a low risk 

10 for submitting fraudulent claims for payment under this 

11 title as established providers for purposes of applying the 

12 protections described in subsection (c). Under such sys13 tem— 

14 ‘‘(1) the Secretary shall establish a process, in 

15 accordance with subsection (c), under which— 

16 ‘‘(A) providers of services and suppliers 

17 may apply for designation as established pro18 viders; 

19 ‘‘(B) such providers and suppliers who 

20 qualify, in accordance with subsection (b), as 

21 established providers are so designated (includ22 ing through the use of entities trained by an 

23 Internet training course of the Centers for 

24 Medicare & Medicaid Services or through train25 ing provided by other specified organizations); 

26 and 


tkelley on DSK3SPTVN1PROD with BILLS
3 

•HR 4077 IH

1 ‘‘(C) such providers and suppliers who no 

2 longer qualify as established providers lose such 

3 designation; and 

4 ‘‘(2) the Secretary shall establish an electronic 

5 system for the submission of documentation by pro6 viders of services, suppliers, or third parties, with re7 spect to a claim for payment under this title that is 

8 under review, for each level of review applicable to 

9 such claim. 

10 ‘‘(b) QUALIFYING AS ESTABLISHED PROVIDERS.— 

11 Under such system, to qualify as an established provider 

12 for a period with respect to a reporting period (as specified 

13 by the Secretary), a provider of services or supplier shall 

14 demonstrate, as specified by the Secretary, that— 

15 ‘‘(1) with respect to the reporting period begin16 ning after the date of the enactment of this section, 

17 at least 90 percent of claims for payment under this 

18 title for items and services furnished by such pro19 vider or supplier for which any review was conducted 

20 under section 1869 were determined to be eligible 

21 for payment or partial payment under this title; and 

22 ‘‘(2) of all claims for payment under this title 

23 for items and services furnished by such provider or 

24 supplier for which an initial determination was made 

25 that payment may not be made under this title, at 


tkelley on DSK3SPTVN1PROD with BILLS
4 

•HR 4077 IH

1 least 90 percent were appealed by such provider or 

2 supplier. 

3 ‘‘(c) DESIGNATION PROCESS.—The process under 

4 subsection (a)(1)— 

5 ‘‘(1) shall allow a provider of services or sup6 plier designated as an established provider under 

7 this section to demonstrate that the provider or sup8 plier maintains compliance with the qualification re9 quirements under subsection (b) based on annual 

10 updates on the status of claims for payment under 

11 this title for items and services furnished by such 

12 provider or supplier with respect to each level of re13 view, including the number of such claims within 

14 each such level of review for which a determination 

15 was made that payment should be made, should be 

16 partially made, or should not be made under this 

17 title; 

18 ‘‘(2) shall provide a method through which it 

19 may be determined whether or not the qualifying re20 quirements under subsection (b) have been satisfied 

21 and maintained by a provider of services or supplier 

22 with respect to a period; 

23 ‘‘(3) provide for the identification of established 

24 providers within appropriate systems of the Centers 

25 of Medicare & Medicaid Services; and 


tkelley on DSK3SPTVN1PROD with BILLS
5 

•HR 4077 IH

1 ‘‘(4) provide for a global track record of compli2 ance by providers of services and suppliers with the 

3 qualifying requirements under subsection (b), includ4 ing by identifying such providers and suppliers by 

5 the management company provider number rather 

6 than by each individual provider, supplier, or facility, 

7 for purposes of efficiency. 

8 ‘‘(d) PROTECTIONS FOR ESTABLISHED PRO9 VIDERS.—Notwithstanding any other provision of law, in 

10 the case of a provider of services or supplier designated 

11 as an established provider under this section with respect 

12 to a period the following protections shall apply: 

13 ‘‘(1) With respect to a claim submitted during 

14 such period for payment under this title for items or 

15 services furnished by such provider or supplier, 

16 which is subject to review for whether or not pay17 ment should be made under such title and with re18 spect to which an additional documentation request 

19 has been issued, payment under this title for such 

20 claim may not be withheld unless a final determina21 tion has been made that such payment should not be 

22 made. 

23 ‘‘(2) In the case that a final determination has 

24 been made that payment under this title should not 

25 have been made with respect to a claim described in 


tkelley on DSK3SPTVN1PROD with BILLS
6 

•HR 4077 IH

1 paragraph (1), repayment of such payment shall be 

2 made electronically by the provider not later than 45 

3 days after notification of such decision. In applying 

4 the previous sentence, if the Secretary determines 

5 that repayment within such 45-day period would re6 sult in a significant hardship to the provider in7 volved, the Secretary may, on a case-by-case basis, 

8 extend the 45-day period described in such sentence 

9 by such number of days as the Secretary determines 

10 appropriate in accordance with a specified repay11 ment plan. 

12 ‘‘(3) The Secretary shall provide for a method 

13 to apply section 1869 with respect to an initial de14 termination of any claim submitted during such pe15 riod for payment under this title for items and serv16 ices furnished by such provider or supplier, without 

17 the application of paragraph (3) of section 1869(a) 

18 (relating to redeterminations).’’. 

Æ 


tkelley on DSK3SPTVN1PROD with BILLS