I 

112TH CONGRESS 

1ST SESSION H. R. 3474 

To amend titles XI and XVIII of the Social Security Act to prevent fraud 

and abuse under the Medicare program and to require National Provider 

Identifiers for reimbursement of prescriptions under part D of the Medicare program, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

NOVEMBER 18, 2011 

Mr. STEARNS 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 XI and XVIII of the Social Security Act 

to prevent fraud and abuse under the Medicare program 

and to require National Provider Identifiers for reimbursement of prescriptions under part D of the Medicare 

program, and for other purposes. 

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 ‘‘Promoting Responsi5 bility in Medical Expenditures Act of 2011’’ or the 

6 ‘‘PRIME Act of 2011’’. 


smartinez on DSK6TPTVN1PROD with BILLS
2 

•HR 3474 IH

1 SEC. 2. INCREASED CIVIL AND CRIMINAL PENALTIES. 

2 (a) INCREASED CIVIL MONEY PENALTIES AND

3 CRIMINAL FINES FOR FEDERAL HEALTH CARE PROGRAM

4 FRAUD AND ABUSE.— 

5 (1) INCREASED CIVIL MONEY PENALTIES.—Sec6 tion 1128A of the Social Security Act (42 U.S.C. 

7 1320a–7a) is amended— 

8 (A) in subsection (a), in the matter fol9 lowing paragraph (10)— 

10 (i) by striking ‘‘$10,000’’ and insert11 ing ‘‘$20,000’’ each place it appears; 

12 (ii) by striking ‘‘$15,000’’ and insert13 ing ‘‘$30,000’’; and 

14 (iii) by striking ‘‘$50,000’’ and insert15 ing ‘‘$100,000’’ each place it appears; and 

16 (B) in subsection (b)— 

17 (i) in paragraph (1), in the flush text 

18 following subparagraph (B), by striking 

19 ‘‘$2,000’’ and inserting ‘‘$4,000’’; 

20 (ii) in paragraph (2), by striking 

21 ‘‘$2,000’’ and inserting ‘‘$4,000’’; and 

22 (iii) in paragraph (3)(A)(i), by strik23 ing ‘‘$5,000’’ and inserting ‘‘$10,000’’. 

24 (2) INCREASED CRIMINAL FINES.—Section 

25 1128B of such Act (42 U.S.C. 1320a–7b) is amend26 ed— 


smartinez on DSK6TPTVN1PROD with BILLS
3 

•HR 3474 IH

1 (A) in subsection (a), in the matter fol2 lowing paragraph (6)— 

3 (i) by striking ‘‘$25,000’’ and insert4 ing ‘‘$100,000’’; and 

5 (ii) by striking ‘‘$10,000’’ and insert6 ing ‘‘$20,000’’; 

7 (B) in subsection (b)— 

8 (i) in paragraph (1), in the flush text 

9 following subparagraph (B), by striking 

10 ‘‘$25,000’’ and inserting ‘‘$100,000’’; and 

11 (ii) in paragraph (2), in the flush text 

12 following subparagraph (B), by striking 

13 ‘‘$25,000’’ and inserting ‘‘$100,000’’; 

14 (C) in subsection (c), by striking 

15 ‘‘$25,000’’ and inserting ‘‘$100,000’’; 

16 (D) in subsection (d), in the flush text fol17 lowing paragraph (2), by striking ‘‘$25,000’’ 

18 and inserting ‘‘$100,000’’; and 

19 (E) in subsection (e), by striking ‘‘$2,000’’ 

20 and inserting ‘‘$4,000’’. 

21 (b) INCREASED SENTENCES FOR FELONIES INVOLV22 ING FEDERAL HEALTH CARE PROGRAM FRAUD AND

23 ABUSE.— 

24 (1) FALSE STATEMENTS AND REPRESENTA25 TIONS.—Section 1128B(a) of the Social Security Act 


smartinez on DSK6TPTVN1PROD with BILLS
4 

•HR 3474 IH

1 (42 U.S.C. 1320a–7b(a)) is amended, in the matter 

2 following paragraph (6), by striking ‘‘not more than 

3 five years or both, or (ii)’’ and inserting ‘‘not more 

4 than 10 years or both, or (ii)’’. 

5 (2) ANTIKICKBACK.—Section 1128B(b) of such 

6 Act (42 U.S.C. 1320a–7b(b)) is amended— 

7 (A) in paragraph (1), in the flush text fol8 lowing subparagraph (B), by striking ‘‘not more 

9 than five years’’ and inserting ‘‘not more than 

10 10 years’’; and 

11 (B) in paragraph (2), in the flush text fol12 lowing subparagraph (B), by striking ‘‘not more 

13 than five years’’ and inserting ‘‘not more than 

14 10 years’’. 

15 (3) FALSE STATEMENT OR REPRESENTATION

16 WITH RESPECT TO CONDITIONS OR OPERATIONS OF

17 FACILITIES.—Section 1128B(c) of such Act (42 

18 U.S.C. 1320a–7b(c)) is amended by striking ‘‘not 

19 more than five years’’ and inserting ‘‘not more than 

20 10 years’’. 

21 (4) EXCESS CHARGES.—Section 1128B(d) of 

22 such Act (42 U.S.C. 1320a–7b(d)) is amended, in 

23 the flush text following paragraph (2), by striking 

24 ‘‘not more than five years’’ and inserting ‘‘not more 

25 than 10 years’’. 


smartinez on DSK6TPTVN1PROD with BILLS
5 

•HR 3474 IH

1 (c) EFFECTIVE DATE.—The amendments made by 

2 this section shall apply to acts committed after the date 

3 of the enactment of this Act. 

4 SEC. 3. ANNUAL MEDICARE, MEDICAID, AND CHIP FRAUD 

5 REPORTS. 

6 (a) IN GENERAL.—By not later than July 1, 2012, 

7 and each subsequent year, the Secretary of Health and 

8 Human Services shall submit to the Committees on Ways 

9 and Means and Energy and Commerce of the House of 

10 Representatives and the Committee on Finance of the 

11 Senate a report that contains the following: 

12 (1) AMOUNT OF FRAUD.—The amount, as esti13 mated by the Secretary— 

14 (A) of total suspected fraud committed 

15 against the Medicare program under title XVIII 

16 of the Social Security Act, the Medicaid pro17 gram under title XIX of such Act, and the Chil18 dren’s Health Insurance Program under title 

19 XXI of such Act; and 

20 (B) the amount of such suspected fraud 

21 that is committed by employees of the Depart22 ment of Health and Human Services who have 

23 access to data from any of the programs under 

24 subparagraph (A). 


smartinez on DSK6TPTVN1PROD with BILLS
6 

•HR 3474 IH

1 (2) DATA ACCESS IMPLEMENTATION.—Informa2 tion on implementation of the data access require3 ment under section 1128J(a)(2) of the Social Secu4 rity Act (42 U.S.C. 1320a–7k(a)(2)). 

5 (b) USE OF AUDITS.— 

6 (1) ESTIMATE BASED ON AUDITED CLAIMS.— 

7 The Secretary shall base the estimate of suspected 

8 fraud under subsection (a)(1)(A) on an audit of a 

9 random sample of at least 10,000 claims for pay10 ment made under the programs under title XVIII, 

11 XIX, or XXI of the Social Security Act. 

12 (2) AUTHORITY OF THE SECRETARY.—For pur13 poses of conducting the audits under paragraph (1), 

14 the Secretary may— 

15 (A) request that a health care provider or 

16 supplier submit documentation relating to the 

17 claim being audited and review such docu18 mentation; 

19 (B) conduct unannounced onsite visits; and 

20 (C) interview patients. 

21 (3) SUBMISSION OF INFORMATION.—Not later 

22 than 30 days after receiving a request for docu23 mentation under paragraph (2)(A), the health care 

24 provider or supplier shall provide to the Secretary all 

25 requested documentation related to such claim. 


smartinez on DSK6TPTVN1PROD with BILLS
7 

•HR 3474 IH

1 (4) INTERNAL AUDIT.—The Secretary shall 

2 base the estimate of suspected fraud committed by 

3 employees of the Department of Health and Human 

4 Services under subsection (a)(1)(B) on an internal 

5 audit. 

6 (c) FRAUD DEFINED.—In this section, the term 

7 ‘‘fraud’’ has the meaning given such term in section 455.2 

8 of title 42, Code of Federal Regulations. 

9 SEC. 4. PROTECTING PREDICTIVE ANALYTICS TECH10 NOLOGIES FROM COMPELLED DISCLOSURE 

11 UNDER THE FREEDOM OF INFORMATION 

12 ACT. 

13 Section 4241 of the Small Business Jobs Act of 2010 

14 (42 U.S.C. 1320a–7m) is amended by adding at the end 

15 the following: 

16 ‘‘(j) EXEMPTION FROM FOIA.—The algorithms used 

17 in predictive modeling and other analytics technologies 

18 under this section are exempt from disclosure under sec19 tion 552(b)(3) of title 5, United States Code. 

20 ‘‘(k) AUDIT AND REVIEW.—The Inspector General of 

21 the Department of Health and Human Services and the 

22 Comptroller General of the United States shall, beginning 

23 on January 1, 2013, and annually thereafter, complete an 

24 audit and review of the implementation of this section, in25 cluding the effectiveness of the algorithms used in preVerDate Mar 15 2010 02:37 Nov 22, 2011 Jkt 019200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H3474.IH H3474

smartinez on DSK6TPTVN1PROD with BILLS
8 

•HR 3474 IH

1 dictive modeling and other analytics technologies under 

2 this section.’’. 

3 SEC. 5. REQUIRING VALID NATIONAL PROVIDER IDENTI4 FIERS FOR PRESCRIBERS ON PHARMACY 

5 CLAIMS AND LIMITING ACCESS TO THE NA6 TIONAL PROVIDER IDENTIFIER REGISTRY. 

7 (a) REQUIRING VALID NATIONAL PROVIDER IDENTI8 FIERS OF PRESCRIBERS ON PHARMACY CLAIMS.— 

9 (1) IN GENERAL.—Section 1860D–2(e)(2) of 

10 the Social Security Act (42 U.S.C. 1395w– 

11 102(e)(2)) is amended by adding at the end the fol12 lowing new subparagraph: 

13 ‘‘(C) DRUGS PRESCRIBED BY NONVALID

14 PRESCRIBERS.—For plan years that begin on or 

15 after January 1, 2013, such term does not in16 clude a drug prescribed by an individual who 

17 does not have a valid National Provider Identi18 fier, as determined through procedures estab19 lished by the Secretary.’’. 

20 (2) IDENTIFYING AND REPORTING INVALID

21 PRESCRIBERS.— 

22 (A) TRANSFER OF INFORMATION TO THE

23 INSPECTOR GENERAL.—In the case that the 

24 procedures established by the Secretary of 

25 Health and Human Services under section 


smartinez on DSK6TPTVN1PROD with BILLS
9 

•HR 3474 IH

1 1860D–2(e)(2) of the Social Security Act result 

2 in a PDP sponsor identifying a claim for reim3 bursement under a prescription drug plan 

4 under part D of title XVIII of such Act as 

5 being for a drug that was prescribed by an indi6 vidual who did not have a valid National Pro7 vider Identifier, the PDP sponsor shall submit 

8 to the Inspector General of the Department of 

9 Health and Human Services any information on 

10 such invalid prescribers on pharmacy claims, in11 cluding any invalid national provider identifiers 

12 being used to submit such claims and any 

13 records related to such claims. 

14 (B) RESPONSIBILITY OF THE INSPECTOR

15 GENERAL.—The Inspector General of the De16 partment of Health and Human Services shall 

17 provide to the appropriate law enforcement 

18 agencies information submitted under subpara19 graph (A). 

20 (C) REPORT TO CONGRESS.—Not later 

21 than January 1, 2014, the Inspector General of 

22 the Department of Health and Human Services 

23 shall submit to Congress a report on the effec24 tiveness of the procedures established under 


smartinez on DSK6TPTVN1PROD with BILLS
10 

•HR 3474 IH

1 section 1860D–2(e)(2)(C) of the Social Security 

2 Act. 

3 (b) LIMITING ACCESS TO NATIONAL PROVIDER

4 IDENTIFIER REGISTRY.— 

5 (1) IN GENERAL.—The Secretary of Health and 

6 Human Services, in consultation with the Attorney 

7 General, the Inspector General of the Department of 

8 Health and Human Services, the Chairman of the 

9 Federal Trade Commission, and affected parties (in10 cluding prescription drug plans under part D of title 

11 XVIII of the Social Security Act (42 U.S.C. 1395w– 

12 101 et seq.), MA–PD plans under part C of title 

13 XVIII of the Social Security Act (42 U.S.C. 1395w– 

14 21 et seq.), pharmacies, physicians, and pharmacy 

15 computer vendors), shall establish procedures and 

16 rules to restrict access to the National Provider 

17 Identifier Registry in order to deter the fraudulent 

18 use of National Provider Identifiers for purposes of 

19 making claims under titles XVIII and XIX of the 

20 Social Security Act. 

21 (2) ACCESS.— 

22 (A) IN GENERAL.—The procedures estab23 lished under paragraph (1) shall provide gov24 ernmental and nongovernmental entities with 

25 appropriate (as determined by the Secretary) 


smartinez on DSK6TPTVN1PROD with BILLS
11 

•HR 3474 IH

1 access to the National Provider Identifier Reg2 istry. 

3 (B) DATA USE AGREEMENTS.—In order to 

4 receive such access, each such governmental 

5 and nongovernmental entity shall enter into a 

6 data use agreement with the Secretary and 

7 agree to use the data in such registry in accord8 ance with rules established by the Secretary 

9 pursuant such paragraph. 

10 SEC. 6. ENCOURAGING THE ESTABLISHMENT OF STATE 

11 PRESCRIPTION DRUG MONITORING PRO12 GRAMS. 

13 (a) IN GENERAL.—Section 1905 of the Social Secu14 rity Act is amended by adding at the end the following: 

15 ‘‘(ee) INCENTIVES FOR STATES TO IDENTIFY FRAUD

16 THROUGH STATE PRESCRIPTION DRUG MONITORING

17 PROGRAMS.— 

18 ‘‘(1) IN GENERAL.—With respect to a calendar 

19 quarter, the Federal medical assistance percentage 

20 for the amounts under clauses (i) and (II) of sub21 paragraph (C) shall be decreased by 10 percent for 

22 such quarter, if— 

23 ‘‘(A) a State is receiving a grant for a 

24 State controlled substance monitoring program 

25 under section 399O of the Public Health ServVerDate Mar 15 2010 02:37 Nov 22, 2011 Jkt 019200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\H3474.IH H3474

smartinez on DSK6TPTVN1PROD with BILLS
12 

•HR 3474 IH

1 ice Act (or the Secretary determines that the 

2 State meets the requirements for such a grant); 

3 ‘‘(B) through such program, the State 

4 identifies fraud, waste, or abuse in connection 

5 the provision of prescription drug coverage 

6 under the State plan; and 

7 ‘‘(C) the State or a political subdivision of 

8 the State— 

9 ‘‘(i) is reimbursed an amount by a 

10 third party (pursuant to the provisions of 

11 the State plan in compliance with section 

12 1902(a)(25)) for expenditures related to 

13 such fraud, waste, or abuse; or 

14 ‘‘(ii) recovered (as such term is used 

15 under section 1903(d)(3)(A)) an amount. 

16 ‘‘(2) USE OF FUNDS.—A State may use the 

17 amounts received as a result of the increased Fed18 eral medical assistance percentage under paragraph 

19 (1) to support the State controlled substance moni20 toring program established by the State.’’. 

21 (b) CONFORMING AMENDMENTS.—Section 1905(b) 

22 of the Social Security Act is amended by striking ‘‘Subject 

23 to subsections (y), (z), and (aa)’’ and inserting ‘‘Subject 

24 to subsections (y), (z), (aa), and (ee)’’. 


smartinez on DSK6TPTVN1PROD with BILLS
13 

•HR 3474 IH

1 (c) EFFECTIVE DATE.—The amendments made by 

2 this subsection shall apply to calendar quarters beginning 

3 on or after the end of the 30-day period after the date 

4 of the enactment of this Act. 

5 SEC. 7. PROHIBITING THE DISPLAY OF SOCIAL SECURITY 

6 ACCOUNT NUMBERS ON NEWLY ISSUED 

7 MEDICARE IDENTIFICATION CARDS AND 

8 COMMUNICATIONS PROVIDED TO MEDICARE 

9 BENEFICIARIES. 

10 (a) IN GENERAL.—Not later than 2 years after the 

11 date of enactment of this Act, the Secretary of Health and 

12 Human Services (referred to in this section as the ‘‘Sec13 retary’’), acting in consultation with the Commissioner of 

14 Social Security, shall establish and implement procedures 

15 to eliminate the unnecessary collection, use, and display 

16 of Social Security account numbers of Medicare bene17 ficiaries under the Medicare program under title XVIII 

18 of the Social Security Act (42 U.S.C. 1395 et seq.). 

19 (b) NEWLY ISSUED MEDICARE CARDS AND COMMU20 NICATIONS PROVIDED TO BENEFICIARIES.—Not later 

21 than 4 years after the date of the enactment of this Act, 

22 the Secretary shall do the following: 

23 (1) NEWLY ISSUED CARDS.—Acting in con24 sultation with the Commissioner of Social Security, 

25 ensure that each newly issued Medicare identificaVerDate Mar 15 2010 02:37 Nov 22, 2011 Jkt 019200 PO 00000 Frm 00013 Fmt 6652 Sfmt 6201 E:\BILLS\H3474.IH H3474

smartinez on DSK6TPTVN1PROD with BILLS
14 

•HR 3474 IH

1 tion card does not display or electronically store, in 

2 an unencrypted format, a Medicare beneficiary’s So3 cial Security account number, except— 

4 (A) if the health insurance claim number 

5 of a beneficiary is the Social Security number 

6 of the beneficiary, the beneficiary’s spouse, or 

7 another individual, the Secretary may use such 

8 number on such card; and 

9 (B) if the Secretary determines that the 

10 risk of fraudulent use of such numbers is not 

11 unacceptably high, the Secretary may use a 

12 partial Social Security account number on a 

13 Medicare identification card. 

14 (2) COMMUNICATIONS PROVIDED TO BENE15 FICIARIES.—Prohibit the display of a Medicare bene16 ficiary’s Social Security account number in any writ17 ten or electronic communication provided to the ben18 eficiary unless the Secretary, in consultation with 

19 the Commissioner of Social Security, determines 

20 that inclusion of Social Security account numbers in 

21 such communications is essential for the operation of 

22 the Medicare program. 

23 (c) MEDICARE BENEFICIARY DEFINED.—In this sec24 tion, the term ‘‘Medicare beneficiary’’ means an individual 

25 who is entitled to, or enrolled for, benefits under part A 


smartinez on DSK6TPTVN1PROD with BILLS
15 

•HR 3474 IH

1 of title XVIII of the Social Security Act or enrolled under 

2 part B of such title. 

3 (d) CONFORMING AMENDMENTS.— 

4 (1) REFERENCE IN THE SOCIAL SECURITY

5 ACT.—Section 205(c)(2)(C) of the Social Security 

6 Act (42 U.S.C. 405(c)(2)(C)) is amended— 

7 (A) by moving clause (x), as added by sec8 tion 1414(a)(2) of the Patient Protection and 

9 Affordable Care Act (Public Law 111–148), 6 

10 ems to the left; 

11 (B) by redesignating clause (x), as added 

12 by section 2(a)(1) of the Social Security Num13 ber Protection Act of 2010 (42 U.S.C. 1305 

14 note), as clause (xii); and 

15 (C) by adding after clause (xii), as redesig16 nated by subparagraph (B), the following new 

17 clause: 

18 ‘‘(xiii) Subject to section 7 of the Promoting Respon19 sibility in Medical Expenditures Act of 2011, social secu20 rity account numbers shall not be displayed on Medicare 

21 identification cards or on communications provided to 

22 Medicare beneficiaries.’’. 

23 (2) ACCESS TO INFORMATION.—Section 205(r) 

24 of the Social Security Act (405 U.S.C. 405(r)) is 


smartinez on DSK6TPTVN1PROD with BILLS
16 

•HR 3474 IH

1 amended by adding at the end the following new 

2 paragraph: 

3 ‘‘(10)(A) To prevent and identify fraudulent activ4 ity— 

5 ‘‘(i) the Attorney General or the Secretary of 

6 Health and Human Services may submit to the 

7 Commissioner a request that the Commissioner 

8 enter into an agreement under this paragraph; and 

9 ‘‘(ii) subject to the requirements of subpara10 graphs (A) and (B) of paragraph (3), upon receiving 

11 a request under subparagraph (A), the Commis12 sioner shall enter into a reimbursable agreement 

13 with the individual making such request to provide 

14 to such individual the information collected under 

15 paragraph (1). 

16 ‘‘(B) The agreement under subparagraph (A)(ii) shall 

17 contain appropriate provisions (as determined by the Com18 missioner) to protect the confidentiality of information 

19 provided by the Commissioner under such agreement.’’. 

20 (e) PILOT PROGRAM.— 

21 (1) ESTABLISHMENT.—Not later than 1 year 

22 after the date of the enactment of this Act, the Sec23 retary shall establish a pilot program utilizing smart 

24 card technology to evaluate— 


smartinez on DSK6TPTVN1PROD with BILLS
17 

•HR 3474 IH

1 (A) the applicability of smart card tech2 nology to the Medicare program under title 

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

4 1395 et seq.); and 

5 (B) whether such cards would be effective 

6 in preventing fraud under the Medicare pro7 gram. 

8 (2) SCOPE AND DURATION.—The Secretary 

9 shall conduct the pilot program— 

10 (A) in not less than 2 States; and 

11 (B) for a period of not less than 180 days 

12 and not more than 2 years. 

13 (3) REPORT.—Not later than 12 months after 

14 the completion of the pilot program under this sub15 section, the Secretary shall submit to the appro16 priate committees of Congress and make available to 

17 the public a report that includes the following: 

18 (A) A summary of the pilot program and 

19 findings resulting from such program, includ20 ing— 

21 (i) any costs or savings to the Medi22 care program as a result of the implemen23 tation of the pilot program; 

24 (ii) whether the use of smart card 

25 technology resulted in improvements in the 


smartinez on DSK6TPTVN1PROD with BILLS
18 

•HR 3474 IH

1 quality of care provided to Medicare bene2 ficiaries under the pilot program; and 

3 (iii) whether such technology was use4 ful in preventing or detecting fraud, waste, 

5 and abuse in the Medicare program. 

6 (B) Recommendations regarding whether 

7 the use of smart card technology should be ex8 panded under the Medicare program. 

9 (4) DEFINITIONS.—In this subsection: 

10 (A) MEDICARE BENEFICIARY.—The term 

11 ‘‘Medicare beneficiary’’ means an individual en12 titled to, or enrolled for, benefits under part A 

13 of title XVIII of the Social Security Act (42 

14 U.S.C. 1395c et seq.) or enrolled for benefits 

15 under part B of such title (42 U.S.C. 1395j et 

16 seq.). 

17 (B) MEDICARE PROVIDER.—The term 

18 ‘‘Medicare provider’’ means— 

19 (i) a provider of services (as defined 

20 in section 1861(u) of the Social Security 

21 Act (42 U.S.C. 1395x(u))); or 

22 (ii) a supplier (as defined in section 

23 1861(d) of such Act (42 U.S.C. 

24 1395x(d))). 


smartinez on DSK6TPTVN1PROD with BILLS
19 

•HR 3474 IH

1 (C) SMART CARD.—The term ‘‘smart 

2 card’’ means an identification card used by a 

3 Medicare beneficiary or a Medicare provider 

4 that includes antifraud attributes. Such a 

5 card— 

6 (i) may rely on existing commercial 

7 data transfer networks or on a network of 

8 proprietary card readers or databases; and 

9 (ii) may include— 

10 (I) cards using technology adapt11 ed from the financial services indus12 try; 

13 (II) cards containing individual 

14 biometric identification, provided that 

15 such identification is encrypted and 

16 not contained in any central database; 

17 (III) cards adapting technology 

18 and processes utilized in the 

19 TRICARE program under chapter 55 

20 of title 10, United States Code, or by 

21 the Veterans Administration; or 

22 (IV) such other technology as the 

23 Secretary determines appropriate. 


smartinez on DSK6TPTVN1PROD with BILLS
20 

•HR 3474 IH

1 SEC. 8. IMPROVING CLAIMS PROCESSING AND DETECTION 

2 OF FRAUD WITHIN THE MEDICAID AND CHIP 

3 PROGRAMS. 

4 (a) MEDICAID.—Section 1903(i) of the Social Secu5 rity Act (42 U.S.C. 1396b(i)) is amended— 

6 (1) in paragraph (25), by striking ‘‘or’’ at the 

7 end; 

8 (2) in paragraph (26), by striking the period 

9 and inserting ‘‘; or’’; and 

10 (3) by inserting after paragraph (26) the fol11 lowing paragraph: 

12 ‘‘(27) with respect to any amount expended for 

13 an item or service unless the claim for payment for 

14 such item or service contains— 

15 ‘‘(A) a valid beneficiary identification num16 ber for the individual to whom such item or 

17 service was furnished, and the State has deter18 mined that such number corresponds to an indi19 vidual who is enrolled under the State plan or 

20 an applicable waiver of a requirement of such 

21 plan; and 

22 ‘‘(B) a valid provider identifier for the pro23 vider who furnished such item or service, and 

24 the State has determined that such identifier 

25 corresponds to a provider that is eligible to re26 ceive payment for furnishing such item or servVerDate Mar 15 2010 02:37 Nov 22, 2011 Jkt 019200 PO 00000 Frm 00020 Fmt 6652 Sfmt 6201 E:\BILLS\H3474.IH H3474

smartinez on DSK6TPTVN1PROD with BILLS
21 

•HR 3474 IH

1 ice under the State plan or an applicable waiver 

2 of a requirement of such plan.’’. 

3 (b) CHIP.—Section 2107(e)(1)(I) of the Social Secu4 rity Act (42 U.S.C. 1397gg(e)(1)(I)) is amended by strik5 ing ‘‘and (17)’’ and inserting ‘‘(17), and (27)’’. 

6 SEC. 9. GAO REPORT. 

7 Not later than January 1, 2013, the Comptroller 

8 General of the United States shall submit to the Congress 

9 a report that contains recommendations on methods that 

10 the Secretary of Health and Human Services could use 

11 to make Medicare claims data available to the public for 

12 the purpose of improving transparency within the Medi13 care program while protecting the privacy of individual 

14 Medicare beneficiaries, providers of services, and sup15 pliers. 

Æ 


smartinez on DSK6TPTVN1PROD with BILLS