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[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 10006 Introduced in House (IH)]

<DOC>

118th CONGRESS
  2d Session
                               H. R. 10006

To amend title XVIII of the Social Security Act to improve transparency 
    with respect to the suspension of Medicare payments pending an 
           investigation into a credible allegation of fraud.

_______________________________________________________________________

                    IN THE HOUSE OF REPRESENTATIVES

                            October 18, 2024

   Mr. Harder of California 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 title XVIII of the Social Security Act to improve transparency 
    with respect to the suspension of Medicare payments pending an 
           investigation into a credible allegation of fraud.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Centers for Medicare & Medicaid 
Services Auditor Transparency Act of 2024'' or the ``CAT Act of 2024''.

SEC. 2. FINDINGS.

    Congress finds the following:
            (1) In 2020, 139,000,000 individuals received health care 
        coverage through the Medicare or Medicaid programs, costing the 
        Federal Government approximately $1,500,000,000,000. Of these 
        funds paid by United States taxpayers, $3,100,000,000 were 
        discovered to have been fraudulent claims.
            (2) Ensuring the integrity of the Medicare and Medicaid 
        programs is crucial to preventing fraud, waste, and abuse and 
        safeguarding the financial sustainability of these important 
        programs.
            (3) Even though the Centers for Medicare & Medicaid 
        Services (CMS) utilization of Unified Program Integrity 
        Contractors (UPICs) has shown to be effective at identifying 
        bad actors defrauding the Federal Government through the 
        Medicare and Medicaid programs, current Federal law and 
        regulations have shown to be harmful to most providers who are 
        submitting Medicare and Medicaid claims in good faith.
            (4) Existing law provides CMS and UPICs broad authority and 
        discretion to suspend Medicare payments for up to a year 
        pending the investigation of ``credible allegations of fraud''.
            (5) However, current law does not require adequate 
        transparency from CMS or UPICs into the nature of the alleged 
        fraud before Medicare payments are suspended. Current law also 
        does not require CMS or UPICs to provide adequate due process 
        to providers whose payments have been suspended to challenge or 
        cure the allegations of fraud prior to the suspension of 
        Medicare payments.
            (6) In addition, anecdotal reports have shown that some 
        UPICs extend the suspension of Medicare payments on a routine 
        basis so that they may have additional time to finish their 
        audit despite not providing evidence that the continuation of a 
        payment suspension is necessary to protect the integrity of the 
        Medicare program.
            (7) The broad authority to suspend Medicare payments 
        pending the investigation of a credible allegation of fraud 
        without adequate due process or transparency places the 
        financial viability of many Medicare providers acting in good 
        faith at risk.
            (8) If Medicare providers acting in good faith close their 
        doors as a result of the unnecessary suspension of payments by 
        CMS or UPICs, Medicare beneficiaries and the American public 
        could face additional barriers to access to necessary health 
        care services as a direct result of unfair Federal law and 
        regulations.

SEC. 3. IMPROVING TRANSPARENCY IN SUSPENSION OF PAYMENTS PENDING 
              INVESTIGATION OF CREDIBLE ALLEGATIONS OF FRAUD UNDER 
              MEDICARE.

    (a) In General.--Section 1862(o) of the Social Security Act (42 
U.S.C. 1395y(o)) is amended--
            (1) in paragraph (1)--
                    (A) by striking ``The Secretary may suspend'' and 
                inserting ``Subject to paragraph (5), the Secretary may 
                suspend''; and
                    (B) by inserting ``An investigation of a credible 
                allegation of fraud, and the suspension of payment 
                pending such investigation under the preceding 
                sentence, may only exceed 180 days if the Secretary 
                determines there is good cause to extend such 
                investigation and suspension.'' at the end;
            (2) in paragraph (4)--
                    (A) by striking ``a fraud hotline tip (as defined 
                by the Secretary)'' and inserting ``the following 
                items''; and
                    (B) by striking ``credible allegation of fraud.'' 
                and inserting ``credible allegation of fraud:
                    ``(A) A fraud hotline tip (as defined by the 
                Secretary).
                    ``(B) Mere error (as defined by the Secretary).
                    ``(C) A billing error found during the course of an 
                audit that is attributable to human error.''.
            (3) by adding at the end the following new paragraphs:
            ``(5) Transparency in suspension of payments.--
                    ``(A) In general.--The Secretary may only suspend 
                payments to a provider of services or supplier under 
                this title pursuant to paragraph (1) if--
                            ``(i) subject to subparagraph (B), not 
                        later than 30 days before the date on which the 
                        payment suspension begins, the Secretary 
                        provides such provider of services or supplier 
                        with information about each credible allegation 
                        of fraud that is the basis for the payment 
                        suspension, including--
                                    ``(I) the specific nature of each 
                                credible allegation of fraud;
                                    ``(II) the date of the alleged 
                                fraud; and
                                    ``(III) the basis of the credible 
                                allegation of fraud, such as whether 
                                the allegation is based upon--
                                            ``(aa) a fraud hotline 
                                        complaint;
                                            ``(bb) data mining of data 
                                        with respect to claims for 
                                        payment under this title, title 
                                        XIX, or title XXI; or
                                            ``(cc) a pattern identified 
                                        through audits of providers of 
                                        services or suppliers; and
                            ``(ii) not less frequently than once every 
                        30 days during such payment suspension, the 
                        Secretary provides such provider of services or 
                        supplier with--
                                    ``(I) a detailed, up-to-date list 
                                of the findings of the investigation;
                                    ``(II) an anticipated timeline for 
                                the completion of the investigation; 
                                and
                                    ``(III) an opportunity to ask the 
                                Centers for Medicare & Medicaid 
                                Services questions regarding the 
                                payment suspension and the 
                                investigation.
                    ``(B) Exception.--The Secretary may elect not to 
                provide a provider of services or supplier with the 
                information described in clause (i) if the provision of 
                such information does not compromise the integrity of 
                the investigation, as determined by the Secretary in 
                consultation with the Inspector General of the 
                Department of Health and Human Services and State 
                auditors (as appropriate).
                    ``(C) Failure to provide information.--If the 
                requirements described in subparagraph (A) are not met 
                with respect to the suspension of payment to a provider 
                of services or a supplier under this title, the 
                Secretary shall immediately resume such payment, and 
                shall pay to the provider of services or supplier the 
                amounts not paid due to such suspension and any 
                interest accrued with respect to such amounts.
                    ``(D) Annual report.--Not later than 180 days after 
                the end of each fiscal year (beginning with fiscal year 
                2024), the Secretary shall submit to Congress a report 
                that includes the following information with respect to 
                such fiscal year:
                            ``(i) The number of payment suspensions 
                        issued as the result of a pending investigation 
                        of a credible allegation of fraud under this 
                        subsection, section 1860D-12(b)(7) (including 
                        as applied pursuant to section 1857(f)(3)(D)), 
                        or section 1903(i)(2)(C).
                            ``(ii) The basis of each such credible 
                        allegation of fraud.
                            ``(iii) The average duration of a payment 
                        suspension described in clause (i).
                            ``(iv) The average duration of an 
                        investigation of a credible allegation of fraud 
                        described in clause (i).
                            ``(v) If applicable, the average time 
                        between the completion of an investigation into 
                        a credible allegation of fraud described in 
                        clause (i) and the reinstatement of payments to 
                        the relevant provider of services or supplier.
            ``(6) Appeals.--Not later than 180 days after the date of 
        the enactment of the CAT Act of 2024, the Secretary shall 
        provide an independent process by which a provider of services 
        or supplier under this title that has received notice of a 
        payment suspension due to a pending investigation of a credible 
        allegation of fraud pursuant to this subsection may appeal such 
        suspension and receive a resolution of such appeal in a timely 
        manner.''.
    (b) Stakeholder Consultation.--In developing the appeals process 
required under section 1862(o)(6) of the Social Security Act, as added 
by subsection (a), the Secretary of Health and Human Services shall 
consult with relevant stakeholders, including providers of services and 
suppliers under title XVIII of the Social Security Act (42 U.S.C. 1395 
et seq.), title XIX of such Act (42 U.S.C. 1396 et seq.), and title XXI 
of such Act (42 U.S.C. 1397aa et seq.), as determined appropriate by 
the Secretary.
    (c) Applicability.--The amendments made by this section shall apply 
with respect to any investigation of a credible allegation of fraud 
under section 1862(o) of the Social Security Act (42 U.S.C. 1395y(o)), 
section 1860D-12(b)(7) of such Act (42 U.S.C. 1395w-112(b)(7)) 
(including as applied pursuant to section 1857(f)(3)(D) of such Act (42 
U.S.C. 1395w-27(f)(3)(D))), or section 1903(i)(2)(C) of such Act (42 
U.S.C. 1396b(i)(2)(C)) that is initiated after the date of enactment of 
this Act.
                                 <all>
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