II 

116TH CONGRESS 

1ST SESSION S. 498 

To provide for an independent outside audit of the Indian Health Service. 

IN THE SENATE OF THE UNITED STATES 

FEBRUARY 14, 2019 

Mr. ROUNDS introduced the following bill; which was read twice and referred 

to the Committee on Indian Affairs 

A BILL 

To provide for an independent outside audit of the Indian 

Health Service. 

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 ‘‘Assessment of the In5 dian Health Service Act of 2019’’. 

6 SEC. 2. ASSESSMENT OF THE INDIAN HEALTH SERVICE. 

7 (a) DEFINITIONS.—In this section: 

8 (1) REPUTABLE PRIVATE ENTITY.—The term 

9 ‘‘reputable private entity’’ means a private entity 

10 that— 


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1 (A) has experience with, and proven out2 comes in optimizing the performance of, Fed3 eral health care delivery systems, the private 

4 sector, and health care management; and 

5 (B) specializes in implementing large-scale 

6 organizational and cultural transformations, es7 pecially with respect to health care delivery sys8 tems. 

9 (2) SECRETARY.—The term ‘‘Secretary’’ means 

10 the Secretary of Health and Human Services. 

11 (3) SERVICE.—The term ‘‘Service’’ means the 

12 Indian Health Service. 

13 (b) ASSESSMENT.—Not later than 180 days after the 

14 date of enactment of this Act, the Secretary shall enter 

15 into one or more contracts with a reputable private entity 

16 to conduct an independent assessment of the health care 

17 delivery systems and financial management processes of 

18 the Service. The Secretary shall not be required to provide 

19 a full and open competition in entering into such con20 tracts. Such independent assessment shall be made only 

21 of Service-operated facilities. 

22 (c) PROGRAM INTEGRATOR.— 

23 (1) IN GENERAL.—If the Secretary enters into 

24 contracts under this section with more than 1 rep25 utable private sector entity, the Secretary shall desVerDate Sep 11 2014 04:03 Feb 22, 2019 Jkt 089200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\S498.IS S498

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1 ignate one such entity that is predominantly a 

2 health care organization as the program integrator. 

3 (2) RESPONSIBILITIES.—The program inte4 grator designated under paragraph (1) shall be re5 sponsible for coordinating the outcomes of the as6 sessments conducted by the reputable private enti7 ties under this section. 

8 (d) COORDINATION WITH GAO AND OIG.—As part 

9 of planning or designing the assessment described in sub10 section (b), the Secretary (or the program integrator des11 ignated under subsection (c)(1) acting on behalf of the 

12 Secretary) shall consult with the Comptroller General of 

13 the United States and the Inspector General of the De14 partment of Health and Human Services to minimize du15 plications in the areas of study required under subsection 

16 (e) and to incorporate the Government Accountability Of17 fice’s and Office of Inspector General’s prior, publicly re18 leased, and relevant report findings dated January 1, 

19 2013, or later, as appropriate. 

20 (e) AREAS OF STUDY.—Each assessment conducted 

21 under subsection (b) shall address each of the following: 

22 (1) Current and projected demographics and 

23 unique health care needs of the patient population 

24 served by the Service. 


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1 (2) Current and projected health care capabili2 ties and resources of the Service, including hospital 

3 care, medical services, and other health care fur4 nished by non-Service facilities under contract with 

5 the Service, to provide timely and accessible care to 

6 eligible patients. 

7 (3) The authorities and mechanisms under 

8 which the Secretary may furnish hospital care, med9 ical services, and other health care at non-Service fa10 cilities. 

11 (4) The appropriate systemwide access standard 

12 applicable to hospital care, medical services, and 

13 other health care furnished by and through the Serv14 ice, including an identification of appropriate access 

15 standards for each individual specialty and post-care 

16 rehabilitation. 

17 (5) The workflow process at each medical facil18 ity of the Service for providing hospital care, medical 

19 services, or other health care from the Service. 

20 (6) The organization, workflow processes, and 

21 tools used by the Service to support clinical staffing, 

22 access to care, effective length-of-stay management 

23 and care transitions, positive patient experience, ac24 curate documentation, and subsequent coding of in25 patient services. 


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1 (7) The staffing level at each medical facility of 

2 the Service and the productivity of each health care 

3 provider at such medical facility, compared with 

4 health care industry performance metrics, which 

5 may include an assessment of any of the following: 

6 (A) The case load of, and number of pa7 tients treated by, each health care provider at 

8 such medical facility during an average week. 

9 (B) The time spent by such health care 

10 provider on matters other than the case load of 

11 such health care provider. 

12 (C) The percentage of Service personnel 

13 carrying out administrative duties compared to 

14 direct health care duties, as compared to the 

15 percentage of private health care institution 

16 personnel carrying out administrative duties 

17 compared to direct health care duties. 

18 (D) The allocation of the budget of the 

19 Service used for administration compared with 

20 the allocation of the budget used for direct 

21 health care at Service-operated facilities. 

22 (E) Any vacancies in positions of full-time 

23 equivalent employees that the Service has not 

24 filled during the 12-month period beginning on 

25 the date on which the position became vacant. 


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1 (F) The disposition of amounts budgeted 

2 for full-time equivalent employees that is not 

3 used for those employees because the positions 

4 of the employees are vacant, including— 

5 (i) whether the amounts are rede6 ployed; and 

7 (ii) if the amounts are redeployed, 

8 how the redeployment is determined. 

9 (G) With respect to the approximately 

10 3,700 Medicaid-reimbursable full-time equiva11 lent employees of the Service— 

12 (i) the number of those employees who 

13 are certified coders; 

14 (ii) how that number of employees 

15 compares with health care industry stand16 ards for staffing of certified coders; and 

17 (iii) how much time is spent on train18 ing and participating in continuing edu19 cation courses once employed by the Serv20 ice. 

21 (8) The information technology strategies of the 

22 Service with respect to furnishing and managing 

23 health care, including an identification of any weak24 nesses and opportunities with respect to the tech25 nology used by the Service, especially those strateVerDate Sep 11 2014 04:03 Feb 22, 2019 Jkt 089200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S498.IS S498

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1 gies with respect to clinical documentation of epi2 sodes of hospital care, medical services, and other 

3 health care, including any clinical images and associ4 ated textual reports, furnished by the Service in 

5 Service or non-Service facilities. 

6 (9) Business processes of the Service, including 

7 processes relating to furnishing non-Service health 

8 care, insurance identification, third-party revenue 

9 collection, and vendor reimbursement, including an 

10 identification of mechanisms as follows: 

11 (A) To avoid the payment of penalties to 

12 vendors. 

13 (B) To increase the collection of amounts 

14 owed to the Service for hospital care, medical 

15 services, or other health care provided by the 

16 Service for which reimbursement from a third 

17 party is authorized and to ensure that such 

18 amounts collected are accurate. 

19 (C) To increase the collection of any other 

20 amounts owed to the Service with respect to 

21 hospital care, medical services, and other health 

22 care and to ensure that such amounts collected 

23 are accurate. 


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1 (D) To increase the accuracy and timeli2 ness of Service payments to vendors and pro3 viders. 

4 (10) The purchasing, distribution, and use of 

5 pharmaceuticals, medical and surgical supplies, med6 ical devices, and health care related services by the 

7 Service, including the following: 

8 (A) The prices paid for, standardization of, 

9 and use by the Service of, the following: 

10 (i) Pharmaceuticals. 

11 (ii) Medical and surgical supplies. 

12 (iii) Medical devices. 

13 (B) The use by the Service of group pur14 chasing arrangements to purchase pharma15 ceuticals, medical and surgical supplies, medical 

16 devices, and health care related services. 

17 (C) The strategy and systems used by the 

18 Service to distribute pharmaceuticals, medical 

19 and surgical supplies, medical devices, and 

20 health care related services to medical facilities 

21 of the Service. 

22 (11) The process of the Service for carrying out 

23 construction and maintenance projects at medical fa24 cilities of the Service and the medical facility leasing 

25 program of the Service, including— 


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1 (A) whether the maintenance budget is up2 dated or increased to reflect increases in main3 tenance costs with the addition of new facilities 

4 and whether any increase is sufficient to sup5 port the growth of the facilities; and 

6 (B) what the process is for facilities that 

7 reach the end of their proposed life cycle. 

8 (12) The competency of leadership with respect 

9 to culture, accountability, reform readiness, leader10 ship development, physician alignment, employee en11 gagement, succession planning, and performance 

12 management, including— 

13 (A) the reasons leading tribal leadership to 

14 request increased transparency and more open 

15 communication between the Service and the 

16 people served by the Service; and 

17 (B) whether any checks and balances exist 

18 to assess potential fraud or misuse of amounts 

19 within the Service. 

20 (13) The lack of a funding formula to distribute 

21 base funding to the 12 Service areas, including the 

22 following: 

23 (A) The establishment of the current proc24 ess of funding being distributed based on hisVerDate Sep 11 2014 04:03 Feb 22, 2019 Jkt 089200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\S498.IS S498

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1 torical allocations and not on need such as pop2 ulation growth, number of facilities, etc. 

3 (B) The communication to area office di4 rectors on distribution decisionmaking. 

5 (C) How the tribal and residual shares are 

6 determined for each Indian tribe and the 

7 amounts of those shares. 

8 (D) The auditing or evaluation process 

9 used by the Service to determine whether 

10 amounts are distributed and expended appro11 priately, including— 

12 (i) whether periodic or end-of-year 

13 records document the actual distributions; 

14 and 

15 (ii) whether any auditing or evalua16 tion is conducted in accordance with gen17 erally accepted accounting principles or 

18 other appropriate practices. 

19 (14) Whether the Service tracks patients eligi20 ble for two or more of either the Medicaid program 

21 under title XIX of the Social Security Act (42 

22 U.S.C. 1396 et seq.), health care received through 

23 the Service, or any other Federal health care pro24 gram (referred to in this section as ‘‘dual eligible paVerDate Sep 11 2014 04:03 Feb 22, 2019 Jkt 089200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\S498.IS S498

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1 tients’’). If so, how dual eligible patients are man2 aged. 

3 (15) The number of procurement contracts en4 tered into and awards made by the Service under 

5 section 23 of the Act of June 25, 1910 (commonly 

6 known as the ‘‘Buy Indian Act’’) (25 U.S.C. 47), 

7 and a comparison of that number, with— 

8 (A) the total number of procurement con9 tracts entered into and awards made by the 

10 Service during 2015, 2016, 2017, and 2018; 

11 and 

12 (B) the process used by the Service facili13 ties to ensure compliance with section 23 of the 

14 Act of June 25, 1910 (commonly known as the 

15 ‘‘Buy Indian Act’’) (25 U.S.C. 47). 

16 (16) An assessment of the availability of cancer 

17 services for populations living on large, rural Indian 

18 reservations, individual billing information, and re19 imbursement claims of patients. 

20 (17) Any other items determined to be ad21 dressed during the course of the assessment. 

22 (f) REPORT ON ASSESSMENT.— 

23 (1) SUBMISSION TO SECRETARY.—Not later 

24 than 240 days after the date that a contract is enVerDate Sep 11 2014 04:03 Feb 22, 2019 Jkt 089200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\S498.IS S498

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1 tered into under subsection (b), the entity carrying 

2 out the assessment under the contract shall— 

3 (A) complete the assessment; and 

4 (B) submit to the Secretary a report de5 scribing the findings and recommendations of 

6 the entity with respect to the assessment. 

7 (2) SUBMISSION TO CONGRESS.—Immediately 

8 on receipt of the report under paragraph (1)(B), the 

9 Secretary shall submit the report to— 

10 (A) the appropriate committees of Con11 gress, including— 

12 (i) the Committee on Appropriations 

13 of the Senate; and 

14 (ii) the Committee on Appropriations 

15 of the House of Representatives; 

16 (B) the Majority Leader of the Senate; 

17 (C) the Minority Leader of the Senate; 

18 (D) the Speaker of the House of Rep19 resentatives; and 

20 (E) the Minority Leader of the House of 

21 Representatives. 

22 (3) PUBLICATION.—Not later than 30 days 

23 after receiving the report under paragraph (1)(B), 

24 the Secretary shall publish such report in the FedVerDate Sep 11 2014 04:03 Feb 22, 2019 Jkt 089200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6201 E:\BILLS\S498.IS S498

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1 eral Register and on an Internet website of the Serv2 ice that is accessible to the public. 

3 (g) FUNDING FOR INDEPENDENT OUTSIDE ASSESS4 MENT.—The Secretary shall use such amounts as are nec5 essary from other amounts available to the Secretary that 

6 are not otherwise obligated to fund the contract under 

7 subsection (b). Such amounts shall not come from funds 

8 available to the Indian Health Service. 

Æ 


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