I 

112TH CONGRESS 

1ST SESSION H. R. 1256 

To amend title XVIII of the Social Security Act to require the use of 

analytic contractors in identifying and analyzing misvalued physician 

services under the Medicare physician fee schedule and an annual review 

of potentially misvalued codes under that fee schedule. 

IN THE HOUSE OF REPRESENTATIVES 

MARCH 30, 2011 

Mr. MCDERMOTT 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 require 

the use of analytic contractors in identifying and analyzing misvalued physician services under the Medicare 

physician fee schedule and an annual review of potentially misvalued codes under that fee schedule. 

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; FINDINGS. 

4 (a) SHORT TITLE.—This Act may be cited as the 

5 ‘‘Medicare Physician Payment Transparency and Assess6 ment Act of 2011’’. 


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1 (b) FINDINGS.—Congress finds the following: 

2 (1) The Centers for Medicare & Medicaid Serv3 ices (CMS) has not had sufficient resources or com4 mitment to undertake the needed surveys and ana5 lytic research needed to keep the Medicare resource6 based relative value scale (RBRVS) current with 

7 changes in medical, surgical, consultative, proce8 dural, and diagnostic practices. For the last 20 

9 years, the American Medical Association has spon10 sored the Specialty Society Relative Value Scale Up11 date Committee (RUC) as a good faith effort to sup12 port CMS in the task of developing the physician fee 

13 schedule but a more robust process is needed. 

14 (2) CMS has depended on the AMA’s RUC for 

15 recommendations as to the values assigned to Medi16 care service codes for over 90 percent of all code 

17 changes over the last 19 years. 

18 (3) Although primary care physicians provide 

19 about 44 percent of Medicare physician visits, they 

constitute only 1⁄6 to 1 20 ⁄13 of the membership of the 

21 RUC. 

22 (4) The RUC lacks voting transparency and re23 lies on self-reported and unrepresentative survey 

24 data that present serious conflict-of-interest con25 cerns. 


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1 (5) The Medicare Payment Advisory Commis2 sion has found that while the RUC tends to identify 

3 and correct undervalued codes, it does not have the 

4 same incentives to find and correct overvalued codes. 

5 Specialists, especially those who derive the majority 

6 of their income through procedural codes, have no 

7 incentive to reduce the value of potentially over8 valued codes, even though the requirements for phy9 sician work in many procedures should generally re10 duce as time passes and proficiency increases. 

11 (6) The assignment of relative values to the 

12 evaluation and management (E/M) codes was the 

13 most unsubstantiated component of the original 

14 RBRVS and has not been systematically and sci15 entifically studied since the institutionalizing of 

16 RBRVS. 

17 (7) The advent of electronic health records will 

18 require new methods to assess the intensity and 

19 work effort of the E/M codes. 

20 (c) PURPOSE.—It is the purpose of this Act to re21 quire the Secretary of Health and Human Services to con22 sider the recommendations of independent, analytic con23 tractors that are responsible for initially identifying and 

24 analyzing misvalued Medicare physician services and to reVerDate Mar 15 2010 04:34 Mar 31, 2011 Jkt 099200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H1256.IH H1256

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1 quire an annual review of potentially misvalued codes 

2 under the Medicare fee schedule. 

3 SEC. 2. REQUIRING USE OF ANALYTIC CONTRACTORS IN 

4 IDENTIFYING AND ANALYZING MISVALUED 

5 MEDICARE PHYSICIAN SERVICES AND AN6 NUAL REVIEW OF POTENTIALLY MISVALUED 

7 CODES UNDER MEDICARE FEE SCHEDULE. 

8 Section 1848(c)(2)(K) of the Social Security Act (42 

9 U.S.C. 1395w–4(c)(2)(K)), as amended by section 

10 3134(a) of the Patient Protection and Affordable Care Act 

11 (Public Law 111–148), is amended— 

12 (1) in clause (i), by striking ‘‘periodically’’ and 

13 inserting ‘‘annually’’; and 

14 (2) in clause (iii)— 

15 (A) subclause (I), by inserting before the 

16 period at the end the following: ‘‘, but only to 

17 the extent consistent with the use of analytic 

18 contractors under subclause (III)’’; and 

19 (B) in subclause (III)— 

20 (i) by striking ‘‘may use’’ and insert21 ing ‘‘shall use’’; and 

22 (ii) by adding at the end the fol23 lowing: ‘‘This subclause shall not be con24 strued as prohibiting the Secretary from 

25 making modifications to one or more codes 


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1 under the fee schedule without use of the 

2 analytic contractors.’’. 

Æ 


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