I 

113TH CONGRESS 

1ST SESSION H. R. 3168 

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 

SEPTEMBER 20, 2013 

Mr. WILLIAMS (for himself, Mr. FLORES, Ms. GRANGER, and Mr. STOCKMAN) 

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 2013’’. 


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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 


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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 but before the date described in paragraph (2), at 

18 least 75 percent of claims for payment under this 

19 title for items and services furnished by such pro20 vider or supplier for which any review was conducted 

21 under section 1869 were determined to be eligible 

22 for payment under this title; 

23 ‘‘(2) with respect to a reporting period begin24 ning after the date that is 2 years after the date of 

25 enactment of this section, at least 80 percent of 


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1 claims for payment under this title for items and 

2 services furnished by such provider or supplier for 

3 which any review was conducted under section 1869 

4 were determined to be eligible for payment under 

5 this title; and 

6 ‘‘(3) of all claims for payment under this title 

7 for items and services furnished by such provider or 

8 supplier for which an initial determination was made 

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

10 least 90 percent were appealed by such provider or 

11 supplier. 

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

13 subsection (a)(1)— 

14 ‘‘(1) shall allow a provider of services or sup15 plier designated as an established provider under 

16 this section to demonstrate that the provider or sup17 plier maintains compliance with the qualification re18 quirements under subsection (b) based on annual 

19 updates on the status of claims for payment under 

20 this title for items and services furnished by such 

21 provider or supplier with respect to each level of re22 view, including the number of such claims within 

23 each such level of review for which a determination 

24 was made that payment should be made, should be 


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1 partially made, or should not be made under this 

2 title; 

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

4 may be determined whether or not the qualifying re5 quirements under subsection (b) have been satisfied 

6 and maintained by a provider of services or supplier 

7 with respect to a period; 

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

9 providers within appropriate systems of the Centers 

10 of Medicare & Medicaid Services; and 

11 ‘‘(4) provide for a global track record of compli12 ance by providers of services and suppliers with the 

13 qualifying requirements under subsection (b), includ14 ing by identifying such providers and suppliers by 

15 the management company provider number rather 

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

17 for purposes of efficiency. 

18 ‘‘(d) PROTECTIONS FOR ESTABLISHED PRO19 VIDERS.—Notwithstanding any other provision of law, in 

20 the case of a provider of services or supplier designated 

21 as an established provider under this section with respect 

22 to a period the following protections shall apply: 

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

24 such period for payment under this title for items or 

25 services furnished by such provider or supplier, 


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1 which is subject to review for whether or not pay2 ment should be made under such title and with re3 spect to which an additional documentation request 

4 has been issued, payment under this title for such 

5 claim may not be withheld unless a final determina6 tion has been made that such payment should not be 

7 made. 

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

9 been made that payment under this title should not 

10 have been made with respect to a claim described in 

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

12 made electronically by the provider not later than 45 

13 days after notification of such decision. In applying 

14 the previous sentence, if the Secretary determines 

15 that repayment within such 45-day period would re16 sult in a significant hardship to the provider in17 volved, the Secretary may, on a case-by-case basis, 

18 extend the 45-day period described in such sentence 

19 by such number of days as the Secretary determines 

20 appropriate in accordance with a specified repay21 ment plan. 

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

23 to apply section 1869 with respect to an initial de24 termination of any claim submitted during such pe25 riod for payment under this title for items and servVerDate Mar 15 2010 18:09 Sep 26, 2013 Jkt 029200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H3168.IH H3168

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1 ices furnished by such provider or supplier, without 

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

3 (relating to redeterminations).’’. 

Æ 


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