II

104TH CONGRESS

1ST SESSION S. 762

To implement General Accounting Office recommendations regarding the use

of commercial software to detect billing code abuse in medicare claims

processing, and for other purposes.

IN THE SENATE OF THE UNITED STATES

MAY 5 (legislative day, MAY 1), 1995

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

to the Committee on Finance

A BILL

To implement General Accounting Office recommendations

regarding the use of commercial software to detect billing

code abuse in medicare claims processing, 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 ‘‘Medicare Billing Abuse

5 Prevention Act of 1995’’.

6 SEC. 2. FINDINGS.

7 The Congress finds that—
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1 (1) the General Accounting Office has reported

2 that the use of commercial software to detect billing

3 code abuse by medicare supplementary medical in4 surance program carriers may save the taxpayers

5 $2,000,000 per day; and

6 (2) prompt use of such software may be im7 peded by regulatory requirements which are not re8 lated to efficient implementation of the medicare

9 program.

10 SEC. 3. IMPLEMENTATION OF GENERAL ACCOUNTING OF11 FICE RECOMMENDATIONS REGARDING MEDI12 CARE CLAIMS PROCESSING.

13 (a) IN GENERAL.—Not later than 90 days after the

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

15 regulation, contract, change order, or otherwise, require

16 medicare carriers to acquire commercial automatic data

17 processing equipment (in this Act referred to as ‘‘ADPE’’)

18 meeting the requirements of section 4 to process medicare

19 part B claims for the purpose of identifying billing code

20 abuse.

21 (b) SUPPLEMENTATION.—Any ADPE acquired in ac22 cordance with subsection (a) shall be used as a supplement

23 to any other ADPE used in claims processing by medicare

24 carriers.
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1 (c) STANDARDIZATION.—In order to ensure uniform2 ity, the Secretary may require that medicare carriers that

3 use a common claims processing system acquire common

4 ADPE in implementing subsection (a).

5 (d) IMPLEMENTATION DATE.—Any ADPE acquired

6 in accordance with subsection (a) shall be in use by medi7 care carriers not later than 180 days after the date of

8 the enactment of this Act.

9 SEC. 4. MINIMUM SOFTWARE REQUIREMENTS.

10 (a) IN GENERAL.—The requirements described in

11 this section are as follows:

12 (1) The ADPE shall be a commercial item.

13 (2) The ADPE shall surpass the capability of

14 ADPE used in the processing of medicare part B

15 claims for identification of code manipulation on the

16 day before the date of the enactment of this Act.

17 (3) The ADPE shall be capable of being modi18 fied to—

19 (A) satisfy pertinent statutory require20 ments of the medicare program; and

21 (B) conform to general policies of the

22 Health Care Financing Administration regard23 ing claims processing.

24 (b) MINIMUM STANDARDS.—Nothing in this Act

25 shall be construed as preventing the use of ADPE which
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1 exceeds the minimum requirements described in sub2 section (a).

3 SEC. 5. DISCLOSURE.

4 (a) IN GENERAL.—Notwithstanding any other provi5 sion of law, and except as provided in subsection (b), any

6 ADPE or data related thereto acquired by medicare car7 riers in accordance with section 3(a) shall not be subject

8 to public disclosure.

9 (b) EXCEPTION.—The Secretary may authorize the

10 public disclosure of any ADPE or data related thereto ac11 quired by medicare carriers in accordance with section

12 3(a) if the Secretary determines that—

13 (1) release of such information is in the public

14 interest; and

15 (2) the information to be released is not pro16 tected from disclosure under section 552(b) of title

17 5, United States Code.

18 SEC. 6. REVIEW AND MODIFICATION OF REGULATIONS.

19 Not later than 30 days after the date of the enact20 ment of this Act, the Secretary shall order a review of

21 existing regulations, guidelines, and other guidance gov22 erning medicare payment policies and billing code abuse

23 to determine if revision of or addition to those regulations,

24 guidelines, or guidance is necessary to maximize the bene-
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1 fits to the Federal Government of the use of ADPE ac2 quired pursuant to section 3.

3 SEC. 7. DEFINITIONS.

4 For purposes of this Act—

5 (1) The term ‘‘automatic data processing equip6 ment’’ (ADPE) has the same meaning as in section

7 111(a)(2) of the Federal Property and Administra8 tive Services Act of 1949 (40 U.S.C. 759(a)(2)).

9 (2) The term ‘‘billing code abuse’’ means the

10 submission to medicare carriers of claims for serv11 ices that include procedure codes that do not appro12 priately describe the total services provided or other13 wise violate medicare payment policies.

14 (3) The term ‘‘commercial item’’ has the same

15 meaning as in section 4(12) of the Office of Federal

16 Procurement Policy Act (41 U.S.C. 403(12)).

17 (4) The term ‘‘medicare part B’’ means the

18 supplementary medical insurance program author19 ized under part B of title XVIII of the Social Secu20 rity Act (42 U.S.C. 1395j–1395w–4).

21 (5) The term ‘‘medicare carrier’’ means an en22 tity that has a contract with the Health Care Fi23 nancing Administration to determine and make med24 icare payments for medicare part B benefits payable
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1 on a charge basis and to perform other related func2 tions.

3 (6) The term ‘‘payment policies’’ means regula4 tions and other rules that govern billing code abuses

5 such as unbundling, global service violations, double

6 billing, and unnecessary use of assistants at surgery.

7 (7) The term ‘‘Secretary’’ means the Secretary

8 of Health and Human Services.

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