Preventing Medicare Telefraud Act

Subjects: Health, Accounting and auditing, Health care costs and insurance, Health technology, devices, supplies, Medical tests and diagnostic methods, Medicare

Summary:  <p><b>Preventing Medicare Telefraud Act</b></p> <p>This bill establishes conditions for payment of certain telehealth services, laboratory tests, and durable medical equipment under Medicare after the end of the COVID-19 public health emergency. </p> <p>Specifically, after the emergency ends, the bill conditions payment for certain high-cost laboratory tests and durable medical equipment that are ordered via telehealth on at least one in-person visit during the preceding six-month period. Additionally, practitioners must submit claims for separately billable telehealth services under the practitioner's unique national provider identification number.</p>

<html><body><pre>[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 1746 Introduced in House (IH)]

&lt;DOC&gt;






118th CONGRESS
  1st Session
                                H. R. 1746

     To amend title XVIII of the Social Security Act to establish 
  requirements for the provision of certain high-cost durable medical 
       equipment and laboratory testing, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             March 23, 2023

 Mr. Doggett 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 establish 
  requirements for the provision of certain high-cost durable medical 
       equipment and laboratory testing, and for other purposes.

    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 ``Preventing Medicare Telefraud Act''.

SEC. 2. REQUIREMENT FOR PROVISION OF HIGH-COST DURABLE MEDICAL 
              EQUIPMENT AND LABORATORY TESTS.

    (a) High-Cost Durable Medical Equipment.--Section 1834(a)(1)(E) of 
the Social Security Act (42 U.S.C. 1395m(a)(1)(E)) is amended by adding 
at the end the following new clause:
                            ``(vi) Standards for high-cost durable 
                        medical equipment.--
                                    ``(I) Limitation on payment for 
                                high-cost durable medical equipment.--
                                Payment may not be made under this 
                                subsection for a high-cost durable 
                                medical equipment ordered by a 
                                physician or other practitioner 
                                described in clause (ii) via telehealth 
                                for an individual, unless such 
                                physician or practitioner furnished to 
                                such individual a service in-person at 
                                least once during the 6-month period 
                                prior to ordering such high-cost 
                                durable medical equipment.
                                    ``(II) High-cost durable medical 
                                equipment determination.--For purposes 
                                of this clause, the Administrator of 
                                the Centers for Medicare & Medicaid 
                                Services shall define the term `high-
                                cost durable medical equipment' and 
                                specify the durable medical equipment 
                                for which such definition shall apply.
                            ``(vii) Audit of providers and 
                        practitioners furnishing a high volume of 
                        durable medical equipment via telehealth.--
                                    ``(I) Identification of 
                                providers.--Beginning 6 months after 
                                the effective date of this clause, 
                                Medicare administrative contractors 
                                shall conduct reviews on a schedule 
                                determined by the Secretary, of claims 
                                for durable medical equipment 
                                prescribed by a physician or other 
                                practitioner described in clause (ii) 
                                during the 12-month period preceding 
                                such review to identify physicians or 
                                other practitioners with respect to 
                                whom at least 90 percent of all durable 
                                medical equipment prescribed by such 
                                physician or practitioner during such 
                                period was prescribed pursuant to a 
                                telehealth visit.
                                    ``(II) Audit.--In the case of a 
                                physician or practitioner identified 
                                under subclause (I), with respect to a 
                                period described in such subclause, the 
                                Medicare administrative contractors 
                                shall conduct audits of all claims for 
                                durable medical equipment prescribed by 
                                such physicians or practitioners to 
                                determine whether such claims comply 
                                with the requirements for coverage 
                                under this title.''.
    (b) High-Cost Laboratory Tests.--Section 1834A(b) of the Social 
Security Act (42 U.S.C. 1395m-1(b)) is amended by adding at the end the 
following new paragraph:
            ``(6) Requirement for high-cost laboratory tests.--
                    ``(A) Limitation on payment for high-cost 
                laboratory tests.--Payment may not be made under this 
                subsection for a high-cost laboratory test ordered by a 
                physician or practitioner via telehealth for an 
                individual, unless such physician or practitioner 
                furnished to such individual a service in-person at 
                least once during the 6-month period prior to ordering 
                such high-cost laboratory test.
                    ``(B) High-cost laboratory test defined.--For 
                purposes of this paragraph, the Administrator for the 
                Centers for Medicare & Medicaid Services shall define 
                the term `high-cost laboratory test' and specify which 
                laboratory tests such definition shall apply to.
            ``(7) Audit of laboratory testing ordered pursuant to 
        telehealth visit.--
                    ``(A) Identification of providers.--Beginning 6 
                months after the effective date of this paragraph, 
                Medicare administrative contractors shall conduct 
                periodic reviews on a schedule determined by the 
                Secretary, of claims for laboratory tests prescribed by 
                a physician or practitioner during the 12-month period 
                preceding such review to identify physicians or other 
                practitioners with respect to whom at least 90 percent 
                of all laboratory tests prescribed by such physician or 
                practitioner during such period was prescribed pursuant 
                to a telehealth visit.
                    ``(B) Audit.--In the case of a physician or 
                practitioner identified under subparagraph (A), with 
                respect to a period described in such subparagraph, the 
                Medicare administrative contractors shall conduct 
                audits of all claims for laboratory tests prescribed by 
                such physicians or practitioners during such period 
                beginning to determine whether such claims comply with 
                the requirements for coverage under this title.''.
    (c) Effective Date.--The amendments made by this section shall take 
effect upon the termination of the emergency period described in 
section 1135(g)(1)(B) of the Social Security Act (42 U.S.C. 1320b-
5(g)(1)(B)).

SEC. 3. REQUIREMENT TO SUBMIT NPI NUMBER FOR SEPARATELY BILLABLE 
              TELEHEALTH SERVICES.

    (a) Requirement To Submit NPI Number for Separately Billable 
Telehealth Services.--Section 1834(m) of the Social Security Act (42 
U.S.C. 1395m(m)) is amended by adding at the end the following new 
paragraph:
            ``(10) Requirement to submit npi number for separately 
        billable telehealth services.--Payment may not be made under 
        this subsection for separately billable telehealth services 
        furnished by a physician or practitioner unless such physician 
        or practitioner submits a claim for payment under the national 
        provider identification number assigned to such physician or 
        practitioner.''.
    (b) Effective Date.--The amendment made by this section shall take 
effect upon the termination of the emergency period described in 
section 1135(g)(1)(B) of the Social Security Act (42 U.S.C. 1320b-
5(g)(1)(B)).
                                 &lt;all&gt;
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