Stop Schemes and Crimes Against Medicare and Seniors (Stop SCAMS) Act

To amend title XVIII of the Social Security Act to crack down on fraud in the Medicare program to protect seniors, people with disabilities, and taxpayers. 1. Short title This Act may be cited as the Stop Schemes and Crimes Against Medicare and Seniors (Stop SCAMS) Act 2. Ensuring that new medical coding systems do not compromise fraud prevention efforts (a) In general Section 1173(c) of the Social Security Act ( 42 U.S.C. 1320d–2(c) (1) in paragraph (1)— (A) in subparagraph (A), by striking ; or or, if no code sets for such data elements have been developed, establish code sets for the data elements; (B) by striking subparagraph (B) and adding the following new subparagraphs: (B) ensure that any entity producing and transmitting valid transactions that include code sets are subject to a consistent, industry-wide framework that supports a seamless transition to new and modified code sets; and (C) establish, by a rule promulgated after notice and an opportunity for a hearing on the record, an end-to-end testing procedure for new and modified code sets that shall require the participation of any entity producing and transmitting valid transactions that use such new or modified code set. ; and (2) by adding at the end the following paragraphs: (3) Adopting new and modified code sets The Secretary shall not adopt a new or modified code set unless the Secretary— (A) assesses the impact of the code set on fraud prevention and pre-payment review, determines that anti-fraud edits work as intended, and confirms that a plan is in place to ensure continuing effective detection of fraud following the adoption of the code set; (B) ensures that the end-to-end testing procedure established by the Secretary under paragraph (1) has been completed; and (C) completes end-to-end testing with any Federal Government entity that produces and transmits valid transactions that include the code set with private sector tracking partners. (4) Routine updates to existing code sets Paragraph (3) shall not apply to routine, regularly scheduled updates to existing code sets. . (b) Effective date The amendments made by this section shall be effective as of October 1, 2015. 3. Verification of provider ownership interests (a) In general Section 1124(c) of the Social Security Act ( 42 U.S.C. 1320a–3(c) (1) by redesignating paragraph (5) as paragraph (6); and (2) by inserting after paragraph (4) the following paragraph: (5) Verification of Information (A) In general With respect to information supplied by a disclosing entity under subsections (a) and (b), the Secretary shall— (i) verify such information by comparing it to available data on the provider collected through disclosures made to the Secretary under section 1128G(a)(2), or, in the case of a disclosing entity to which section 1128G(a)(2) does not apply, verify such information through comparison with at least one other public or private database which contains information as to the identity of each person with an ownership or control interest in the entity; and (ii) confirm the accuracy of any social security account number or employer identification number supplied under subsection (a) by verifying— (I) each social security account number with the Commissioner of Social Security; and (II) each employer identification number with the Secretary of the Treasury. (B) Discrepancies If the comparison described in subparagraph (A)(i) reveals a discrepancy between information supplied by a disclosing entity under subsections (a) and (b) and available data on the provider collected through disclosures made to the Secretary under section 1128G(a)(2), the Secretary shall independently verify the accuracy of such data collected under section 1128G(a)(2) before taking any action against a provider based on such discrepancy. . (b) Effective date The amendments made by this section shall be effective as of the date that is 1 year after the date of enactment of this Act. 4. Supporting public and private information sharing to prevent health care fraud (a) Definitions In this section: (1) Healthcare fraud prevention partnership; Partnership The terms Healthcare Fraud Prevention Partnership Partnership (2) Private insurer The term private insurer health insurance issuer 42 U.S.C. 300GG–91(b)(2) (b) Safe harbor for the sharing of information (1) General immunity (A) In general A non-governmental entity participating in the Partnership (including a private insurer) that— (i) provides data or information described in clause (i) or (ii) of subparagraph (B) to the Department of Health and Human Services, the Department of Justice, any other Federal or State law enforcement agency, any contractor of such Department or agency, or another entity participating in the Partnership (including a private insurer); or (ii) uses such data or information as permitted by this subsection, shall be immune from civil liability with respect to the provision or authorized use of such data or information. (B) Data or information (i) Data The data described in this clause is aggregated claims data or other information described in clause (ii) that does not include individually identifiable information with respect to any health care provider, supplier, or beneficiary, whether or not analysis of such information results in the identification of a health care provider, supplier, or other person or organization as having committed fraud or having committed acts suspected of being fraudulent. (ii) Information The information described in this clause is information concerning fraud or suspected fraudulent acts that identifies a specific health care provider, supplier, or other person or organization if the provider, supplier, or other person or organization so identified— (I) is the subject of a bona fide fraud investigation conducted by the entity participating in the Partnership, including a private insurer, that is providing the information; (II) is the subject of a fraud-related allegation that has been filed by or received by the entity participating in the Partnership, including a private insurer, that is providing the information; or (III) has been convicted of a fraud-related offense. (2) Limitation The immunity described in paragraph (1) shall apply only where— (A) the data or information involved was provided in good faith and without malice; and (B) the data or information provided is true, based on a reasonable belief, to the knowledge of the person providing the information, or if false, the information is provided without knowledge of, and without reckless disregard for, its falsity. (3) Use of Partnership data or information For purposes of this subsection, data or information relating to a specific provider or supplier received by a private insurer solely through the Partnership shall be used, with respect to such provider or supplier, only for the purpose of informing decisionmaking by the private insurer related to fraud investigations, including whether to conduct such an investigation. Nothing in the preceding sentence shall prevent a private insurer or other entity participating in the Partnership from taking other actions, not specific to such provider or supplier, based on such data or information. (c) Report Not later than October 1 of each calendar year that begins after the date of enactment of this Act, the Secretary of Health and Human Services shall submit to the Special Committee on Aging, the Committee on Finance, and the Committee on Homeland Security and Governmental Affairs of the Senate, and the Committee on Ways and Means and the Committee on Energy and Commerce of the House of Representatives, a report that describes the activities of the Healthcare Fraud Prevention Partnership. Such report shall include— (1) a description of how input was obtained from private insurers regarding the appropriate usage of data shared through the Healthcare Fraud Prevention Partnership; and (2) plans for the Partnership to be expanded to encompass a representative sample of national private insurers and to include health care provider organizations. 5. MedPAC study and report (a) Study The Medicare Payment Advisory Commission shall conduct a study on administrative efforts to strengthen program integrity in the Medicare program. Such study may include— (1) an evaluation of ways to detect fraudulent claims before payment is made; (2) a review of the efficiency and effectiveness of post-payment recovery methods; (3) analysis by the Centers for Medicare & Medicaid Services and public reporting of claims and spending patterns; and (4) a review of the organizational structure and resources of the Centers for Medicare & Medicaid Services as they relate to program integrity. (b) Report Not later than June 15, 2016, the Medicare Payment Advisory Commission shall submit to Congress a report on the study conducted under subsection (a), together with recommendations for such legislative and administrative action as the Commission determines appropriate. 6. Ability to measure fraud prevention efforts Section 4241 of the Small Business Jobs Act of 2010 ( 42 U.S.C. 1320a–7m (1) in subsection (b)(4), by inserting and on civil recoveries, administrative actions, and criminal convictions for fraud reimbursement (2) in subsection (c), by adding at the end the following paragraph: (7) Implementation of amendments The Secretary shall implement amendments made to this subsection by the Stop Schemes and Crimes Against Medicare and Seniors (Stop SCAMS) Act .

Summary: Stop Schemes and Crimes Against Medicare and Seniors (Stop SCAMS) Act - Amends title XI of the Social Security Act with respect to standards for financial and administrative transactions and their data elements to enable the electronic exchange of health information. Requires the Secretary of Health and Human Services (HHS) to adopt standards that: (1) ensure that any entity producing and transmitting valid transactions that include code sets for appropriate data elements is subject to a consistent, industry-wide framework that supports a seamless transition to new and modified code sets; and (2) establish an end-to-end testing procedure for new and modified code sets that shall require the participation of any entity producing and transmitting valid transactions that use the new or modified code set. Prohibits the Secretary from adopting a new or modified code set unless the Secretary: (1) assesses its impact on fraud prevention and pre-payment review, determines that anti-fraud edits work as intended, and confirms that a plan is in place to ensure continuing effective detection of fraud following the adoption of the code set; (2) ensures that the end-to-end testing procedure established has been completed; and (3) completes end-to-end testing with any federal government entity that produces and transmits valid transactions that include the code set with private sector tracking partners. Exempts routine, regularly scheduled updates to existing code sets from such prohibition. Directs the Secretary, with respect to information supplied to it by a disclosing entity about those with an ownership or control interest in the entity, to verify such information in a specified manner and confirm the accuracy of any Social Security account number or employer identification number. Holds immune from civil liability (in a safe harbor) any non-governmental entity participating in a Healthcare Fraud Prevention Partnership, including private insurers, for sharing information about potentially fraudulent providers with each other, HHS, the Department of Justice (DOJ), any other federal or state law enforcement agency, any federal or state agency contractor, and another Partnership participant. Directs the Medicare Payment Advisory Commission (MEDPAC) to study administrative efforts to strengthen program integrity in the Medicare program. Amends the Small Business Jobs Act of 2010, with respect to the use of predictive modeling and other analytics technologies to identify and prevent waste, fraud, and abuse in the Medicare fee-for-service program, to require predictive analytics technologies to capture outcome information on civil recoveries, administrative actions, and criminal convictions for fraud.