Preventing and Reducing Improper Medicare and Medicaid Expenditures to Restore Integrity to Benefits Act of 2015

To amend titles XVIII and XIX of the Social Security Act to curb waste, fraud, and abuse in the Medicare and Medicaid programs. 1. Short title This Act may be cited as the Preventing and Reducing Improper Medicare and Medicaid Expenditures to Restore Integrity to Benefits Act of 2015 2. Strengthening Medicaid Program integrity through flexibility Section 1936 of the Social Security Act ( 42 U.S.C. 1396u–6 (1) in subsection (a), by inserting , or otherwise, entities (2) in subsection (e)— (A) in paragraph (1), in the matter preceding subparagraph (A), by inserting (including the costs of equipment, salaries and benefits, and travel and training) Program under this section (B) in paragraph (3), by striking by 100 by 100, or such number as determined necessary by the Secretary to carry out the Program, 3. Establishing Medicare administrative contractor error reduction incentives (a) In general Section 1874A(b)(1)(D) of the Social Security Act ( 42 U.S.C. 1395kk–1(b)(1)(D) (1) by striking quality quality (i) In general Subject to clauses (ii) and (iii), the Secretary ; and (2) by inserting after clause (i), as added by paragraph (1), the following new clauses: (ii) Improper payment rate reduction incentives The Secretary shall provide incentives for medicare administrative contractors to reduce the improper payment error rates in their jurisdictions. (iii) Incentives The incentives provided for under clause (ii)— (I) may include a sliding scale of award fee payments and additional incentives to medicare administrative contractors that either reduce the improper payment rates in their jurisdictions to certain thresholds, as determined by the Secretary, or accomplish tasks, as determined by the Secretary, that further improve payment accuracy; and (II) may include substantial reductions in award fee payments under cost-plus-award-fee contracts, for medicare administrative contractors that reach an upper end improper payment rate threshold or other threshold as determined by the Secretary, or fail to accomplish tasks, as determined by the Secretary, that further improve payment accuracy. . (b) Effective date (1) In general The amendments made by subsection (a) shall apply to contracts entered into or renewed on or after the date that is 3 years after the date of enactment of this Act. (2) Application to existing contracts In the case of contracts in existence on or after the date of the enactment of this Act and that are not subject to the effective date under paragraph (1), the Secretary of Health and Human Services shall, when appropriate and practicable, seek to apply the incentives provided for in the amendments made by subsection (a) through contract modifications. 4. Strengthening penalties for the illegal distribution of a Medicare, Medicaid, or CHIP beneficiary identification or billing privileges Section 1128B(b) of the Social Security Act (42 U.S.C. 1320a–7b(b)) is amended by adding at the end the following: (4) Whoever without lawful authority knowingly and willfully purchases, sells or distributes, or arranges for the purchase, sale, or distribution of a beneficiary identification number or unique health identifier for a health care provider under title XVIII, title XIX, or title XXI shall be imprisoned for not more than 10 years or fined not more than $500,000 ($1,000,000 in the case of a corporation), or both. . 5. Improving the sharing of data between the Federal Government and State Medicaid programs (a) In general The Secretary of Health and Human Services (in this section referred to as the Secretary Medi-Medi Program 42 U.S.C. 1395ddd(g) (b) Program revisions To improve Medi-Medi Data Match Program participation by States Section 1893(g)(1)(A) of the Social Security Act ( 42 U.S.C. 1395ddd(g)(1)(A) (1) in the matter preceding clause (i), by inserting or otherwise eligible entities (2) in clause (i)— (A) by inserting to review claims data algorithms (B) by striking service, time, or patient provider, service, time, or patient (3) in clause (ii)— (A) by inserting to investigate and recover amounts with respect to suspect claims appropriate actions (B) by striking ; and (4) in clause (iii), by striking the period and inserting ; and (5) by adding at the end the following new clause: (iv) furthering the Secretary’s design, development, installation, or enhancement of an automated data system architecture— (I) to collect, integrate, and assess data for purposes of program integrity, program oversight, and administration, including the Medi-Medi Program; and (II) that improves the coordination of requests for data from States. . (c) Providing states with data on improper payments made for items or services provided to dual eligible individuals (1) In general The Secretary shall develop and implement a plan that allows each State agency responsible for administering a State plan for medical assistance under title XIX of the Social Security Act access to relevant data on improper or fraudulent payments made under the Medicare program under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. (2) Dual eligible individual defined In this section, the term dual eligible individual 42 U.S.C. 1395c et seq. 42 U.S.C. 1395j et seq. 42 U.S.C. 1396 et seq. 6. Report on implementation Not later than 18 months after the date of the enactment of this Act, the Secretary of Health and Human Services shall submit to Congress a report on the implementation of the provisions of, and the amendments made by— (1) this Act; and (2) sections 506 and 507 of the Medicare Access and CHIP Reauthorization Act of 2015 ( Public Law 114–10

Summary: Preventing and Reducing Improper Medicare and Medicaid Expenditures to Restore Integrity to Benefits Act of 2015 This bill amends title XIX (Medicaid) of the Social Security Act to make several changes related to the prevention of Medicaid fraud. With respect to the Medicaid Integrity Program (MIP), the bill: (1) specifies that program appropriations may cover costs of equipment, travel, training, and salaries and benefits; and (2) allows the Department of Health and Human Services (HHS) flexibility in determining the number of additional staff necessary to carry out the program. (MIP is a federal program aimed at preventing and reducing provider fraud, waste, and abuse in the Medicaid program.) Under current law, HHS may contract with Medicare administrative contractors (MACs), which are private insurers that process Medicare claims within specified geographic jurisdictions. The bill requires HHS to provide specified incentives for MACs to reduce improper payment error rates within their jurisdictions. The bill establishes criminal penalties of up to 10 years imprisonment and up to $500,000 in fines for illegally purchasing or distributing Medicare, Medicaid, or Children's Health Insurance Program (CHIP) beneficiary identification or billing privileges. The bill increases the scope of the Medicare-Medicaid Data Match Program (Medi-Medi Program), an existing program through which contractors and participating governmental agencies collaboratively analyze Medicare and Medicaid billing trends. HHS must establish a plan to encourage states to participate in the Medi-Medi Program. HHS shall develop and implement a plan to allow states to access relevant data on improper or fraudulent payments made under the Medicare program on behalf of individuals dually eligible for both Medicare and Medicaid.