Preventing Medicare Telefraud Act

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. 1. Short title This Act may be cited as the Preventing Medicare Telefraud Act 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) (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 (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) (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 (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) 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) (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)

Summary: Preventing Medicare Telefraud Act 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. 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.