Medicare Established Provider Act of 2015

To amend title XVIII of the Social Security Act to provide for a Medicare established provider system under which providers of services and suppliers representing a low risk for submitting fraudulent Medicare claims are provided certain claim review protections. 1. Short title This Act may be cited as the Medicare Established Provider Act of 2015 2. Medicare established provider system Title XVIII of the Social Security Act is amended by inserting after section 1893 of such Act ( 42 U.S.C. 1395ddd 1893A. Medicare established provider system (a) In general The Secretary shall develop and implement a system (in this section referred to as the Medicare Established Provider System (1) the Secretary shall establish a process, in accordance with subsection (c), under which— (A) providers of services and suppliers may apply for designation as established providers; (B) such providers and suppliers who qualify, in accordance with subsection (b), as established providers are so designated (including through the use of entities trained by an Internet training course of the Centers for Medicare & Medicaid Services or through training provided by other specified organizations); and (C) such providers and suppliers who no longer qualify as established providers lose such designation; and (2) the Secretary shall establish an electronic system for the submission of documentation by providers of services, suppliers, or third parties, with respect to a claim for payment under this title that is under review, for each level of review applicable to such claim. (b) Qualifying as established providers Under such system, to qualify as an established provider for a period with respect to a reporting period (as specified by the Secretary), a provider of services or supplier shall demonstrate, as specified by the Secretary, that— (1) with respect to the reporting period beginning after the date of the enactment of this section, at least 90 percent of claims for payment under this title for items and services furnished by such provider or supplier for which any review was conducted under section 1869 were determined to be eligible for payment or partial payment under this title; and (2) of all claims for payment under this title for items and services furnished by such provider or supplier for which an initial determination was made that payment may not be made under this title, at least 90 percent were appealed by such provider or supplier. (c) Designation process The process under subsection (a)(1)— (1) shall allow a provider of services or supplier designated as an established provider under this section to demonstrate that the provider or supplier maintains compliance with the qualification requirements under subsection (b) based on annual updates on the status of claims for payment under this title for items and services furnished by such provider or supplier with respect to each level of review, including the number of such claims within each such level of review for which a determination was made that payment should be made, should be partially made, or should not be made under this title; (2) shall provide a method through which it may be determined whether or not the qualifying requirements under subsection (b) have been satisfied and maintained by a provider of services or supplier with respect to a period; (3) provide for the identification of established providers within appropriate systems of the Centers of Medicare & Medicaid Services; and (4) provide for a global track record of compliance by providers of services and suppliers with the qualifying requirements under subsection (b), including by identifying such providers and suppliers by the management company provider number rather than by each individual provider, supplier, or facility, for purposes of efficiency. (d) Protections for established providers Notwithstanding any other provision of law, in the case of a provider of services or supplier designated as an established provider under this section with respect to a period the following protections shall apply: (1) With respect to a claim submitted during such period for payment under this title for items or services furnished by such provider or supplier, which is subject to review for whether or not payment should be made under such title and with respect to which an additional documentation request has been issued, payment under this title for such claim may not be withheld unless a final determination has been made that such payment should not be made. (2) In the case that a final determination has been made that payment under this title should not have been made with respect to a claim described in paragraph (1), repayment of such payment shall be made electronically by the provider not later than 45 days after notification of such decision. In applying the previous sentence, if the Secretary determines that repayment within such 45-day period would result in a significant hardship to the provider involved, the Secretary may, on a case-by-case basis, extend the 45-day period described in such sentence by such number of days as the Secretary determines appropriate in accordance with a specified repayment plan. (3) The Secretary shall provide for a method to apply section 1869 with respect to an initial determination of any claim submitted during such period for payment under this title for items and services furnished by such provider or supplier, without the application of paragraph (3) of section 1869(a) (relating to redeterminations). .

Summary: Medicare Established Provider Act of 2015 This bill amends title XVIII (Medicare) of the Social Security Act to direct the Department of Health and Human Services (HHS) to develop a system for designating providers that represent a low risk of submitting fraudulent Medicare claims as "established providers" for purposes of applying for special treatment in the claim review process. To qualify as an established provider, a provider must demonstrate that, within a specified timeframe: (1) at least 90% of Medicare claims submitted by the provider were determined to be eligible for full or partial payment, and (2) the provider appealed at least 90% of all Medicare claims that were not initially determined to be eligible for payment. HHS may withhold payment for a Medicare claim made by an established provider only if a final determination has been made that the claim is ineligible for payment. If such a final determination is made, the provider shall repay such payment electronically and within a specified timeframe.