I 
113TH CONGRESS 
1ST SESSION H. R. 3168 
To amend title XVIII of the Social Security Act to provide for a Medicare 
established provider system under which providers of services and sup-
pliers representing a low risk for submitting fraudulent Medicare claims 
are provided certain claim review protections. 
IN THE HOUSE OF REPRESENTATIVES 
SEPTEMBER 20, 2013 
Mr. WILLIAMS (for himself, Mr. FLORES, Ms. GRANGER, and Mr. STOCKMAN) 
introduced the following bill; which was referred to the Committee on 
Ways and Means, and in addition to the Committee on Energy and Com-
merce, for a period to be subsequently determined by the Speaker, in 
each case for consideration of such provisions as fall within the jurisdic-
tion of the committee concerned 
A BILL 
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 pro-
vided certain claim review protections. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Medicare Established 
Provider Act of 2013’’. 
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SEC. 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) the following new section: 
‘‘SEC. 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’) to designate pro-
viders of services and suppliers who represent a low risk 
for submitting fraudulent claims for payment under this 
title as established providers for purposes of applying the 
protections described in subsection (c). Under such sys-
tem— 
‘‘(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 pro-
viders; 
‘‘(B) such providers and suppliers who 
qualify, in accordance with subsection (b), as 
established providers are so designated (includ-
ing through the use of entities trained by an 
Internet training course of the Centers for 
Medicare & Medicaid Services or through train-
ing provided by other specified organizations); 
and 
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‘‘(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 pro-
viders of services, suppliers, or third parties, with re-
spect 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 begin-
ning after the date of the enactment of this section 
but before the date described in paragraph (2), at 
least 75 percent of claims for payment under this 
title for items and services furnished by such pro-
vider or supplier for which any review was conducted 
under section 1869 were determined to be eligible 
for payment under this title; 
‘‘(2) with respect to a reporting period begin-
ning after the date that is 2 years after the date of 
enactment of this section, at least 80 percent of 
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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 under 
this title; and 
‘‘(3) 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 sup-
plier designated as an established provider under 
this section to demonstrate that the provider or sup-
plier maintains compliance with the qualification re-
quirements 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 re-
view, 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 
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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 re-
quirements 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 compli-
ance by providers of services and suppliers with the 
qualifying requirements under subsection (b), includ-
ing 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
PRO-
VIDERS.—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, 
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which is subject to review for whether or not pay-
ment should be made under such title and with re-
spect to which an additional documentation request 
has been issued, payment under this title for such 
claim may not be withheld unless a final determina-
tion 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 re-
sult in a significant hardship to the provider in-
volved, 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 repay-
ment plan. 
‘‘(3) The Secretary shall provide for a method 
to apply section 1869 with respect to an initial de-
termination of any claim submitted during such pe-
riod for payment under this title for items and serv-
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ices furnished by such provider or supplier, without 
the application of paragraph (3) of section 1869(a) 
(relating to redeterminations).’’. 
Æ 
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