H. R. 1—344
recoup the overpayment until the date the decision on
the reconsideration has been rendered. If the provisions
of section 1869(b)(1) (providing for such a reconsideration
by a qualified independent contractor) are not in effect,
in applying the previous sentence any reference to such
a reconsideration shall be treated as a reference to a
redetermination by the fiscal intermediary or carrier
involved.
‘‘(B) COLLECTION WITH INTEREST.—Insofar as the deter-
mination on such appeal is against the provider of services
or supplier, interest on the overpayment shall accrue on
and after the date of the original notice of overpayment.
Insofar as such determination against the provider of serv-
ices or supplier is later reversed, the Secretary shall provide
for repayment of the amount recouped plus interest at
the same rate as would apply under the previous sentence
for the period in which the amount was recouped.
‘‘(C) MEDICARE CONTRACTOR DEFINED.—For purposes
of this subsection, the term ‘medicare contractor’ has the
meaning given such term in section 1889(g).
‘‘(3) LIMITATION ON USE OF EXTRAPOLATION.—A medicare
contractor may not use extrapolation to determine overpayment
amounts to be recovered by recoupment, offset, or otherwise
unless the Secretary determines that—
‘‘(A) there is a sustained or high level of payment
error; or
‘‘(B) documented educational intervention has failed
to correct the payment error.
There shall be no administrative or judicial review under section
1869, section 1878, or otherwise, of determinations by the Secretary
of sustained or high levels of payment errors under this paragraph.
‘‘(4) PROVISION OF SUPPORTING DOCUMENTATION.—In the
case of a provider of services or supplier with respect to which
amounts were previously overpaid, a medicare contractor may
request the periodic production of records or supporting docu-
mentation for a limited sample of submitted claims to ensure
that the previous practice is not continuing.
‘‘(5) CONSENT SETTLEMENT REFORMS.—
‘‘(A) IN GENERAL.—The Secretary may use a consent
settlement (as defined in subparagraph (D)) to settle a
projected overpayment.
‘‘(B) OPPORTUNITY TO SUBMIT ADDITIONAL INFORMATION
BEFORE
CONSENT
SETTLEMENT
OFFER.—Before offering a
provider of services or supplier a consent settlement, the
Secretary shall—
‘‘(i) communicate to the provider of services or
supplier—
‘‘(I) that, based on a review of the medical
records requested by the Secretary, a preliminary
evaluation of those records indicates that there
would be an overpayment;
‘‘(II) the nature of the problems identified in
such evaluation; and
‘‘(III) the steps that the provider of services
or supplier should take to address the problems;
and
H. R. 1—345
‘‘(ii) provide for a 45-day period during which the
provider of services or supplier may furnish additional
information concerning the medical records for the
claims that had been reviewed.
‘‘(C) CONSENT
SETTLEMENT
OFFER.—The Secretary
shall review any additional information furnished by the
provider of services or supplier under subparagraph (B)(ii).
Taking into consideration such information, the Secretary
shall determine if there still appears to be an overpayment.
If so, the Secretary—
‘‘(i) shall provide notice of such determination to
the provider of services or supplier, including an expla-
nation of the reason for such determination; and
‘‘(ii) in order to resolve the overpayment, may offer
the provider of services or supplier—
‘‘(I) the opportunity for a statistically valid
random sample; or
‘‘(II) a consent settlement.
The opportunity provided under clause (ii)(I) does not waive
any appeal rights with respect to the alleged overpayment
involved.
‘‘(D) CONSENT SETTLEMENT DEFINED.—For purposes of
this paragraph, the term ‘consent settlement’ means an
agreement between the Secretary and a provider of services
or supplier whereby both parties agree to settle a projected
overpayment based on less than a statistically valid sample
of claims and the provider of services or supplier agrees
not to appeal the claims involved.
‘‘(6) NOTICE OF OVER-UTILIZATION OF CODES.—The Secretary
shall establish, in consultation with organizations representing
the classes of providers of services and suppliers, a process
under which the Secretary provides for notice to classes of
providers of services and suppliers served by the contractor
in cases in which the contractor has identified that particular
billing codes may be overutilized by that class of providers
of services or suppliers under the programs under this title
(or provisions of title XI insofar as they relate to such pro-
grams).
‘‘(7) PAYMENT AUDITS.—
‘‘(A) WRITTEN NOTICE FOR POST-PAYMENT AUDITS.—Sub-
ject to subparagraph (C), if a medicare contractor decides
to conduct a post-payment audit of a provider of services
or supplier under this title, the contractor shall provide
the provider of services or supplier with written notice
(which may be in electronic form) of the intent to conduct
such an audit.
‘‘(B) EXPLANATION OF FINDINGS FOR ALL AUDITS.—Sub-
ject to subparagraph (C), if a medicare contractor audits
a provider of services or supplier under this title, the
contractor shall—
‘‘(i) give the provider of services or supplier a full
review and explanation of the findings of the audit
in a manner that is understandable to the provider
of services or supplier and permits the development
of an appropriate corrective action plan;
‘‘(ii) inform the provider of services or supplier
of the appeal rights under this title as well as consent
H. R. 1—346
settlement options (which are at the discretion of the
Secretary);
‘‘(iii) give the provider of services or supplier an
opportunity to provide additional information to the
contractor; and
‘‘(iv) take into account information provided, on
a timely basis, by the provider of services or supplier
under clause (iii).
‘‘(C) EXCEPTION.—Subparagraphs (A) and (B) shall not
apply if the provision of notice or findings would com-
promise pending law enforcement activities, whether civil
or criminal, or reveal findings of law enforcement-related
audits.
‘‘(8) STANDARD METHODOLOGY FOR PROBE SAMPLING.—The
Secretary shall establish a standard methodology for medicare
contractors to use in selecting a sample of claims for review
in the case of an abnormal billing pattern.’’.
(b) EFFECTIVE DATES AND DEADLINES.—
(1) USE OF REPAYMENT PLANS.—Section 1893(f)(1) of the
Social Security Act, as added by subsection (a), shall apply
to requests for repayment plans made after the date of the
enactment of this Act.
(2) LIMITATION ON RECOUPMENT.—Section 1893(f)(2) of the
Social Security Act, as added by subsection (a), shall apply
to actions taken after the date of the enactment of this Act.
(3) USE OF EXTRAPOLATION.—Section 1893(f)(3) of the Social
Security Act, as added by subsection (a), shall apply to statis-
tically valid random samples initiated after the date that is
1 year after the date of the enactment of this Act.
(4) PROVISION
OF
SUPPORTING
DOCUMENTATION.—Section
1893(f)(4) of the Social Security Act, as added by subsection
(a), shall take effect on the date of the enactment of this
Act.
(5) CONSENT SETTLEMENT.—Section 1893(f)(5) of the Social
Security Act, as added by subsection (a), shall apply to consent
settlements entered into after the date of the enactment of
this Act.
(6) NOTICE OF OVERUTILIZATION.—Not later than 1 year
after the date of the enactment of this Act, the Secretary
shall first establish the process for notice of overutilization
of billing codes under section 1893A(f)(6) of the Social Security
Act, as added by subsection (a).
(7) PAYMENT
AUDITS.—Section 1893A(f)(7) of the Social
Security Act, as added by subsection (a), shall apply to audits
initiated after the date of the enactment of this Act.
(8) STANDARD FOR ABNORMAL BILLING PATTERNS.—Not later
than 1 year after the date of the enactment of this Act, the
Secretary shall first establish a standard methodology for selec-
tion of sample claims for abnormal billing patterns under sec-
tion 1893(f)(8) of the Social Security Act, as added by subsection
(a).
SEC. 936. PROVIDER ENROLLMENT PROCESS; RIGHT OF APPEAL.
(a) IN GENERAL.—Section 1866 (42 U.S.C. 1395cc) is amended—
(1) by adding at the end of the heading the following:
‘‘; ENROLLMENT PROCESSES’’; and
(2) by adding at the end the following new subsection:
H. R. 1—347
‘‘(j) ENROLLMENT PROCESS FOR PROVIDERS OF SERVICES AND
SUPPLIERS.—
‘‘(1) ENROLLMENT PROCESS.—
‘‘(A) IN
GENERAL.—The Secretary shall establish by
regulation a process for the enrollment of providers of
services and suppliers under this title.
‘‘(B) DEADLINES.—The Secretary shall establish by
regulation procedures under which there are deadlines for
actions on applications for enrollment (and, if applicable,
renewal of enrollment). The Secretary shall monitor the
performance of medicare administrative contractors in
meeting the deadlines established under this subpara-
graph.
‘‘(C) 
CONSULTATION
BEFORE
CHANGING
PROVIDER
ENROLLMENT FORMS.—The Secretary shall consult with pro-
viders of services and suppliers before making changes
in the provider enrollment forms required of such providers
and suppliers to be eligible to submit claims for which
payment may be made under this title.
‘‘(2) HEARING
RIGHTS
IN
CASES
OF
DENIAL
OR
NON-
RENEWAL.—A provider of services or supplier whose application
to enroll (or, if applicable, to renew enrollment) under this
title is denied may have a hearing and judicial review of such
denial under the procedures that apply under subsection
(h)(1)(A) to a provider of services that is dissatisfied with a
determination by the Secretary.’’.
(b) EFFECTIVE DATES.—
(1) ENROLLMENT PROCESS.—The Secretary shall provide for
the establishment of the enrollment process under section
1866(j)(1) of the Social Security Act, as added by subsection
(a)(2), within 6 months after the date of the enactment of
this Act.
(2) CONSULTATION.—Section 1866(j)(1)(C) of the Social
Security Act, as added by subsection (a)(2), shall apply with
respect to changes in provider enrollment forms made on or
after January 1, 2004.
(3) HEARING RIGHTS.—Section 1866(j)(2) of the Social Secu-
rity Act, as added by subsection (a)(2), shall apply to denials
occurring on or after such date (not later than 1 year after
the date of the enactment of this Act) as the Secretary specifies.
SEC. 937. PROCESS FOR CORRECTION OF MINOR ERRORS AND OMIS-
SIONS WITHOUT PURSUING APPEALS PROCESS.
(a) CLAIMS.—The Secretary shall develop, in consultation with
appropriate medicare contractors (as defined in section 1889(g) of
the Social Security Act, as inserted by section 301(a)(1)) and rep-
resentatives of providers of services and suppliers, a process
whereby, in the case of minor errors or omissions (as defined by
the Secretary) that are detected in the submission of claims under
the programs under title XVIII of such Act, a provider of services
or supplier is given an opportunity to correct such an error or
omission without the need to initiate an appeal. Such process shall
include the ability to resubmit corrected claims.
(b) DEADLINE.—Not later than 1 year after the date of the
enactment of this Act, the Secretary shall first develop the process
under subsection (a).