Medicare Established Provider Act of 2015

SECTION 1. SHORT TITLE.

     This Act may be cited as the ``Medicare Established Provider Act 
of 2015''.

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 providers 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 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&nbsp;that were not initially determined to be eligible for payment. HHS may withhold payment for a Medicare claim made by an established provider&nbsp;only if a&nbsp;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.