Title: Improving Transparency and Accuracy in Medicare Part D Spending Act
Policy area: Health

Summary:
Improving Transparency and Accuracy in Medicare Part D Spending Act
This bill amends title XVIII (Medicare) of the Social Security Act to prohibit Medicare Prescription Drug Plan sponsors from retroactively reducing payment on clean claims submitted by pharmacies. (A "clean claim" is a Medicare claim that is free of defects such as incomplete documentation.)

[Congressional Bills 115th Congress]
[From the U.S. Government Publishing Office]
[S. 413 Introduced in Senate (IS)]

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115th CONGRESS
  1st Session
                                 S. 413

      To amend title XVIII of the Social Security Act to prohibit 
   prescription drug plan sponsors and MA-PD organizations under the 
 Medicare program from retroactively reducing payment on clean claims 
                        submitted by pharmacies.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                           February 16, 2017

 Mrs. Capito (for herself, Mr. Tester, Mr. Lankford, Mr. Grassley, Ms. 
   Heitkamp, Mr. Wicker, Mr. Boozman, and Mr. Cotton) introduced the 
 following bill; which was read twice and referred to the Committee on 
                                Finance

_______________________________________________________________________

                                 A BILL


 
      To amend title XVIII of the Social Security Act to prohibit 
   prescription drug plan sponsors and MA-PD organizations under the 
 Medicare program from retroactively reducing payment on clean claims 
                        submitted by pharmacies.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Improving Transparency and Accuracy 
in Medicare Part D Spending Act''.

SEC. 2. PROHIBITING MEDICARE PDP SPONSORS AND MA-PD ORGANIZATIONS FROM 
              RETROACTIVELY REDUCING PAYMENT ON CLEAN CLAIMS SUBMITTED 
              BY PHARMACIES.

    (a) In General.--Section 1860D-12(b)(4)(A) of the Social Security 
Act (42 U.S.C. 1395w-112(b)(4)(A)) is amended by adding at the end the 
following new clause:
                            ``(iv) Prohibiting retroactive reductions 
                        in payments on clean claims.--Each contract 
                        entered into with a PDP sponsor under this part 
                        with respect to a prescription drug plan 
                        offered by such sponsor shall provide that 
                        after the date of receipt of a clean claim 
                        submitted by a pharmacy, the PDP sponsor (or an 
                        agent of the PDP sponsor) may not retroactively 
                        reduce payment on such claim directly or 
                        indirectly through aggregated effective rate or 
                        otherwise except in the case such claim is 
                        found to not be a clean claim (such as in the 
                        case of a claim lacking required substantiating 
                        documentation) during the course of a routine 
                        audit as permitted pursuant to written 
                        agreement between the PDP sponsor (or such an 
                        agent) and such pharmacy. The previous sentence 
                        shall not prohibit any retroactive increase in 
                        payment to a pharmacy pursuant to a written 
                        agreement between a PDP sponsor (or an agent of 
                        such sponsor) and such pharmacy.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply with respect to contracts entered into on or after January 1, 
2018.
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