PRIME Act of 2015

Bill: 114-s-861
Sponsor: Sen. Carper, Thomas R. [D-DE]
Introduced: 2015-03-25 in the Senate
Policy area: Health
Subjects: Accounting and auditing
Child health
Employee hiring
Fraud offenses and financial crimes
Government information and archives
Government studies and investigations
Health care costs and insurance
Health programs administration and funding
Medicaid
Medicare
Prescription drugs
Public contracts and procurement

Summary:
action_date: 2015-03-25
text: 

Preventing and Reducing Improper Medicare and Medicaid Expenditures Act of 2015 or the PRIME Act of 2015

 
Amends part D (Prescription Drug Benefits) of title XVIII (Medicare) of the Social Security Act (SSAct) to direct the Secretary of Health and Human Services (HHS) to prohibit sponsors of prescription drug plans from paying claims for prescription drugs that do not include the valid National Provider Identifier for the drug's prescriber.
 
Requires the Secretary's annual report to Congress on the use of recovery audit contractors under the Medicare Integrity Program to: (1) describe the types and financial cost of improper payment vulnerabilities identified by recovery audit contractors and how the Secretary is addressing them, and (2) assess the effectiveness of changes made to Medicare payment policies and procedures in order to address those vulnerabilities. 
 
Requires the Secretary to address improper payment vulnerabilities in a timely manner, prioritized based on the risk to the Medicare program. 
 
Authorizes the Secretary, under recovery audit contracts under both Medicare and Medicaid (SSAct title XIX), to retain a certain portion of the recovered amounts for a program management account for activities addressing problems that contribute to improper payments and fraud. 
 
Requires the Secretary, under such contracts, to retain an additional 5% of the recovered amounts to be made available to the HHS Inspector General to investigate improper payments or audit internal controls associated with Medicare or Medicaid payments. 
 
Directs the Secretary to develop a plan to revise the incentive program under the Health Insurance Portability and Accountability Act of 1996 for the reporting of fraud and abuse to encourage greater participation by individuals reporting Medicare fraud and abuse. Requires the plan to include certain recommendations for: (1) ways to enhance rewards for individuals reporting, and (2) extension of the incentive program to the Medicaid program.
 
Amends SSAct title XIX to cover the costs of equipment, salaries and benefits, and travel and training in appropriations for the Medicaid Integrity Program. Allows the Secretary to increase Centers for Medicare and Medicaid Services (CMS) staff whose duties consist solely of protecting the integrity of the Medicare program by a number determined necessary to carry out the Program (currently, by 100).
 
Directs the Secretary to provide incentives for Medicare administrative contractors to reduce the improper payment error rates in their jurisdictions.
 
Requires imprisonment for up to 10 years or a fine of up to $500,000 ($1 million in the case of a corporation), or both, for knowingly, intentionally, and with the intent to defraud purchasing, selling, distributing, or arranging for the purchase, sale, or distribution of a Medicare, Medicaid, or CHIP beneficiary identification number or billing privileges under SSAct titles XVIII, title XIX, or title XXI (Children's Health Insurance Program) (CHIP).
 
Amends SSAct title IV part D (Child Support and Establishment of Paternity) with respect to the Federal Parent Locator Service to give the CMS Administrator access to information in the National Directory of New Hires to determine the eligibility of an applicant for, or enrollee in, the Medicare program or an applicable state health subsidy program under the Patient Protection and Affordable Care Act (PPACA). 
 
Requires the Secretary to disclose to the HHS Inspector General information on individuals and their employers in the National Directory of New Hires if the HHS Inspector General gives the Secretary their names and Social Security account numbers. Restricts the use of such information to: (1) determining the eligibility of an applicant for, or enrollee in, the Medicare program or an applicable state health subsidy program; or (2) evaluating the integrity of such programs. Sets forth rules for the use and disclosure of such information by state agencies.
 
Directs the Secretary to establish a plan to encourage and facilitate the participation of states in the Medicare-Medicaid Data Match Program (Medi-Medi Program). Revises Medi-Medi Data Match Program purposes.
 
Amends SSAct title XIX, as amended by PPACA, and SSAct XXI with respect to claims processing and detection of fraud within the Medicaid and CHIP programs.

action_date: 2015-07-30
text: 

Preventing and Reducing Improper Medicare and Medicaid Expenditures Act of 2015 or the PRIME Act of 2015

 
(Sec. 2) Amends title XIX (Medicaid) of the Social Security Act (SSAct) to cover the costs of equipment, salaries and benefits, and travel and training in appropriations for the Medicaid Integrity Program. Allows the Department of Health and Human Services (HHS) to increase Centers for Medicare and Medicaid Services staff whose duties consist solely of protecting the integrity of the Medicare program under SSAct title XVIII by a number determined necessary to carry out the Program (currently, by 100).
 
(Sec. 3) Directs HHS to provide incentives for Medicare administrative contractors (MACs) to reduce the improper payment error rates in their jurisdictions.
 
Authorizes among such incentives:
 
 
a sliding scale of award fee payments and additional incentives to MACs that either reduce the improper payment rates in their jurisdictions to certain HHS-determined thresholds or accomplish tasks that further improve payment accuracy; and
 
substantial reductions in award fee payments under cost-plus-award-fee contracts for MACs that reach an upper end improper payment rate threshold or fail to accomplish tasks that further improve payment accuracy.
 
 
(Sec. 4) Requires imprisonment for up to 10 years or a fine of up to $500,000 ($1 million in the case of a corporation), or both, for without lawful authority knowingly and willfully purchasing, selling, distributing, or arranging for the purchase, sale, or distribution of a beneficiary identification number or unique health identifier for a health care provider under SSAct titles XVIII, XIX, or XXI (Children's Health Insurance Program) (CHIP).
 
(Sec. 5) Directs HHS to establish a plan to encourage and facilitate the participation of states in the Medicare-Medicaid Data Match Program (Medi-Medi Program). Revises Medi-Medi Data Match Program purposes.
 
Directs HHS to develop and implement a plan that allows state agencies responsible for administering a state Medicaid plan access to relevant data on improper or fraudulent payments made under the Medicare program for health care items or services provided to dual eligible individuals (eligible for both Medicare and Medicaid).


Legislative actions:
action_date: 2015-07-30
text: Placed on Senate Legislative Calendar under General Orders. Calendar No. 183.
action_date: 2015-07-30
text: Committee on Finance. Reported by Senator Hatch with an amendment in the nature of a substitute. With written report No. 114-104.
action_date: 2015-07-30
text: Committee on Finance. Reported by Senator Hatch with an amendment in the nature of a substitute. With written report No. 114-104.
action_date: 2015-06-24
text: Committee on Finance. Ordered to be reported without amendment favorably.
action_date: 2015-03-25
text: Read twice and referred to the Committee on Finance.
action_date: 2015-03-25
text: Introduced in Senate