Summary
# Medicare Fraud Detection and Deterrence Act of 2023 (H.R. 1745)
## WHAT THIS BILL DOES
This bill updates federal laws that govern Medicare and other health care programs run by the government. It strengthens rules designed to catch and stop fraud, waste and abuse (dishonest or careless use of health care money) in these programs.
## WHO IT AFFECTS
- Health care providers and suppliers who participate in Medicare
- Medicare Advantage plans (insurance plans that cover Medicare beneficiaries)
- Telehealth companies and physicians who provide remote medical services
- The Department of Health and Human Services and its Inspector General
- Individuals and entities excluded from federal health care programs
## KEY PROVISIONS
- The Secretary of Health and Human Services must deactivate (turn off) provider identification numbers for most entities excluded from federal health care programs within 90 days, and for certain others only with the Inspector General's request. The deactivation ends when the exclusion ends. (Sec. 2(a))
- Medicare Advantage plans must include provider identification numbers in data they submit about certain medical items and services (such as equipment, devices, lab tests, imaging tests and home health services) starting immediately after the bill passes. Plans that submit data without these numbers will have that data rejected. (Sec. 2(b))
- The Secretary must create a special code (modifier) within 90 days to identify telehealth services provided by physicians and practitioners who work for telehealth companies. Claims without this code cannot be paid. (Sec. 2(c))
## WHAT CHANGES
If this becomes law, health care providers excluded from Medicare will have their identification numbers turned off automatically. Medicare Advantage plans will need to collect and report who ordered medical equipment and services. Telehealth services from company-affiliated doctors will be tracked with a special identifying code.
## IMPORTANT DEFINITIONS
- "Durable medical equipment": items like wheelchairs or oxygen machines prescribed for home use
- "Prosthetic or orthotic device": artificial body parts or supportive devices
- "Clinical diagnostic laboratory test": blood work and other lab tests used to diagnose conditions
- "Telehealth service": medical care provided remotely, typically through video or phone
- "Specified entity": a doctor or practitioner who has an employment or contract relationship with a telehealth company
- "Telehealth company": a business that hires doctors to provide remote medical services and does not significantly employ doctors to see patients in person
## EFFECTIVE DATE
Not specified in bill text
I
118TH CONGRESS
1ST SESSION H. R. 1745
To amend titles XI and XVIII of the Social Security Act to strengthen
health care waste, fraud, and abuse provisions.
IN THE HOUSE OF REPRESENTATIVES
MARCH 23, 2023
Mr. DOGGETT introduced the following bill; which was referred to the Com-
mittee on Energy and Commerce, and in addition to the Committee on
Ways and Means, for a period to be subsequently determined by the
Speaker, in each case for consideration of such provisions as fall within
the jurisdiction of the committee concerned
A BILL
To amend titles XI and XVIII of the Social Security Act
to strengthen health care waste, fraud, and abuse provisions.
Be it enacted by the Senate and House of Representa-
1
tives of the United States of America in Congress assembled,
2
SECTION 1. SHORT TITLE.
3
This Act may be cited as the ‘‘Medicare Fraud Detec-
4
tion and Deterrence Act of 2023’’.
5
SEC. 2. STRENGTHENING HEALTH CARE WASTE, FRAUD,
6
AND ABUSE PROVISIONS.
7
(a) DEACTIVATION OF NATIONAL PROVIDER IDENTI-
8
FIER
FOR
CERTAIN
EXCLUDED
ENTITIES.—Section
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1173(b) of the Social Security Act (42 U.S.C. 1320d–
1
2(b)) is amended by adding at the end the following new
2
paragraph:
3
‘‘(3) MANDATORY DEACTIVATION OF CERTAIN
4
IDENTIFIERS.—
5
‘‘(A) IN
GENERAL.—Not later than 90
6
days after the date of the enactment of this
7
paragraph, the Secretary shall revise the stand-
8
ards adopted under paragraph (1) to provide
9
for—
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‘‘(i) the deactivation of a standard
11
unique health identifier of entity type 1 (as
12
defined for purposes of such standards) as-
13
signed to an entity if such entity is ex-
14
cluded from participation in any Federal
15
health care program under section 1128 or
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1128A;
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‘‘(ii) the deactivation of a standard
18
unique health identifier of entity type 2 (as
19
defined for purposes of such standards) as-
20
signed to an entity if such entity is so ex-
21
cluded, but only if—
22
‘‘(I) the Inspector General of the
23
Department of Health and Human
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Services submits to the Secretary a
1
request for such deactivation; and
2
‘‘(II) the Secretary determines
3
such deactivation to be appropriate;
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and
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‘‘(iii) the reactivation of a standard
6
unique health identifier deactivated pursu-
7
ant to clause (i) or (ii) at the end of such
8
deactivation (as described in subparagraph
9
(B)).
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‘‘(B) TERM OF DEACTIVATION.—A deacti-
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vation described in subparagraph (A) made
12
with respect to an entity excluded from partici-
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pation in any Federal health care program
14
under section 1128 or 1128A shall begin on the
15
date of such exclusion and shall end on the date
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such exclusion is terminated.
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‘‘(C)
NONAPPLICATION
OF
DEACTIVA-
18
TION.—Notwithstanding subparagraph (A), no
19
deactivation of a standard unique health identi-
20
fier assigned to an entity excluded from partici-
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pation in any Federal health care program
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under section 1128 or 1128A shall be made
23
pursuant to such subparagraph if the Secretary
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has waived such exclusion with respect to any
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Federal health care program pursuant to sec-
1
tion 1128(c)(3)(B).
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‘‘(D) ANNUAL
REVIEW
OF
EXCLUSION
3
LIST.—Not later than 1 year after the date of
4
the enactment of this paragraph and not less
5
frequently than annually thereafter, the Sec-
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retary shall compare the list of individuals and
7
entities excluded from participation in any Fed-
8
eral health care program under section 1128 or
9
1128A maintained by the Inspector General of
10
the Department of Health and Human Services
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(or a successor list) with a list of active stand-
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ard unique health identifiers described in sub-
13
paragraph (A) to ensure compliance with such
14
subparagraph.’’.
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(b) MEDICARE ADVANTAGE PLAN PROVISION OF NA-
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TIONAL PROVIDER IDENTIFIER FOR CERTAIN ITEMS AND
17
SERVICES.—Section 1859 of the Social Security Act (42
18
U.S.C. 1395w–28) is amended by adding at the end the
19
following new subsection:
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‘‘(j) PROVISION OF NATIONAL PROVIDER IDENTI-
21
FIER FOR CERTAIN ITEMS AND SERVICES.—
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‘‘(1) IN GENERAL.—In the case of any encoun-
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ter data submitted by a Medicare Advantage plan
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with respect to a designated item or service fur-
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nished to an individual under such plan on or after
1
the date of the enactment of this subsection, the
2
Secretary shall require that such data include the
3
standard unique health identifier established pursu-
4
ant to standards described in section 1173(b) of the
5
provider of services or supplier that ordered such
6
item or service or referred such individual for such
7
item or service.
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‘‘(2) REJECTION
OF
DATA.—The Secretary
9
shall reject any encounter data submitted by a Medi-
10
care Advantage plan if—
11
‘‘(A) such data does not comply with the
12
requirement described in paragraph (1); or
13
‘‘(B) the Secretary determines that a
14
standard unique health identifier included in
15
such data in accordance with such requirement
16
is not active or is otherwise invalid.
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‘‘(3) DEFINITION
OF
DESIGNATED
ITEM
OR
18
SERVICE.—For purposes of this subsection, the term
19
‘designated item or service’ means any of the fol-
20
lowing:
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‘‘(A) An item of durable medical equip-
22
ment.
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‘‘(B) A prosthetic or orthotic device.
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‘‘(C) A clinical diagnostic laboratory test.
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‘‘(D) A diagnostic imaging test (as speci-
1
fied by the Secretary).
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‘‘(E) A home health service (as specified
3
by the Secretary).’’.
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(c) IDENTIFICATION OF RELATIONSHIPS BETWEEN
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TELEHEALTH SUPPLIERS AND TELEHEALTH COMPANIES
6
UNDER MEDICARE.—Section 1834(m) of the Social Secu-
7
rity Act (42 U.S.C. 1395m(m)) is amended by adding at
8
the end the following new paragraph:
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‘‘(10) IDENTIFICATION OF RELATIONSHIPS BE-
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TWEEN TELEHEALTH SUPPLIERS AND TELEHEALTH
11
COMPANIES.—
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‘‘(A) IN GENERAL.—In the case of a tele-
13
health service furnished on or after the date of
14
the enactment of this paragraph by a specified
15
entity, no payment may be made under this sec-
16
tion for such service unless the claim for such
17
service includes the modifier established pursu-
18
ant to subparagraph (B).
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‘‘(B) ESTABLISHMENT OF MODIFIER.—Not
20
later than 90 days after the date of the enact-
21
ment of this paragraph, the Secretary shall es-
22
tablish a claims modifier for purposes of identi-
23
fying telehealth services payable under this sec-
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tion furnished by a specified entity (as defined
1
in subparagraph (C)).
2
‘‘(C) DEFINITIONS.—In this section:
3
‘‘(i) SPECIFIED
ENTITY.—The term
4
‘specified entity’ means a physician or
5
practitioner (as such terms are defined in
6
paragraph (4)) that has an employment or
7
other contractual relationship in effect with
8
a telehealth company relating to the fur-
9
nishing telehealth services.
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‘‘(ii) TELEHEALTH
COMPANY.—The
11
term ‘telehealth company’ means an enti-
12
ty—
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‘‘(I) that employs or otherwise
14
contracts with physicians or practi-
15
tioners to furnish telehealth services;
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and
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‘‘(II) that does not employ or
18
otherwise contract with any physician
19
or practitioner to furnish items and
20
services in-person (or that employs or
21
otherwise contracts with physicians or
22
practitioners to furnish such in-person
23
items and services in a de minimis
24
manner compared to the amount of
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telehealth services furnished by such
1
physicians or practitioners, as speci-
2
fied by the Secretary).’’.
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Æ
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