Preventing Hospital Overbilling of Medicare Act

I 118TH CONGRESS 1ST SESSION H. R. 2863 To amend title XVIII of the Social Security Act and title XXVII of the Public Health Service Act to address incorrect billing by off-campus hospital locations, and for other purposes. IN THE HOUSE OF REPRESENTATIVES APRIL 25, 2023 Mrs. SPARTZ 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 title XVIII of the Social Security Act and title XXVII of the Public Health Service Act to address incor- rect billing by off-campus hospital locations, and for other purposes. 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 ‘‘Preventing Hospital 4 Overbilling of Medicare Act’’. 5 VerDate Sep 11 2014 04:16 May 02, 2023 Jkt 039200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H2863.IH H2863 kjohnson on DSK79L0C42PROD with BILLS 2 •HR 2863 IH SEC. 2. ADDRESSING INCORRECT BILLING BY OFF-CAMPUS 1 HOSPITAL LOCATIONS. 2 (a) PROMOTING MEDICARE SITE-NEUTRAL PAY- 3 MENTS.— 4 (1) REMOVING CERTAIN EXCEPTIONS TO THE 5 DEFINITION OF AN OFF-CAMPUS OUTPATIENT DE- 6 PARTMENT OF A PROVIDER.— 7 (A) IN GENERAL.—Section 1833(t)(21)(B) 8 of the Social Security Act (42 U.S.C. 9 1395l(t)(21)(B)) is amended to read as follows: 10 ‘‘(B) OFF-CAMPUS OUTPATIENT DEPART- 11 MENT OF A PROVIDER.—For purposes of para- 12 graph (1)(B)(v) and this paragraph, the term 13 ‘off-campus outpatient department of a pro- 14 vider’ means a department of a provider (as de- 15 fined in section 413.65(a)(2) of title 42 of the 16 Code of Federal Regulations, as in effect as of 17 the date of the enactment of the Bipartisan 18 Budget Act of 2015) that is not located— 19 ‘‘(i) on the campus (as defined in such 20 section 413.65(a)(2)) of such provider; or 21 ‘‘(ii) within the distance (described in 22 such definition of campus) from a remote 23 location of a hospital facility (as defined in 24 such section 413.65(a)(2)).’’. 25 VerDate Sep 11 2014 04:16 May 02, 2023 Jkt 039200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H2863.IH H2863 kjohnson on DSK79L0C42PROD with BILLS 3 •HR 2863 IH (B) EFFECTIVE DATE.—The amendment 1 made by subparagraph (A) shall apply with re- 2 spect to items and services furnished on or 3 after January 1, 2024. 4 (2) REMOVING SITE-NEUTRAL EXCEPTION FOR 5 OFF-CAMPUS EMERGENCY DEPARTMENTS.—Section 6 1833(t)(21)(A) of the Social Security Act (42 7 U.S.C. 1395l(t)(21)(A)) is amended by inserting 8 ‘‘before January 1, 2024’’ after ‘‘furnished’’. 9 (3) CLARIFYING SECRETARIAL AUTHORITY TO 10 PROMOTE SITE-NEUTRAL PAYMENTS.—Section 11 1833(t)(2)(F) of the Social Security Act (42 U.S.C. 12 1395l(t)(2)(F)) is amended by adding at the end the 13 following new sentence: ‘‘Such method may include 14 actions determined appropriate by the Secretary to 15 promote site-neutral payment policies to reduce ex- 16 penditures attributable to items and services fur- 17 nished under this part, such as actions to prevent 18 hospitals from billing for items and services fur- 19 nished at an off-campus outpatient department of a 20 provider as if such items and services were furnished 21 at such hospital.’’. 22 (b) ENSURING SEPARATE NPIS FOR OFF-CAMPUS 23 OUTPATIENT DEPARTMENTS OF A PROVIDER.— 24 VerDate Sep 11 2014 04:16 May 02, 2023 Jkt 039200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H2863.IH H2863 kjohnson on DSK79L0C42PROD with BILLS 4 •HR 2863 IH (1) IN GENERAL.—Section 1173(b) of the So- 1 cial Security Act (42 U.S.C. 1320d–2(b)) is amend- 2 ed by adding at the end the following new para- 3 graph: 4 ‘‘(3) ENSURING SEPARATE NPIS FOR OFF-CAM- 5 PUS OUTPATIENT DEPARTMENTS OF A PROVIDER.— 6 The standards specified under paragraph (1) shall 7 ensure that, not later than January 1, 2024, each 8 off-campus outpatient department of a provider (as 9 defined in section 1833(t)(21)(B)) is assigned a sep- 10 arate unique health identifier from such provider.’’. 11 (2) TREATMENT OF CERTAIN DEPARTMENTS AS 12 SUBPARTS OF A HOSPITAL.—Not later than January 13 1, 2024, the Secretary of Health and Human Serv- 14 ices shall revise sections 162.408 and 162.410 of 15 title 45, Code of Federal Regulations, to ensure that 16 each off-campus outpatient department of a provider 17 (as defined in section 1833(t)(21)(B) of the Social 18 Security Act (42 U.S.C. 1395l(t)(21)(B))) is treated 19 as a subpart (as described in such sections) of such 20 provider and assigned a unique health identifier pur- 21 suant to section 1173(b)(3) of such Act (as added 22 by paragraph (1)). 23 (c) OFF-CAMPUS DEPARTMENTS OF A PROVIDER 24 BILLING REQUIREMENTS.— 25 VerDate Sep 11 2014 04:16 May 02, 2023 Jkt 039200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H2863.IH H2863 kjohnson on DSK79L0C42PROD with BILLS 5 •HR 2863 IH (1) MEDICARE.—Section 1866(a)(1) of the So- 1 cial Security Act (42 U.S.C. 1395cc(a)(1)) is 2 amended— 3 (A) in subparagraph (X), by striking 4 ‘‘and’’ at the end; 5 (B) in subparagraph (Y)(ii)(V), by striking 6 the period and inserting ‘‘, and’’; and 7 (C) by inserting after subparagraph (Y) 8 the following new subparagraph: 9 ‘‘(Z) in the case of a hospital with an off-cam- 10 pus outpatient department of a provider (as defined 11 in section 1833(t)(21)(B)), with respect to items 12 and services furnished at such department of a pro- 13 vider on or after January 1, 2024, to bill under this 14 title (including under part C of this title) for such 15 items and services using the unique health identifier 16 established for such department of a provider pursu- 17 ant to section 1173(b)(3) on a HIPAA X12 837P 18 transaction or CMS 1500 form (or a successor 19 transaction or form).’’. 20 (2) OTHER PROVIDERS.—Part E of title XXVII 21 of the Public Health Service Act (42 U.S.C. 300gg– 22 131 et seq.) is amended by adding at the end the 23 following new section: 24 VerDate Sep 11 2014 04:16 May 02, 2023 Jkt 039200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H2863.IH H2863 kjohnson on DSK79L0C42PROD with BILLS 6 •HR 2863 IH ‘‘SEC. 2799B–10. BILLING REQUIREMENTS FOR OFF-CAMPUS 1 DEPARTMENTS OF A PROVIDER. 2 ‘‘A health care provider may not, with respect to 3 items and services furnished to an individual at an off- 4 campus outpatient department of a provider (as defined 5 in section 1833(t)(21)(B) of the Social Security Act), sub- 6 mit a claim for such items and services to a group health 7 plan or health insurance issuer, and may not hold such 8 individual liable for such items and services, unless such 9 items and services are billed— 10 ‘‘(1) using the separate unique health identifier 11 established for such department pursuant to section 12 1173(b)(3) of such Act; and 13 ‘‘(2) on a HIPAA X12 837P transaction or 14 CMS 1500 form (or a successor transaction or 15 form).’’. 16 (3) EFFECTIVE DATE.—The amendment made 17 by paragraph (1) shall apply with respect to claims 18 submitted for items and services furnished on or 19 after January 1, 2024. 20 (d) NAIC MODEL ACT OR REGULATION.—The Sec- 21 retary of Health and Human Services shall request that, 22 not later than 6 months after the date of the enactment 23 of this Act, the National Association of Insurance Com- 24 missioners establish a model Act or regulation designed 25 to address the issue of hospitals inappropriately billing for 26 VerDate Sep 11 2014 04:16 May 02, 2023 Jkt 039200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H2863.IH H2863 kjohnson on DSK79L0C42PROD with BILLS 7 •HR 2863 IH items and services furnished at off-campus outpatient de- 1 partments of a provider (as defined in section 2 1833(t)(21)(B) of the Social Security Act (42 U.S.C. 3 1935l(t)(21)(B))) by allowing health insurance issuers and 4 group health plans (as such terms are defined in section 5 2791 of the Public Health Service Act (42 U.S.C. 300gg– 6 91)) to reject such claims unless such department of a 7 provider bills in accordance with the provisions of section 8 2799B–10 of such Act. The Secretary shall request that 9 such model Act or regulation include requirements similar 10 to those found in Colorado House Bill 18–1282. 11 Æ VerDate Sep 11 2014 04:16 May 02, 2023 Jkt 039200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6301 E:\BILLS\H2863.IH H2863 kjohnson on DSK79L0C42PROD with BILLS