42 USC 1320a-7m - Use of predictive modeling and other analytics technologies to identify and prevent waste, fraud, and abuse in the Medicare fee-for-service program

U.S Code last checked for updates: May 01, 2024

§ 1320a–7m.

Use of predictive modeling and other analytics technologies to identify and prevent waste, fraud, and abuse in the Medicare fee-for-service program

(a)

Use in the Medicare fee-for-service program

(b)

Predictive analytics technologies requirements

The predictive analytics technologies used by the Secretary shall—

(1)

capture Medicare provider and Medicare beneficiary activities across the Medicare fee-for-service program to provide a comprehensive view across all providers, beneficiaries, and geographies within such program in order to—

(A)

identify and analyze Medicare provider networks, provider billing patterns, and beneficiary utilization patterns; and

(B)

identify and detect any such patterns and networks that represent a high risk of fraudulent activity;

(2)

be integrated into the existing Medicare fee-for-service program claims flow with minimal effort and maximum efficiency;

(3)

be able to—

(A)

analyze large data sets for unusual or suspicious patterns or anomalies or contain other factors that are linked to the occurrence of waste, fraud, or abuse;

(B)

undertake such analysis before payment is made; and

(C)

prioritize such identified transactions for additional review before payment is made in terms of the likelihood of potential waste, fraud, and abuse to more efficiently utilize investigative resources;

(4)

capture outcome information on adjudicated claims for reimbursement to allow for refinement and enhancement of the predictive analytics technologies on the basis of such outcome information, including post-payment information about the eventual status of a claim; and

(5)

prevent the payment of claims for reimbursement that have been identified as potentially wasteful, fraudulent, or abusive until such time as the claims have been verified as valid.

(c)

Implementation requirements

(1)

Request for proposals

Not later than January 1, 2011, the Secretary shall issue a request for proposals to carry out this section during the first year of implementation. To the extent the Secretary determines appropriate—

(A)

the initial request for proposals may include subsequent implementation years; and

(B)

the Secretary may issue additional requests for proposals with respect to subsequent implementation years.

(2)

First implementation year

(3)

Second implementation year

(4)

Third implementation year

(5)

Fourth implementation year

(6)

Option for refinement and evaluation

(d)

Contractor selection, qualifications, and data access requirements

(1)

Selection

(A)

In general

(B)

Number of contractors

(2)

Qualifications

(A)

In general

The Secretary shall enter into a contract under this section with an entity only if the entity—

(i)

has leadership and staff who—

(I)

have the appropriate clinical knowledge of, and experience with, the payment rules and regulations under the Medicare fee-for-service program; and

(II)

have direct management experience and proficiency utilizing predictive analytics technologies necessary to carry out the requirements under subsection (b); or

(ii)

has a contract, or will enter into a contract, with another entity that has leadership and staff meeting the criteria described in clause (i).

(B)

Conflict of interest

(3)

Data access

(e)

Reporting requirements

(1)

First implementation year report

Not later than 3 months after the completion of the first implementation year under this section, the Secretary shall submit to the appropriate committees of Congress and make available to the public a report that includes the following:

(A)

A description of the implementation of the use of predictive analytics technologies during the year.

(B)

A certification of the Inspector General of the Department of Health and Human Services that—

(i)

specifies the actual and projected savings to the Medicare fee-for-service program as a result of the use of predictive analytics technologies, including estimates of the amounts of such savings with respect to both improper payments recovered and improper payments avoided;

(ii)

the actual and projected savings to the Medicare fee-for-service program as a result of such use of predictive analytics technologies relative to the return on investment for the use of such technologies and in comparison to other strategies or technologies used to prevent and detect fraud, waste, and abuse in the Medicare fee-for-service program; and

(iii)

includes recommendations regarding—

(I)

whether the Secretary should continue to use predictive analytics technologies;

(II)

whether the use of such technologies should be expanded in accordance with the requirements of subsection (c); and

(III)

any modifications or refinements that should be made to increase the amount of actual or projected savings or mitigate any adverse impact on Medicare beneficiaries or providers.

(C)

An analysis of the extent to which the use of predictive analytics technologies successfully prevented and detected waste, fraud, or abuse in the Medicare fee-for-service program.

(D)

A review of whether the predictive analytics technologies affected access to, or the quality of, items and services furnished to Medicare beneficiaries.

(E)

A review of what effect, if any, the use of predictive analytics technologies had on Medicare providers.

(F)

Any other items determined appropriate by the Secretary.

(2)

Second year implementation report

(3)

Third year implementation report

Not later than 3 months after the completion of the third implementation year under this section, the Secretary shall submit to the appropriate committees of Congress, and make available to the public, a report that includes 1

 So in original. Probably should be followed by a comma.

with respect to such year, the items required under paragraph (1),2

 So in original. The comma probably should not appear.

as well as any other additional items determined appropriate by the Secretary with respect to the report for such year, and the following:

(A)

An analysis of the cost-effectiveness and feasibility of expanding the use of predictive analytics technologies to Medicaid and CHIP.

(B)

An analysis of the effect, if any, the application of predictive analytics technologies to claims under Medicaid and CHIP would have on States and the commonwealths and territories.

(C)

Recommendations regarding the extent to which technical assistance may be necessary to expand the application of predictive analytics technologies to claims under Medicaid and CHIP, and the type of any such assistance.

(f)

Independent evaluation and report

(1)

Evaluation

(2)

Report

(g)

Waiver authority

(h)

Funding

(1)

Appropriation

(2)

Reservations

(A)

Independent evaluation

(B)

Application to Medicaid and CHIP

(i)

Definitions

In this section:

(1)

Commonwealths and territories

(2)

CHIP

(3)

Medicaid

(4)

Medicare beneficiary

(5)

Medicare fee-for-service program

(6)

Medicare provider

(7)

Secretary

(8)

State

(Pub. L. 111–240, title IV, § 4241, Sept. 27, 2010, 124 Stat. 2599.)

cite as: 42 USC 1320a-7m