Medicare Transaction Fraud Prevention Act
Sponsored By: Representative Schweikert
Introduced
Summary
Uses predictive AI risk scores to screen Medicare payments for durable medical equipment and lab tests. This bill would create a two-year pilot, starting by January 1, 2026, that applies a predictive risk-scoring algorithm to claims for durable medical equipment and clinical diagnostic laboratory tests for beneficiaries who opt in to electronic Medicare Summary Notices. The algorithm would score transactions from 1 to 99 and trigger human review, alerts, and possible payment suspension when a score exceeds a threshold set by the Secretary.
Show full summary
- Beneficiaries: People who opt in to electronic Medicare Summary Notices get automatic alerts and a chance by email or phone to confirm or "cure" a flagged claim; notices repeat every two weeks for three months after the first alert.
- Suppliers and labs: Durable medical equipment suppliers and clinical diagnostic laboratories must collaborate on the pilot and may see individual claims reviewed or temporarily suspended if flagged as high risk.
- Administration and oversight: The Secretary must test and evaluate the algorithm, follow Executive Order 14179 guidance on AI, and require a human review step before suspending payments.
- Fraud response and card authority: Alerts will include instructions on reporting suspected fraud and the Secretary may terminate or reissue Medicare cards to prevent abuse.
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Bill Overview
Analyzed Economic Effects
1 provisions identified: 0 benefits, 0 costs, 1 mixed.
Opt-in Medicare fraud check pilot
This bill would create a two-year pilot, starting no later than January 1, 2026. It would test computer risk scores (1–99) on Medicare claims for durable medical equipment and lab tests. You could join only if you opt in to electronic Medicare Summary Notices and to the pilot; you could leave anytime. High-risk scores could trigger a human review and a temporary hold until you confirm by email or phone. If a claim is suspended, you would get an electronic MSN alert and follow-ups every two weeks for three months, plus tips on reporting fraud. To prevent fraud, HHS could cancel your Medicare card and issue a new one.
Sponsors & CoSponsors
Sponsor
Schweikert
AZ • R
Cosponsors
There are no cosponsors for this bill.
Roll Call Votes
No roll call votes available for this bill.
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