Medicare Transaction Fraud Prevention Act
Sponsored By: Senator Tim Sheehy
Introduced
Summary
Tests predictive risk-scoring algorithms to oversee Medicare payments for durable medical equipment and clinical diagnostic laboratory tests. The pilot would run for two years and rely on beneficiary opt‑in and electronic notices to flag and review suspect transactions.
Show full summary
- Beneficiaries: People who opt in must receive electronic Medicare Summary Notices (MSNs) and would get an automatic alert if a flagged transaction is suspended. Follow-up MSNs would be sent every two weeks for three months and beneficiaries can confirm or correct charges.
- Providers and suppliers: Durable medical equipment suppliers and clinical labs would see claims scored and may face human review and temporary suspension for high-risk transactions while the algorithm is evaluated. The Secretary must collaborate with industry in designing and implementing the pilot.
- Program mechanics and oversight: Transactions would be scored from 1 (least risky) to 99 (most risky) and scores above a Secretary‑set threshold would trigger review, possible suspension, and coordination with the Office of the Inspector General.
- Fraud prevention tools: The Secretary would have authority to terminate or reissue Medicare cards as a corrective measure to prevent fraud.
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Bill Overview
Analyzed Economic Effects
1 provisions identified: 0 benefits, 0 costs, 1 mixed.
Medicare fraud scoring pilot for beneficiaries
If enacted, the bill would create a two-year Medicare pilot starting no later than January 1, 2026. If you have Medicare you could opt in and agree to get electronic Medicare Summary Notices to join. The pilot would test a predictive algorithm that scores durable medical equipment and lab test claims from 1 (low) to 99 (high). A human reviewer would assess high scores before any payment is suspended. If a claim is flagged, you would get an email or phone chance to fix or confirm it. Suspended transactions would trigger an automatic electronic Medicare Summary Notice alert and follow-up MSNs every two weeks for three months with fraud-reporting info. The Secretary could work with industry and the HHS Office of Inspector General and could reissue or terminate Medicare cards to prevent fraud in the pilot.
Sponsors & CoSponsors
Sponsor
Tim Sheehy
MT • R
Cosponsors
Maggie Hassan
NH • D
Sponsored 6/12/2025
Eric Schmitt
MO • R
Sponsored 6/12/2025
Bill Cassidy
LA • R
Sponsored 6/12/2025
Roll Call Votes
No roll call votes available for this bill.
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