§1320a–7k Medicare and Medicaid program integrity provisions

Summary

Requires a big federal health data system to hold claims and payment records from Medicare (parts A, B, C, and D), Medicaid, the Children’s Health Insurance Program, the Veterans Affairs and Department of Defense health programs, Social Security old‑age, survivors, and disability insurance, and the Indian Health Service (including Contract Health Service). Getting Medicare data is the top priority. The Health and Human Services Secretary must make data‑sharing agreements with the Social Security Commissioner, the VA Secretary, the Defense Secretary, and the Indian Health Service Director so records can be matched to find possible fraud, waste, and abuse. The HHS Inspector General and the U.S. Attorney General may access these claims and payment records for law enforcement and oversight, as long as privacy, security, and disclosure laws (like HIPAA and the Privacy Act) and system security rules are followed. The HHS Inspector General can also require information and supporting documents from providers, suppliers, contractors, beneficiaries, or anyone who provides, orders, makes, distributes, prescribes, supplies, or gets items or services that federal health programs pay for. That includes medical records needed to check prescriptions covered under Medicare Part B or Part D (including drugs paid through Medicare Advantage with drug coverage or standalone prescription drug plans) and other records for program reviews. If a covered person knowingly takes part in federal health care fraud, HHS must impose an appropriate administrative penalty. People or organizations that get an overpayment must report and return it within 60 days or by the cost‑report deadline, or it becomes a legal obligation under the False Claims Act. Definitions (brief): “system of records” = agency files about individuals; “overpayment” = funds kept that were not owed after reconciliation; “person” = providers, suppliers, Medicaid managed care organizations, Medicare Advantage organizations, or PDP sponsors (not beneficiaries); “knowing/knowingly” = as defined in 31 U.S.C. 3729(b); “applicable individual” = people enrolled in Medicare Part A or B, eligible for Medicaid, or eligible for CHIP.