§1320a–7k Medicare and Medicaid Program Integrity Provisions

Summary

The law requires the Centers for Medicare & Medicaid Services to keep a central set of claims and payment records that at least includes Medicare (parts A, B, C, and D), Medicaid, and also data from the Children’s Health Insurance Program, the Department of Veterans Affairs, the Department of Defense, Social Security old‑age/survivors/disability benefits, and the Indian Health Service. Medicare data (parts A–D) get top priority; the others must be added as appropriate. The Secretary must make agreements with the Social Security Commissioner, the VA, the DoD, and the Indian Health Service to share and match records to spot possible fraud. The Inspector General and the Attorney General may see claims and payment records for law enforcement and oversight, as long as privacy, HIPAA, section 552a of title 5, and security rules are followed. The Inspector General may also get information and supporting documents from any provider, supplier, contractor, or anyone who directly or indirectly provides items or services paid by federal health programs, and may get records from beneficiaries if privacy protections are met. That includes things like a prescribing doctor’s records for Medicare Part B or for Part D drugs paid under MA‑PD or PDP plans, and other records needed to check program efficiency. If a beneficiary knowingly takes part in federal health care fraud or a conspiracy to commit it, the Secretary must impose a matching administrative penalty. Anyone who receives an overpayment must report and return it within 60 days of finding it or by the related cost report due date, whichever is later, and must notify in writing why the overpayment happened; failure to return it on time creates an obligation under section 3729 of title 31. Definitions used: “knowing/knowingly” means the meaning in 31 U.S.C. 3729(b); “overpayment” means funds received under Medicare or Medicaid that after reconciliation a person is not entitled to; “person” means providers, suppliers, Medicaid managed care organizations, Medicare Advantage organizations, or PDP sponsors and does not include beneficiaries. Finally, by January 1, 2011 the Secretary must require providers who qualify for a National Provider Identifier to put that number on enrollment forms and on all claims.