Title 42, The Public Health and WelfareRelease 119-110
§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
Title 42 › CHAPTER 7 — SOCIAL SECURITY › SUBCHAPTER XI — GENERAL PROVISIONS, PEER REVIEW, AND ADMINISTRATIVE SIMPLIFICATION › Part A — General Provisions › § 1320a–7m
Summary
The Secretary of Health and Human Services must use predictive modeling and other data tools to find likely improper Medicare fee‑for‑service claims and stop payments until the claims are checked. The tools must look across providers, patients, billing, and places in the program. They must fit into the current claims system, scan large data sets for odd patterns before paying, rank suspicious claims for review, learn from claim outcomes, and block payments found likely to be wasteful, fraudulent, or abusive until verified. The Secretary must run competitive bids and hire at least two contractors each year who have clinical and analytics experience (or who hire those experts). An RFP was required by January 1, 2011, with contractors beginning July 1, 2011 in the 10 States judged highest risk; expand Oct 1, 2012 to 10 more States; expand Jan 1, 2014 to all remaining States and U.S. territories; and begin applying the tools to Medicaid and CHIP on April 1, 2015 (phased expansion allowed). If the Inspector General finds little or no savings, the Secretary may pause expansion up to 12 months. The Secretary must report to Congress and the public within 3 months after each implementation year with results, savings estimates certified by the Inspector General, impact reviews, and recommendations. After the first year that Medicaid and CHIP use the tools, an independent evaluation must be done and Congress must get a report within 18 months of starting that review. The Secretary may waive certain Social Security Act rules as needed. Congress provided $100,000,000 starting January 1, 2011 (available until spent), with up to 5% held for the independent evaluation and some funds reserved to help States if Medicaid/CHIP are added. Key terms (one line each): commonwealths and territories — U.S. territories such as Puerto Rico and Guam; CHIP — Children’s Health Insurance Program; Medicaid — State medical assistance programs; Medicare beneficiary — someone in Medicare fee‑for‑service; Medicare fee‑for‑service — original Medicare Parts A and B; Medicare provider — service providers and suppliers; Secretary — HHS Secretary acting through CMS; State — the 50 States and the District of Columbia.
Full Legal Text
Title 42, §1320a–7m
The Public Health and Welfare, Source: USLM XML via OLRC
(a)Use in the Medicare fee-for-service program
The Secretary shall use predictive modeling and other analytics technologies (in this section referred to as “predictive analytics technologies”) to identify improper claims for reimbursement and to prevent the payment of such claims under 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
The initial request for proposals issued under paragraph (1) shall require the contractors selected to commence using predictive analytics technologies on July 1, 2011, in the 10 States identified by the Secretary as having the highest risk of waste, fraud, or abuse in the Medicare fee-for-service program.
(3)Second implementation year
Based on the results of the report and recommendation required under subsection (e)(1)(B), the Secretary shall expand the use of predictive analytics technologies on October 1, 2012, to apply to an additional 10 States identified by the Secretary as having the highest risk of waste, fraud, or abuse in the Medicare fee-for-service program, after the States identified under paragraph (2).
(4)Third implementation year
Based on the results of the report and recommendation required under subsection (e)(2), the Secretary shall expand the use of predictive analytics technologies on January 1, 2014, to apply to the Medicare fee-for-service program in any State not identified under paragraph (2) or (3) and the commonwealths and territories.
(5)Fourth implementation year
Based on the results of the report and recommendation required under subsection (e)(3), the Secretary shall expand the use of predictive analytics technologies, beginning April 1, 2015, to apply to Medicaid and CHIP. To the extent the Secretary determines appropriate, such expansion may be made on a phased-in basis.
(6)Option for refinement and evaluation
If, with respect to the first, second, or third implementation year, the Inspector General of the Department of Health and Human Services certifies as part of the report required under subsection (e) for that year no or only nominal actual savings to the Medicare fee-for-service program, the Secretary may impose a moratorium, not to exceed 12 months, on the expansion of the use of predictive analytics technologies under this section for the succeeding year in order to refine the use of predictive analytics technologies to achieve more than nominal savings before further expansion. If a moratorium is imposed in accordance with this paragraph, the implementation dates applicable for the succeeding year or years shall be adjusted to reflect the length of the moratorium period.
(d)Contractor selection, qualifications, and data access requirements
(1)Selection
(A)In general
The Secretary shall select contractors to carry out this section using competitive procedures as provided for in the Federal Acquisition Regulation.
(B)Number of contractors
The Secretary shall select at least 2 contractors to carry out this section with respect to any year.
(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
The Secretary may only enter into a contract under this section with an entity to the extent that the entity complies with such conflict of interest standards as are generally applicable to Federal acquisition and procurement.
(3)Data access
The Secretary shall provide entities with a contract under this section with appropriate access to data necessary for the entity to use predictive analytics technologies in accordance with the contract.
(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
Not later than 3 months after the completion of the second 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, with respect to such year, the items required under paragraph (1) as well as any other additional items determined appropriate by the Secretary with respect to the report for such year.
(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 with respect to such year, the items required under paragraph (1), 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
Upon completion of the first year in which predictive analytics technologies are used with respect to claims under Medicaid and CHIP, the Secretary shall, by grant, contract, or interagency agreement, conduct an independent evaluation of the use of predictive analytics technologies under the Medicare fee-for-service program and Medicaid and CHIP. The evaluation shall include an analysis with respect to each such program of the items required for the third year implementation report under subsection (e)(3).
(2)Report
Not later than 18 months after the evaluation required under paragraph (1) is initiated, the Secretary shall submit a report to Congress on the evaluation that shall include the results of the evaluation, the Secretary’s response to such results and, to the extent the Secretary determines appropriate, recommendations for legislation or administrative actions.
(g)Waiver authority
The Secretary may waive such provisions of titles XI, XVIII, XIX, and XXI of the Social Security Act [42 U.S.C. 1301 et seq., 1395 et seq., 1396 et seq., 1397aa et seq.], including applicable prompt payment requirements under titles XVIII and XIX of such Act, as the Secretary determines to be appropriate to carry out this section.
(h)Funding
(1)Appropriation
Out of any funds in the Treasury not otherwise appropriated, there is appropriated to the Secretary to carry out this section, $100,000,000 for the period beginning January 1, 2011, to remain available until expended.
(2)Reservations
(A)Independent evaluation
The Secretary shall reserve not more than 5 percent of the funds appropriated under paragraph (1) for purposes of conducting the independent evaluation required under subsection (f).
(B)Application to Medicaid and CHIP
The Secretary shall reserve such portion of the funds appropriated under paragraph (1) as the Secretary determines appropriate for purposes of providing assistance to States for administrative expenses in the event of the expansion of predictive analytics technologies to claims under Medicaid and CHIP.
(i)Definitions
In this section: (1) Commonwealths and territories
(2)CHIP
The term “CHIP” means the Children’s Health Insurance Program established under title XXI of the Social Security Act (42 U.S.C. 1397aa et seq.).
(3)Medicaid
The term “Medicaid” means the program to provide grants to States for medical assistance programs established under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.).
(4)Medicare beneficiary
The term “Medicare beneficiary” means an individual enrolled in the Medicare fee-for-service program.
(5)Medicare fee-for-service program
The term “Medicare fee-for-service program” means the original medicare fee-for-service program under parts A and B of title XVIII of the Social Security Act (42 U.S.C. 1395[c] et seq.[; 1395j et seq.]).
(6)Medicare provider
The term “Medicare provider” means a provider of services (as defined in subsection (u) of section 1861 of the Social Security Act (42 U.S.C. 1395x)) and a supplier (as defined in subsection (d) of such section).
(7)Secretary
The term “Secretary” means the Secretary of Health and Human Services, acting through the Administrator of the Centers for Medicare & Medicaid Services.
(8)State
The term “State” means each of the 50 States and the District of Columbia.
Legislative History
Notes & Related Subsidiaries
Editorial Notes
References in Text
The Social Security Act, referred to in subsecs. (g) and (i)(2), (3), (5), is act Aug. 14, 1935, ch. 531, 49 Stat. 620. Titles XI, XVIII, XIX, and XXI of the Act are classified generally to subchapters XI (§ 1301 et seq.), XVIII (§ 1395 et seq.), XIX (§ 1396 et seq.), and XXI (§ 1397aa et seq.), respectively, of this chapter. Parts A and B of title XVIII of the Act are classified generally to Parts A (§ 1395c et seq.) and B (§ 1395j et seq.) of subchapter XVIII of this chapter. For complete classification of this Act to the Code, see section 1305 of this title and Tables. Codification Section was enacted as part of the Small Business Jobs Act of 2010, and not as part of the Social Security Act which comprises this chapter.
Reference
Citations & Metadata
Citation
42 U.S.C. § 1320a–7m
Title 42, The Public Health and Welfare
Last Updated
Sep 23, 2026
Release point: 119-110