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[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3996 Introduced in House (IH)]
<DOC>
119th CONGRESS
1st Session
H. R. 3996
To amend title XI of the Social Security Act to establish a pilot
program for testing the use of a predictive risk-scoring algorithm to
provide oversight of payments for durable medical equipment and
clinical diagnostic laboratory tests under the Medicare program.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
June 12, 2025
Mr. Schweikert introduced the following bill; which was referred to the
Committee on Energy and Commerce, and in addition to the Committee on
Ways and Means, for a period to be subsequently determined by the
Speaker, in each case for consideration of such provisions as fall
within the jurisdiction of the committee concerned
_______________________________________________________________________
A BILL
To amend title XI of the Social Security Act to establish a pilot
program for testing the use of a predictive risk-scoring algorithm to
provide oversight of payments for durable medical equipment and
clinical diagnostic laboratory tests under the Medicare program.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Medicare Transaction Fraud
Prevention Act''.
SEC. 2. PILOT PROGRAM TESTING USE OF PREDICTIVE RISK-SCORING ALGORITHM
TO PROVIDE OVERSIGHT OF PAYMENTS FOR DURABLE MEDICAL
EQUIPMENT AND CLINICAL DIAGNOSTIC LABORATORY TESTS UNDER
THE MEDICARE PROGRAM.
Section 1128K of the Social Security Act (42 U.S.C. 1320a-7n) is
amended--
(1) in the section heading by inserting ``; pilot program
testing use of predictive risk-scoring algorithm to provide
oversight of payments for durable medical equipment and
clinical diagnostic laboratory tests under the medicare
program'' after ``abuse''; and
(2) by adding at the end the following new subsection:
``(d) Pilot Program Testing Use of Predictive Risk-Scoring
Algorithm To Provide Oversight of Payments for Durable Medical
Equipment and Clinical Diagnostic Laboratory Tests Under the Medicare
Program.--
``(1) In general.--The Secretary shall establish a pilot
program to test the use of predictive risk-scoring algorithms
to provide oversight of relevant transactions (as defined in
paragraph (8)(B)).
``(2) Duration.--The pilot program shall be conducted for a
period of 2 years, beginning not later than January 1, 2026.
``(3) Scope.--
``(A) In general.--The Secretary shall limit the
implementation of the pilot program to relevant
transactions involving applicable items or services
furnished to applicable beneficiaries (as defined in
subparagraph (B)).
``(B) Applicable beneficiary defined.--In this
subsection, the term `applicable beneficiary' means an
individual who has opted in to--
``(i) receive electronic Medicare Summary
Notices; and
``(ii) participate in the pilot program in
accordance with subparagraph (C).
``(C) Voluntary participation.--An applicable
beneficiary may participate in the pilot program on a
voluntary basis and may terminate participation at any
time.
``(4) Considerations.--The Secretary may, for purposes of
identifying and calculating the risks of relevant transactions
under the pilot program, consider the following factors:
``(A) The absence of a prior relationship between
the beneficiary and a provider of services (as defined
in section 1861(u)) or supplier (as defined in section
1861(d)).
``(B) Aberrant billing patterns for a provider of
services or supplier with regards to volume of claims
in one particular area.
``(C) Electronic fund transfer (EFT) changes.
``(D) Changes in ownership of a provider of
services or supplier.
``(5) Collaboration.--The Secretary shall work with
industry representatives (including suppliers of durable
medical equipment) on the development and implementation of the
pilot program.
``(6) Requirements.--Under the pilot program, the Secretary
shall--
``(A) adopt a predictive risk-scoring algorithm
that would learn from beneficiary data to score
relevant transactions from 1 (least risky) to 99 (most
risky);
``(B) prior to implementation of any predictive
risk-scoring algorithm adopted under subparagraph (A)
under the pilot program--
``(i) require sufficient testing,
evaluation, and review of such algorithm,
taking into consideration Executive Order 14179
(90 Fed. Reg. 8741; relating to removing
barriers to American leadership in artificial
intelligence);
``(ii) establish methods for notifying
applicable beneficiaries and providers of
services and suppliers impacted by the use of
the algorithm regarding such usage (including
information regarding how beneficiary data is
collected and processed under the pilot program
to produce a risk score for relevant
transactions and the possible implications
associated with the use of the algorithm); and
``(iii) establish methods of communication
with the Office of the Inspector General of the
Department of Health and Human Service, and the
ability to waive or forgo notice to an
applicable beneficiary or a provider of
services or supplier if appropriate;
``(C) for any relevant transaction involving an
item or service furnished to an applicable beneficiary
identified by a predictive risk-scoring algorithm
adopted under subparagraph (A) and implemented under
subparagraph (B) as having a risk score that exceeds a
level of risk specified by the Secretary--
``(i) review the relevant transaction to
determine whether it should be suspended
pending the applicable beneficiary's response
under clause (ii);
``(ii) provide the applicable beneficiary
the opportunity, by email or phone call
response--
``(I) to cure a high-risk score or
suspended transaction that the
beneficiary believes is based on
inaccurate underlying data; and
``(II) confirm the relevant
transaction; and
``(iii) if, based on the results of the
review, the relevant transaction is suspended--
``(I) trigger an automatic alert to
the applicable beneficiary by
electronically sending a Medicare
Summary Notice that includes the
relevant transaction;
``(II) require that all subsequent
Medicare Summary Notices involving the
relevant transaction be sent
electronically and in two week
intervals for 3 months after the first
alert is sent under subclause (I); and
``(III) include on such Medicare
Summary Notices, as determined
appropriate by the Secretary,
information explaining how the
beneficiary may report suspected fraud
to relevant law enforcement agencies;
and
``(D) have the authority to determine when a
Medicare card must be terminated or a new card issued
to prevent fraud and abuse.
``(7) Clarification.--Any suspension of an account or
transaction under the pilot program shall be based on a human
review process, informed through the implementation of the
predictive risk-scoring algorithm.
``(8) Definitions.--In this subsection:
``(A) Applicable item or service.--The term
`applicable item or service' means--
``(i) an item of durable medical equipment
(as defined in section 1861(n)); and
``(ii) a clinical diagnostic laboratory
test.
``(B) Relevant transaction.--The term `relevant
transaction' means a claim for payment for an
applicable item or service furnished to an applicable
beneficiary, as determined by the Secretary.''.
<all>
Introduced in House
Introduced in House
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
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