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[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 6863 Introduced in House (IH)]
<DOC>
119th CONGRESS
1st Session
H. R. 6863
To amend title XVIII of the Social Security Act to improve transparency
with respect to the suspension of Medicare payments pending an
investigation into a credible allegation of fraud.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
December 18, 2025
Mr. Harder of California (for himself and Mrs. Kim) 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 XVIII of the Social Security Act to improve transparency
with respect to the suspension of Medicare payments pending an
investigation into a credible allegation of fraud.
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 ``Centers for Medicare & Medicaid
Services Auditor Transparency Act of 2025'' or the ``CAT Act of 2025''.
SEC. 2. FINDINGS.
Congress finds the following:
(1) In 2020, 139,000,000 individuals received health care
coverage through the Medicare or Medicaid programs, costing the
Federal Government approximately $1,500,000,000,000. Of these
funds paid by United States taxpayers, $3,100,000,000 were
discovered to have been fraudulent claims.
(2) Ensuring the integrity of the Medicare and Medicaid
programs is crucial to preventing fraud, waste, and abuse and
safeguarding the financial sustainability of these important
programs.
(3) Even though the Centers for Medicare & Medicaid
Services (CMS) utilization of Unified Program Integrity
Contractors (UPICs) has shown to be effective at identifying
bad actors defrauding the Federal Government through the
Medicare and Medicaid programs, current Federal law and
regulations have shown to be harmful to most providers who are
submitting Medicare and Medicaid claims in good faith.
(4) Existing law provides CMS and UPICs broad authority and
discretion to suspend Medicare payments for up to a year
pending the investigation of ``credible allegations of fraud''.
(5) However, current law does not require adequate
transparency from CMS or UPICs into the nature of the alleged
fraud before Medicare payments are suspended. Current law also
does not require CMS or UPICs to provide adequate due process
to providers whose payments have been suspended to challenge or
cure the allegations of fraud prior to the suspension of
Medicare payments.
(6) In addition, anecdotal reports have shown that some
UPICs extend the suspension of Medicare payments on a routine
basis so that they may have additional time to finish their
audit despite not providing evidence that the continuation of a
payment suspension is necessary to protect the integrity of the
Medicare program.
(7) The broad authority to suspend Medicare payments
pending the investigation of a credible allegation of fraud
without adequate due process or transparency places the
financial viability of many Medicare providers acting in good
faith at risk.
(8) If Medicare providers acting in good faith close their
doors as a result of the unnecessary suspension of payments by
CMS or UPICs, Medicare beneficiaries and the American public
could face additional barriers to access to necessary health
care services as a direct result of unfair Federal law and
regulations.
SEC. 3. IMPROVING TRANSPARENCY IN SUSPENSION OF PAYMENTS PENDING
INVESTIGATION OF CREDIBLE ALLEGATIONS OF FRAUD UNDER
MEDICARE.
(a) In General.--Section 1862(o) of the Social Security Act (42
U.S.C. 1395y(o)) is amended--
(1) in paragraph (1)--
(A) by striking ``The Secretary may suspend'' and
inserting ``Subject to paragraph (5), the Secretary may
suspend''; and
(B) by inserting ``An investigation of a credible
allegation of fraud, and the suspension of payment
pending such investigation under the preceding
sentence, may only exceed 180 days if the Secretary
determines there is good cause to extend such
investigation and suspension.'' at the end;
(2) in paragraph (4)--
(A) by striking ``a fraud hotline tip (as defined
by the Secretary)'' and inserting ``the following
items''; and
(B) by striking ``credible allegation of fraud.''
and inserting ``credible allegation of fraud:
``(A) A fraud hotline tip (as defined by the
Secretary).
``(B) Mere error (as defined by the Secretary).
``(C) A billing error found during the course of an
audit that is attributable to human error.''.
(3) by adding at the end the following new paragraphs:
``(5) Transparency in suspension of payments.--
``(A) In general.--The Secretary may only suspend
payments to a provider of services or supplier under
this title pursuant to paragraph (1) if--
``(i) subject to subparagraph (B), not
later than 30 days before the date on which the
payment suspension begins, the Secretary
provides such provider of services or supplier
with information about each credible allegation
of fraud that is the basis for the payment
suspension, including--
``(I) the specific nature of each
credible allegation of fraud;
``(II) the date of the alleged
fraud; and
``(III) the basis of the credible
allegation of fraud, such as whether
the allegation is based upon--
``(aa) a fraud hotline
complaint;
``(bb) data mining of data
with respect to claims for
payment under this title, title
XIX, or title XXI; or
``(cc) a pattern identified
through audits of providers of
services or suppliers; and
``(ii) not less frequently than once every
30 days during such payment suspension, the
Secretary provides such provider of services or
supplier with--
``(I) a detailed, up-to-date list
of the findings of the investigation;
``(II) an anticipated timeline for
the completion of the investigation;
and
``(III) an opportunity to ask the
Centers for Medicare & Medicaid
Services questions regarding the
payment suspension and the
investigation.
``(B) Exception.--The Secretary may elect not to
provide a provider of services or supplier with the
information described in subparagraph (A)(i) if the
provision of such information would compromise the
integrity of the investigation, as determined by the
Secretary in consultation with the Inspector General of
the Department of Health and Human Services and State
auditors (as appropriate).
``(C) Failure to provide information.--If the
requirements described in subparagraph (A) are not met
with respect to the suspension of payment to a provider
of services or a supplier under this title, the
Secretary shall immediately resume such payment, and
shall pay to the provider of services or supplier the
amounts not paid due to such suspension and any
interest accrued with respect to such amounts.
``(D) Annual report.--Not later than 180 days after
the end of each fiscal year (beginning with fiscal year
2025), the Secretary shall submit to Congress a report
that includes the following information with respect to
such fiscal year:
``(i) The number of payment suspensions
issued as the result of a pending investigation
of a credible allegation of fraud under this
subsection, section 1860D-12(b)(7) (including
as applied pursuant to section 1857(f)(3)(D)),
or section 1903(i)(2)(C).
``(ii) The basis of each such credible
allegation of fraud.
``(iii) The average duration of a payment
suspension described in clause (i).
``(iv) The average duration of an
investigation of a credible allegation of fraud
described in clause (i).
``(v) If applicable, the average time
between the completion of an investigation into
a credible allegation of fraud described in
clause (i) and the reinstatement of payments to
the relevant provider of services or supplier.
``(6) Appeals.--Not later than 180 days after the date of
the enactment of the CAT Act of 2025, the Secretary shall
provide an independent process by which a provider of services
or supplier under this title that has received notice of a
payment suspension due to a pending investigation of a credible
allegation of fraud pursuant to this subsection may appeal such
suspension and receive a resolution of such appeal in a timely
manner.''.
(b) Stakeholder Consultation.--In developing the appeals process
required under section 1862(o)(6) of the Social Security Act, as added
by subsection (a), the Secretary of Health and Human Services shall
consult with relevant stakeholders, including providers of services and
suppliers under title XVIII of the Social Security Act (42 U.S.C. 1395
et seq.), title XIX of such Act (42 U.S.C. 1396 et seq.), and title XXI
of such Act (42 U.S.C. 1397aa et seq.), as determined appropriate by
the Secretary.
(c) Applicability.--The amendments made by this section shall apply
with respect to any investigation of a credible allegation of fraud
under section 1862(o) of the Social Security Act (42 U.S.C. 1395y(o)),
section 1860D-12(b)(7) of such Act (42 U.S.C. 1395w-112(b)(7))
(including as applied pursuant to section 1857(f)(3)(D) of such Act (42
U.S.C. 1395w-27(f)(3)(D))), or section 1903(i)(2)(C) of such Act (42
U.S.C. 1396b(i)(2)(C)) that is initiated after the date of enactment of
this Act.
<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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