42 USC § 1320a–7k - Medicare and Medicaid program integrity provisions
(a)
Data matching
(1)
Integrated data repository
(A)
Inclusion of certain data
(i)
In general
The Integrated Data Repository of the Centers for Medicare & Medicaid Services shall include, at a minimum, claims and payment data from the following:
(I)
The programs under subchapters XVIII and XIX (including parts A, B, C, and D of subchapter XVIII).
(ii)
Priority for inclusion of certain data
Inclusion of the data described in subclause (I) of such clause
[1]
in the Integrated Data Repository shall be a priority. Data described in subclauses (II) through (VI) of such clause
[1]
shall be included in the Integrated Data Repository as appropriate.
(B)
Data sharing and matching
(i)
In general
The Secretary shall enter into agreements with the individuals described in clause (ii) under which such individuals share and match data in the system of records of the respective agencies of such individuals with data in the system of records of the Department of Health and Human Services for the purpose of identifying potential fraud, waste, and abuse under the programs under subchapters XVIII and XIX.
(2)
Access to claims and payment databases
For purposes of conducting law enforcement and oversight activities and to the extent consistent with applicable information, privacy, security, and disclosure laws, including the regulations promulgated under the Health Insurance Portability and Accountability Act of 1996 and section
552a of title
5, and subject to any information systems security requirements under such laws or otherwise required by the Secretary, the Inspector General of the Department of Health and Human Services and the Attorney General shall have access to claims and payment data of the Department of Health and Human Services and its contractors related to subchapters XVIII, XIX, and XXI.
(b)
OIG authority to obtain information
(1)
In general
Notwithstanding and in addition to any other provision of law, the Inspector General of the Department of Health and Human Services may, for purposes of protecting the integrity of the programs under subchapters XVIII and XIX, obtain information from any individual (including a beneficiary provided all applicable privacy protections are followed) or entity that—
(A)
is a provider of medical or other items or services, supplier, grant recipient, contractor, or subcontractor; or
(B)
directly or indirectly provides, orders, manufactures, distributes, arranges for, prescribes, supplies, or receives medical or other items or services payable by any Federal health care program (as defined in section
1320a–7b
(f) of this title) regardless of how the item or service is paid for, or to whom such payment is made.
(2)
Inclusion of certain information
Information which the Inspector General may obtain under paragraph (1) includes any supporting documentation necessary to validate claims for payment or payments under subchapter XVIII or XIX, including a prescribing physician’s medical records for an individual who is prescribed an item or service which is covered under part B of subchapter XVIII, a covered part D drug (as defined in section
1395w–102
(e) of this title) for which payment is made under an MA–PD plan under part C of such subchapter, or a prescription drug plan under part D of such subchapter, and any records necessary for evaluation of the economy, efficiency, and effectiveness of the programs under subchapters XVIII and XIX.
(c)
Administrative remedy for knowing participation by beneficiary in health care fraud scheme
(1)
In general
In addition to any other applicable remedies, if an applicable individual has knowingly participated in a Federal health care fraud offense or a conspiracy to commit a Federal health care fraud offense, the Secretary shall impose an appropriate administrative penalty commensurate with the offense or conspiracy.
(2)
Applicable individual
For purposes of paragraph (1), the term “applicable individual” means an individual—
(A)
entitled to, or enrolled for, benefits under part A of subchapter XVIII or enrolled under part B of such subchapter;
(d)
Reporting and returning of overpayments
(1)
In general
If a person has received an overpayment, the person shall—
(2)
Deadline for reporting and returning overpayments
An overpayment must be reported and returned under paragraph (1) by the later of—
(4)
Definitions
In this subsection:
(B)
Overpayment
The term “overpayment” means any funds that a person receives or retains under subchapter XVIII or XIX to which the person, after applicable reconciliation, is not entitled under such subchapter.
(C)
Person
(i)
In general
The term “person” means a provider of services, supplier, medicaid managed care organization (as defined in section
1396b
(m)(1)(A) of this title), Medicare Advantage organization (as defined in section
1395w–28
(a)(1) of this title), or PDP sponsor (as defined in section
1395w–151
(a)(13) of this title).
(e)
Inclusion of national provider identifier on all applications and claims
The Secretary shall promulgate a regulation that requires, not later than January 1, 2011, all providers of medical or other items or services and suppliers under the programs under subchapters XVIII and XIX that qualify for a national provider identifier to include their national provider identifier on all applications to enroll in such programs and on all claims for payment submitted under such programs.
[1] So in original. Probably should be “clause (i)”.
(a)
Data matching
(1)
Integrated data repository
(A)
Inclusion of certain data
(i)
In general
The Integrated Data Repository of the Centers for Medicare & Medicaid Services shall include, at a minimum, claims and payment data from the following:
(I)
The programs under subchapters XVIII and XIX (including parts A, B, C, and D of subchapter XVIII).
(ii)
Priority for inclusion of certain data
Inclusion of the data described in subclause (I) of such clause
[1]
in the Integrated Data Repository shall be a priority. Data described in subclauses (II) through (VI) of such clause
[1]
shall be included in the Integrated Data Repository as appropriate.
(B)
Data sharing and matching
(i)
In general
The Secretary shall enter into agreements with the individuals described in clause (ii) under which such individuals share and match data in the system of records of the respective agencies of such individuals with data in the system of records of the Department of Health and Human Services for the purpose of identifying potential fraud, waste, and abuse under the programs under subchapters XVIII and XIX.
(2)
Access to claims and payment databases
For purposes of conducting law enforcement and oversight activities and to the extent consistent with applicable information, privacy, security, and disclosure laws, including the regulations promulgated under the Health Insurance Portability and Accountability Act of 1996 and section
552a of title
5, and subject to any information systems security requirements under such laws or otherwise required by the Secretary, the Inspector General of the Department of Health and Human Services and the Attorney General shall have access to claims and payment data of the Department of Health and Human Services and its contractors related to subchapters XVIII, XIX, and XXI.
(b)
OIG authority to obtain information
(1)
In general
Notwithstanding and in addition to any other provision of law, the Inspector General of the Department of Health and Human Services may, for purposes of protecting the integrity of the programs under subchapters XVIII and XIX, obtain information from any individual (including a beneficiary provided all applicable privacy protections are followed) or entity that—
(A)
is a provider of medical or other items or services, supplier, grant recipient, contractor, or subcontractor; or
(B)
directly or indirectly provides, orders, manufactures, distributes, arranges for, prescribes, supplies, or receives medical or other items or services payable by any Federal health care program (as defined in section
1320a–7b
(f) of this title) regardless of how the item or service is paid for, or to whom such payment is made.
(2)
Inclusion of certain information
Information which the Inspector General may obtain under paragraph (1) includes any supporting documentation necessary to validate claims for payment or payments under subchapter XVIII or XIX, including a prescribing physician’s medical records for an individual who is prescribed an item or service which is covered under part B of subchapter XVIII, a covered part D drug (as defined in section
1395w–102
(e) of this title) for which payment is made under an MA–PD plan under part C of such subchapter, or a prescription drug plan under part D of such subchapter, and any records necessary for evaluation of the economy, efficiency, and effectiveness of the programs under subchapters XVIII and XIX.
(c)
Administrative remedy for knowing participation by beneficiary in health care fraud scheme
(1)
In general
In addition to any other applicable remedies, if an applicable individual has knowingly participated in a Federal health care fraud offense or a conspiracy to commit a Federal health care fraud offense, the Secretary shall impose an appropriate administrative penalty commensurate with the offense or conspiracy.
(2)
Applicable individual
For purposes of paragraph (1), the term “applicable individual” means an individual—
(A)
entitled to, or enrolled for, benefits under part A of subchapter XVIII or enrolled under part B of such subchapter;
(d)
Reporting and returning of overpayments
(1)
In general
If a person has received an overpayment, the person shall—
(2)
Deadline for reporting and returning overpayments
An overpayment must be reported and returned under paragraph (1) by the later of—
(4)
Definitions
In this subsection:
(B)
Overpayment
The term “overpayment” means any funds that a person receives or retains under subchapter XVIII or XIX to which the person, after applicable reconciliation, is not entitled under such subchapter.
(C)
Person
(i)
In general
The term “person” means a provider of services, supplier, medicaid managed care organization (as defined in section
1396b
(m)(1)(A) of this title), Medicare Advantage organization (as defined in section
1395w–28
(a)(1) of this title), or PDP sponsor (as defined in section
1395w–151
(a)(13) of this title).
(e)
Inclusion of national provider identifier on all applications and claims
The Secretary shall promulgate a regulation that requires, not later than January 1, 2011, all providers of medical or other items or services and suppliers under the programs under subchapters XVIII and XIX that qualify for a national provider identifier to include their national provider identifier on all applications to enroll in such programs and on all claims for payment submitted under such programs.
[1] So in original. Probably should be “clause (i)”.
Source
(Aug. 14, 1935, ch. 531, title XI, § 1128J, as added Pub. L. 111–148, title VI, § 6402(a),Mar. 23, 2010, 124 Stat. 753.)
References in Text
The Health Insurance Portability and Accountability Act of 1996, referred to in subsec. (a)(2), is Pub. L. 104–191, Aug. 21, 1996, 110 Stat. 1936. For complete classification of this Act to the Code, see Short Title of 1996 Amendments note set out under section
201 of this title and Tables.
The table below lists the classification updates, since Jan. 3, 2012, for this section. Updates to a broader range of sections may be found at the update page for containing chapter, title, etc.
The most recent Classification Table update that we have noticed was Tuesday, May 21, 2013
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