SEC. 306. DEMONSTRATION PROJECT FOR USE OF RECOVERY AUDIT
CONTRACTORS.
(a) IN GENERAL- The Secretary shall conduct
a demonstration project under this section (in this section referred to as the
`project') to demonstrate the use of recovery audit contractors under the Medicare
Integrity Program in identifying underpayments and overpayments and recouping
overpayments under the medicare program for services for which payment is made
under part A or B of title XVIII of the Social Security Act. Under the project--
(1) payment may be made to such a contractor
on a contingent basis;
(2) such percentage as the Secretary
may specify of the amount recovered shall be retained by the Secretary and
shall be available to the program management account of the Centers for Medicare
& Medicaid Services; and
(3) the Secretary shall examine the
efficacy of such use with respect to duplicative payments, accuracy of coding,
and other payment policies in which inaccurate payments arise.
(b) SCOPE AND DURATION-
(1) SCOPE- The project shall cover
at least 2 States that are among the States with--
(A) the highest per capita
utilization rates of medicare services, and
(B) at least 3 contractors.
(2) DURATION- The project shall last
for not longer than 3 years.
(c) WAIVER- The Secretary shall waive such
provisions of title XVIII of the Social Security Act as may be necessary to
provide for payment for services under the project in accordance with subsection
(a).
(d) QUALIFICATIONS OF CONTRACTORS-
(1) IN GENERAL- The Secretary shall
enter into a recovery audit contract under this section with an entity only
if the entity has staff that has the appropriate clinical knowledge of and
experience with the payment rules and regulations under the medicare program
or the entity has or will contract with another entity that has such knowledgeable
and experienced staff.
(2) INELIGIBILITY OF CERTAIN CONTRACTORS-
The Secretary may not enter into a recovery audit contract under this section
with an entity to the extent that the entity is a fiscal intermediary under
section 1816 of the Social Security Act (42 U.S.C. 1395h), a carrier under
section 1842 of such Act (42 U.S.C. 1395u), or a Medicare Administrative Contractor
under section 1874A of such Act.
(3) PREFERENCE FOR ENTITIES WITH DEMONSTRATED
PROFICIENCY- In awarding contracts to recovery audit contractors under this
section, the Secretary shall give preference to those risk entities that the
Secretary determines have demonstrated more than 3 years direct management
experience and a proficiency for cost control or recovery audits with private
insurers, health care providers, health plans, or under the medicaid program
under title XIX of the Social Security Act.
(e) CONSTRUCTION RELATING TO CONDUCT OF INVESTIGATION
OF FRAUD- A recovery of an overpayment to a provider by a recovery audit contractor
shall not be construed to prohibit the Secretary or the Attorney General from
investigating and prosecuting, if appropriate, allegations of fraud or abuse
arising from such overpayment.
(f) REPORT- The Secretary shall submit to Congress
a report on the project not later than 6 months after the date of its completion.
Such reports shall include information on the impact of the project on savings
to the medicare program and recommendations on the cost-effectiveness of extending
or expanding the project.information' means information about a conviction for
a relevant crime or a finding of patient or resident abuse.
