HR1784-119

1. Short title This Act may be cited as the Medicare Fraud Detection and Deterrence Act of 2025.

2. Strengthening health care waste, fraud, and abuse provisions Section 1173(b) of the Social Security Act (42 U.S.C. 1320d–2(b)) is amended by adding at the end the following new paragraph: Not later than 180 days after the date of the enactment of this paragraph, the Secretary shall revise the standards adopted under paragraph (1) to provide for— the deactivation of a standard unique health identifier of entity type 1 (as defined for purposes of such standards) assigned to an entity if such entity is excluded from participation in any Federal health care program under section 1128 or 1128A; the deactivation of a standard unique health identifier of entity type 2 (as defined for purposes of such standards) assigned to an entity if such entity is so excluded, but only if— the Inspector General of the Department of Health and Human Services submits to the Secretary a request for such deactivation; and the Secretary determines such deactivation to be appropriate; and the reactivation of a standard unique health identifier deactivated pursuant to clause (i) or (ii) at the end of such deactivation (as described in subparagraph (B)). A deactivation described in subparagraph (A) made with respect to an entity excluded from participation in any Federal health care program under section 1128 or 1128A shall begin on the date of such exclusion and shall end on the date such exclusion is terminated. Notwithstanding subparagraph (A), no deactivation of a standard unique health identifier assigned to an entity excluded from participation in any Federal health care program under section 1128 or 1128A shall be made pursuant to such subparagraph if the Secretary has waived such exclusion with respect to any Federal health care program pursuant to section 1128(c)(3)(B). Not later than 1 year after the date of the enactment of this paragraph and not less frequently than annually thereafter, the Secretary shall compare the list of individuals and entities excluded from participation in any Federal health care program under section 1128 or 1128A maintained by the Inspector General of the Department of Health and Human Services (or a successor list) with a list of active standard unique health identifiers described in subparagraph (A) to ensure compliance with such subparagraph. Section 1859 of the Social Security Act (42 U.S.C. 1395w–28) is amended by adding at the end the following new subsection: In the case of any encounter data submitted by a Medicare Advantage plan with respect to a designated item or service furnished to an individual under such plan on or after the date of the enactment of this subsection, the Secretary shall require that such data include the standard unique health identifier established pursuant to standards described in section 1173(b) of the provider of services or supplier that ordered such item or service or referred such individual for such item or service. The Secretary shall reject any encounter data submitted by a Medicare Advantage plan if— such data does not comply with the requirement described in paragraph (1); or the Secretary determines that a standard unique health identifier included in such data in accordance with such requirement is not active or is otherwise invalid. For purposes of this subsection, the term designated item or service means any of the following: An item of durable medical equipment. A prosthetic or orthotic device. A clinical diagnostic laboratory test. A diagnostic imaging test (as specified by the Secretary). A home health service (as specified by the Secretary). Section 1834(m) of the Social Security Act (42 U.S.C. 1395m(m)) is amended by adding at the end the following new paragraph: In the case of a telehealth service furnished on or after the date that is 180 days after the date of the enactment of this paragraph by a specified entity, no payment may be made under this section for such service unless the claim for such service includes the modifier established pursuant to subparagraph (B). Not later than 180 days after the date of the enactment of this paragraph, the Secretary shall establish a claims modifier for purposes of identifying telehealth services payable under this section furnished by a specified entity (as defined in subparagraph (C)). In this section: The term specified entity means a physician or practitioner (as such terms are defined in paragraph (4)) that has an employment or other contractual relationship in effect with a telehealth company relating to the furnishing telehealth services. The term telehealth company means an entity— that employs or otherwise contracts with physicians or practitioners to furnish telehealth services; and that does not employ or otherwise contract with any physician or practitioner to furnish items and services in-person (or that employs or otherwise contracts with physicians or practitioners to furnish such in-person items and services in a de minimis manner compared to the amount of telehealth services furnished by such physicians or practitioners, as specified by the Secretary). (3)Mandatory deactivation of certain identifiers (A)In generalNot later than 180 days after the date of the enactment of this paragraph, the Secretary shall revise the standards adopted under paragraph (1) to provide for— (i)the deactivation of a standard unique health identifier of entity type 1 (as defined for purposes of such standards) assigned to an entity if such entity is excluded from participation in any Federal health care program under section 1128 or 1128A; (ii)the deactivation of a standard unique health identifier of entity type 2 (as defined for purposes of such standards) assigned to an entity if such entity is so excluded, but only if— (I)the Inspector General of the Department of Health and Human Services submits to the Secretary a request for such deactivation; and (II)the Secretary determines such deactivation to be appropriate; and (iii)the reactivation of a standard unique health identifier deactivated pursuant to clause (i) or (ii) at the end of such deactivation (as described in subparagraph (B)). (B)Term of deactivationA deactivation described in subparagraph (A) made with respect to an entity excluded from participation in any Federal health care program under section 1128 or 1128A shall begin on the date of such exclusion and shall end on the date such exclusion is terminated. (C)Nonapplication of deactivationNotwithstanding subparagraph (A), no deactivation of a standard unique health identifier assigned to an entity excluded from participation in any Federal health care program under section 1128 or 1128A shall be made pursuant to such subparagraph if the Secretary has waived such exclusion with respect to any Federal health care program pursuant to section 1128(c)(3)(B). (D)Annual review of exclusion listNot later than 1 year after the date of the enactment of this paragraph and not less frequently than annually thereafter, the Secretary shall compare the list of individuals and entities excluded from participation in any Federal health care program under section 1128 or 1128A maintained by the Inspector General of the Department of Health and Human Services (or a successor list) with a list of active standard unique health identifiers described in subparagraph (A) to ensure compliance with such subparagraph. . (j)Provision of national provider identifier for certain items and services (1)In generalIn the case of any encounter data submitted by a Medicare Advantage plan with respect to a designated item or service furnished to an individual under such plan on or after the date of the enactment of this subsection, the Secretary shall require that such data include the standard unique health identifier established pursuant to standards described in section 1173(b) of the provider of services or supplier that ordered such item or service or referred such individual for such item or service. (2)Rejection of dataThe Secretary shall reject any encounter data submitted by a Medicare Advantage plan if— (A)such data does not comply with the requirement described in paragraph (1); or (B)the Secretary determines that a standard unique health identifier included in such data in accordance with such requirement is not active or is otherwise invalid. (3)Definition of designated item or serviceFor purposes of this subsection, the term designated item or service means any of the following: (A)An item of durable medical equipment. (B)A prosthetic or orthotic device. (C)A clinical diagnostic laboratory test. (D)A diagnostic imaging test (as specified by the Secretary). (E)A home health service (as specified by the Secretary).. (10)Identification of relationships between telehealth suppliers and telehealth companies (A)In generalIn the case of a telehealth service furnished on or after the date that is 180 days after the date of the enactment of this paragraph by a specified entity, no payment may be made under this section for such service unless the claim for such service includes the modifier established pursuant to subparagraph (B). (B)Establishment of modifierNot later than 180 days after the date of the enactment of this paragraph, the Secretary shall establish a claims modifier for purposes of identifying telehealth services payable under this section furnished by a specified entity (as defined in subparagraph (C)). (C)DefinitionsIn this section: (i)Specified entityThe term specified entity means a physician or practitioner (as such terms are defined in paragraph (4)) that has an employment or other contractual relationship in effect with a telehealth company relating to the furnishing telehealth services. (ii)Telehealth companyThe term telehealth company means an entity— (I)that employs or otherwise contracts with physicians or practitioners to furnish telehealth services; and (II)that does not employ or otherwise contract with any physician or practitioner to furnish items and services in-person (or that employs or otherwise contracts with physicians or practitioners to furnish such in-person items and services in a de minimis manner compared to the amount of telehealth services furnished by such physicians or practitioners, as specified by the Secretary). .