HR1785-119

1. Short title This Act may be cited as the Preventing Medicare Telefraud Act.

2. Requirement for provision of high-cost durable medical equipment and laboratory tests Section 1834(a)(1)(E) of the Social Security Act (42 U.S.C. 1395m(a)(1)(E)) is amended by adding at the end the following new clause: Payment may not be made under this subsection for a high-cost durable medical equipment ordered by a physician or other practitioner described in clause (ii) via telehealth for an individual on or after the date that is 180 days after the date of the enactment of this clause, unless such physician or practitioner furnished to such individual a service in-person at least once during the 6 month period prior to ordering such high-cost durable medical equipment. For purposes of this clause, the Administrator of the Centers for Medicare & Medicaid Services shall define the term high-cost durable medical equipment and specify the durable medical equipment for which such definition shall apply. Beginning 6 months after the date of the enactment of this clause, Medicare administrative contractors shall conduct reviews on a schedule determined by the Secretary, of claims for durable medical equipment prescribed by a physician or other practitioner described in clause (ii) during the 12 month period preceding such review to identify physicians or other practitioners with respect to whom at least 90 percent of all durable medical equipment prescribed by such physician or practitioner during such period was prescribed pursuant to a telehealth visit. In the case of a physician or practitioner identified under subclause (I), with respect to a period described in such subclause, the Medicare administrative contractors shall conduct audits of all claims for durable medical equipment prescribed by such physicians or practitioners to determine whether such claims comply with the requirements for coverage under this title. Section 1834A(b) of the Social Security Act (42 U.S.C. 1395m–1(b)) is amended by adding at the end the following new paragraph: Payment may not be made under this subsection for a high-cost laboratory test ordered by a physician or practitioner via telehealth for an individual on or after the date that is 180 days after the date of the enactment of this paragraph, unless such physician or practitioner furnished to such individual a service in-person at least once during the 6 month period prior to ordering such high-cost laboratory test. For purposes of this paragraph, the Administrator for the Centers for Medicare & Medicaid Services shall define the term high-cost laboratory test and specify which laboratory tests such definition shall apply to. Beginning 6 months after the date of the enactment of this paragraph, Medicare administrative contractors shall conduct periodic reviews on a schedule determined by the Secretary, of claims for laboratory tests prescribed by a physician or practitioner during the 12 month period preceding such review to identify physicians or other practitioners with respect to whom at least 90 percent of all laboratory tests prescribed by such physician or practitioner during such period was prescribed pursuant to a telehealth visit. In the case of a physician or practitioner identified under subparagraph (A), with respect to a period described in such subparagraph, the Medicare administrative contractors shall conduct audits of all claims for laboratory tests prescribed by such physicians or practitioners during such period beginning to determine whether such claims comply with the requirements for coverage under this title. (vi)Standards for high-cost durable medical equipment(I)Limitation on payment for high-cost durable medical equipmentPayment may not be made under this subsection for a high-cost durable medical equipment ordered by a physician or other practitioner described in clause (ii) via telehealth for an individual on or after the date that is 180 days after the date of the enactment of this clause, unless such physician or practitioner furnished to such individual a service in-person at least once during the 6 month period prior to ordering such high-cost durable medical equipment.(II)High-cost durable medical equipment determinationFor purposes of this clause, the Administrator of the Centers for Medicare & Medicaid Services shall define the term high-cost durable medical equipment and specify the durable medical equipment for which such definition shall apply.(vii)Audit of providers and practitioners furnishing a high volume of durable medical equipment via telehealth(I)Identification of providersBeginning 6 months after the date of the enactment of this clause, Medicare administrative contractors shall conduct reviews on a schedule determined by the Secretary, of claims for durable medical equipment prescribed by a physician or other practitioner described in clause (ii) during the 12 month period preceding such review to identify physicians or other practitioners with respect to whom at least 90 percent of all durable medical equipment prescribed by such physician or practitioner during such period was prescribed pursuant to a telehealth visit.(II)AuditIn the case of a physician or practitioner identified under subclause (I), with respect to a period described in such subclause, the Medicare administrative contractors shall conduct audits of all claims for durable medical equipment prescribed by such physicians or practitioners to determine whether such claims comply with the requirements for coverage under this title.. (6)Requirement for high-cost laboratory tests(A)Limitation on payment for high-cost laboratory testsPayment may not be made under this subsection for a high-cost laboratory test ordered by a physician or practitioner via telehealth for an individual on or after the date that is 180 days after the date of the enactment of this paragraph, unless such physician or practitioner furnished to such individual a service in-person at least once during the 6 month period prior to ordering such high-cost laboratory test.(B)High-cost laboratory test definedFor purposes of this paragraph, the Administrator for the Centers for Medicare & Medicaid Services shall define the term high-cost laboratory test and specify which laboratory tests such definition shall apply to.(7)Audit of laboratory testing ordered pursuant to telehealth visit(A)Identification of providersBeginning 6 months after the date of the enactment of this paragraph, Medicare administrative contractors shall conduct periodic reviews on a schedule determined by the Secretary, of claims for laboratory tests prescribed by a physician or practitioner during the 12 month period preceding such review to identify physicians or other practitioners with respect to whom at least 90 percent of all laboratory tests prescribed by such physician or practitioner during such period was prescribed pursuant to a telehealth visit. (B)AuditIn the case of a physician or practitioner identified under subparagraph (A), with respect to a period described in such subparagraph, the Medicare administrative contractors shall conduct audits of all claims for laboratory tests prescribed by such physicians or practitioners during such period beginning to determine whether such claims comply with the requirements for coverage under this title..

3. Requirement to submit NPI number for separately billable telehealth services 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: Payment may not be made under this subsection for separately billable telehealth services furnished on or after the date that is 180 days after the date of the enactment of this paragraph by a physician or practitioner unless such physician or practitioner submits a claim for payment under the national provider identification number assigned to such physician or practitioner. (10)Requirement to submit NPI number for separately billable telehealth servicesPayment may not be made under this subsection for separately billable telehealth services furnished on or after the date that is 180 days after the date of the enactment of this paragraph by a physician or practitioner unless such physician or practitioner submits a claim for payment under the national provider identification number assigned to such physician or practitioner..