Bill summaries are authored by CRS.

Shown Here:
Passed House amended (12/04/2001)

Medicare Regulatory and Contracting Reform Act of 2001 - Title I: Regulatory Reform - Amends part D (Miscellaneous) of title XVIII (Medicare) of the Social Security Act (SSA) to require the Secretary of Health and Human Services (HHS) to issue proposed or final regulations to carry out Medicare only on one business day of every month; but allows the Secretary to issue a proposed or final regulation on any other day if its issuance on another day is necessary to comply with requirements under law or if the limitation of issuance on the monthly date described is contrary to the public interest. Requires the Secretary to establish and publish on a regular timeline final regulations based on the previous publication of a proposed regulation or an interim final regulation.

(Sec. 102) Prohibits the retroactive application of a substantive change in regulations, manual instructions, interpretative rules, statements of policy, or guidelines of general applicability under Medicare to items and services furnished before the change's effective date, unless the Secretary determines that retroactive application is necessary to comply with statutory requirements or failure to apply the change retroactively would be contrary to the public interest. Prohibits a substantive change from becoming effective until after the Secretary has issued or published it, except as provided for in this Act.

States that if a service provider or supplier reasonably relies on the written guidance of the Secretary or a Medicare contractor with respect to the furnishing of items or services and submission of a claim, and the Secretary determines that the provider or supplier has accurately presented the circumstances relating to such items, services, and claim to the contractor in writing, and the guidance was in error, the provider or supplier shall not be subject to any sanction.

(Sec. 103) Directs the Comptroller General to study and report to Congress on the feasibility of establishing in the Secretary authority to provide legally binding advisory opinions on appropriate interpretation and application of regulations to carry out the Medicare program.

Title II: Contracting Reform - Amends SSA title XVIII to authorize the Secretary to contract with an eligible entity to serve as a Medicare administrative contractor. Prescribes contract terms and conditions and performance requirements.

(Sec. 202) Outlines requirements for information security for Medicare administrative contractors and the general application of such requirements to fiscal intermediaries and carriers.

Title III: Education and Outreach - Amends SSA title XVIII to require the Secretary to: (1) coordinate the educational activities provided through Medicare administrative contractors to maximize the effectiveness of Federal education efforts for service providers and suppliers; (2) develop and implement a methodology to measure the specific claims payment error rates of such contractors in the processing or reviewing of Medicare claims, in order to give them an incentive to implement effective education and outreach programs for service providers and suppliers; (3) develop a strategy for communications with individuals entitled to benefits under Medicare part A (Hospital Insurance) or enrolled under Medicare part B (Supplementary Medical Insurance), or both, and with service providers and suppliers under Medicare; and (4) establish and make public standards to monitor the accuracy, consistency, and timeliness of the information provided in response to inquiries of service providers, suppliers, and beneficiaries concerning the programs under Medicare.

(Sec. 301) Requires each Medicare administrative contractor, consistent with such standards, to maintain a system for identifying who provides such information and to monitor the accuracy, consistency, and timeliness of the information so provided.

Authorizes appropriations to the Secretary for FY 2003 and 2004 for improved provider education and training.

Requires: (1) a Medicare contractor that conducts education and training activities to tailor them to meet the special needs of small service providers or suppliers; and (2) the Secretary, and each Medicare contractor that provides services for service providers or suppliers, to maintain an Internet site which provides answers in an easily accessible format to frequently asked questions and includes other published materials of the contractor, that relate to service providers and suppliers under the programs under Medicare.

Prohibits a Medicare contractor from using a record of attendance at (or failure to attend) educational activities or other information gathered during an educational program conducted under Medicare or otherwise by the Secretary to select or track service providers or suppliers for the purpose of conducting any type of audit or prepayment review.

(Sec. 302) Directs the Secretary to establish a demonstration program under which technical assistance is made available upon request to small service providers or suppliers to improve compliance with applicable Medicare requirements. Authorizes appropriations.

(Sec. 303) Amends SSA title XVIII to direct the Secretary to appoint within HHS a Medicare Provider Ombudsman and a Medicare Beneficiary Ombudsman to handle and provide assistance in resolving complaints and requests for information with respect to Medicare. Authorizes appropriations.

Directs the Secretary to provide through a toll-free number (1-800-MEDICARE) for a means by which individuals seeking information about, or assistance with, Medicare programs are transferred to appropriate entities for the provision of such information or assistance.

Requires the Comptroller General to monitor and report to Congress on the accuracy and consistency of information provided to individuals entitled to benefits under Medicare part A or enrolled under Medicare part B, or both, through the toll-free number.

(Sec. 304) Directs the Secretary to establish a demonstration program under which HHS Medicare specialists provide advice and assistance to individuals entitled to benefits under Medicare part A, or enrolled under Medicare part B, or both, regarding the Medicare program at the location of existing local offices of the Social Security Administration.

Title IV: Appeals and Recovery - Requires the Commissioner of Social Security and the Secretary to develop and implement a plan under which the functions of administrative law judges responsible for hearing Medicare cases are transferred from the Social Security Administration to HHS.

(Sec. 401) Provides for increased financial support for administrative law judges and the Departmental Appeals Board.

(Sec. 402) Amends SSA title XVIII, as amended by the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, to revise the Medicare appeals process, providing for expedited access to judicial review of the Secretary's final decision in a hearing on an initial determination with respect to benefits under Medicare parts A or B, among other changes.

(Sec. 404) Authorizes Medicare administrative contractors to conduct random prepayment reviews only to develop contractor or program-wide claims payment error rates.

Prohibits Medicare administrative contractors from initiating non-random prepayment reviews of a service provider or supplier based on the initial identification by that service provider or supplier of an improper billing practice unless there is a likelihood of sustained or high level of payment error.

Requires the Secretary to issue regulations relating to the termination of the non-random payment review.

(Sec. 405) Provides for the recovery of overpayments under the Medicare integrity program.

(Sec. 406) Directs the Secretary to establish by regulation a process for the enrollment of service providers and suppliers under Medicare.

(Sec. 407) Requires the Secretary to develop a process whereby, in the case of minor errors or omissions that are detected in the submission of claims under the programs under Medicare, a service provider or supplier is given an opportunity to correct such an error or omission without the need to initiate an appeal.

(Sec. 408) Provides that, with respect to a Medicare administrative contractor with a contract that provides for making Medicare payments for eligible items and services, the Secretary shall establish a prior determination process that meets specified requirements and that shall be applied by such contractor in the case of eligible requestors.

Requires the Secretary to establish a process for the collection of information on the instances in which: (1) an advance beneficiary notice has been provided; and (2) a beneficiary indicates on such a notice that he or she does not intend to seek or to have the item or service that is the subject of the notice furnished.

Requires the Secretary to establish a program of outreach and education for beneficiaries and service providers and other persons on the appropriate use of advance beneficiary notices and coverage policies under Medicare.

Requires the Comptroller General to report to Congress on the use of advance beneficiary notices and prior determination process under Medicare.

Title V: Miscellaneous Provisions - Prohibits the Secretary from implementing any new documentation guidelines for evaluation and management physician services under Medicare unless the Secretary: (1) has developed the guidelines in collaboration with practicing physicians and provided for an assessment of the proposed guidelines by the physician community; (2) has established a plan that contains specific goals for improving the use of such guidelines; (3) has conducted appropriate and representative pilot projects to test modifications to the evaluation and management documentation guidelines; (4) finds that the objectives will be met in the implementation of such guidelines; and (5) has established, and is implementing, a program to educate physicians on the use of such guidelines.

(Sec. 501) Directs the Secretary to: (1) make changes to the manner in which existing evaluation and management documentation guidelines are implemented to reduce paperwork burdens on physicians; (2) conduct appropriate and representative pilot projects to test such new guidelines; (3) study and report to Congress on the development of a simpler alternative system of requirements for documentation accompanying claims for evaluation and management physician services for which Medicare payment is made, and consideration of systems other than current coding and documentation requirements for payment for such physician services; and (4) study and report to Congress on the appropriateness of coding in cases of extended office visits in which no diagnosis is made.

(Sec. 502) Provides for improved coordination between the Food and Drug Administration and the Centers for Medicare and Medicaid Services on Medicare (CMS) coverage of certain class III medical devices subject to premarket approval under the Federal Food, Drug, and Cosmetic Act.

Amends SSA title XVIII to direct the Secretary to establish a Council for Technology and Innovation within the Centers for Medicare and Medicaid Services to coordinate the activities of coverage, coding, and payment processes under Medicare with respect to new technologies and procedures, and to coordinate the exchange of information on new technologies between CMS and other entities that make similar decisions.

Directs the Comptroller General to study and report to Congress on which external data can be collected in a shorter time frame by the CMS for use in computing payments for inpatient hospital services.

Requires the Secretary to arrange with the Institute of Medicine of the National Academy of Sciences for a study and report on local Medicare coverage determinations.

Directs the Secretary by regulation to establish procedures for determining the basis for, and amount of, Medicare payment for any clinical diagnostic laboratory test with respect to which a new or substantially revised Healthcare Common Procedure Coding System (HCPCS) code is assigned on or after January 1, 2003.

(Sec. 503) Provides for the treatment of hospitals for certain services under Medicare secondary payor requirements.

(Sec. 504) Amends SSA title XVIII to make changes with regard to Emergency Medical Treatment and Active Labor Act (EMTALA) matters, including requiring the Secretary to establish a procedure to notify hospitals and physicians when an investigation is closed.

(Sec. 505) Directs the Secretary to establish a Technical Advisory Group to review issues related to EMTALA and its implementation.

(Sec. 506) Amends SSA title XVIII to authorize a hospice program to enter into arrangements with another hospice program to provide core hospice services in certain circumstances.

(Sec. 507) Provides for the application of the Occupational Safety and Health Act of 1970 bloodborne pathogens standard to certain hospitals.

(Sec. 508) Amends part C (Medicare+Choice) of SSA title XVIII to: (1) provide a one-year delay in lock-in procedures for Medicare+Choice plans; and (2) change Medicare+Choice reporting deadlines and the annual, coordinated election period for 2002.

(Sec. 511) Provides for the treatment of certain dental claims under Medicare.

(Sec. 512) Directs the Comptroller General to report to Congress on physician compensation.

Directs the Secretary to: (1) submit to Congress as expeditiously as practicable the reports required under the Balanced Budget Act of 1997 relating to alternatives to a single annual dollar cap on outpatient therapy and under the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 relating to utilization patterns for outpatient therapy; and (2) provide, in an appropriate annual publication to the public, a list of national Medicare coverage determinations made in the previous year, and information on how to get more information about them.