[Pages S2046-S2047]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

  SA 3677. Mr. LeMIEUX submitted an amendment intended to be proposed 
by him to the bill H.R. 4872, to provide for reconciliation pursuant to 
Title II of the concurrent resolution on the budget for fiscal year 
2010 (S. Con. Res. 13); which was ordered to lie on the table; as 
follows:

       At the end of subtitle D of title I, add the following:

     SEC. 1305. HEALTH CARE FRAUD PREVENTION SYSTEM.

       (a) Health Care Fraud Prevention System.--
       (1) In general.--The Secretary of Health and Human Services 
     (referred to in this section as the ``Secretary'') shall 
     establish a fraud prevention system which shall be designed 
     as follows:
       (A) In general.--The fraud prevention system shall--
       (i) be holistic;
       (ii) be able to view all provider and patient activities 
     across all Federal health program payers;
       (iii) be able to integrate into the existing health care 
     claims flow with minimal effort, time, and cost;
       (iv) be modeled after systems used in the Financial 
     Services industry; and
       (v) utilize integrated real-time transaction risk scoring 
     and referral strategy capabilities to identify claims that 
     are statistically unusual.
       (B) Modularized architecture.--The fraud prevention system 
     shall be designed from an end-to-end modularized perspective 
     to allow for ease of integration into multiple points along a 
     health care claim flow (pre- or post-adjudication), which 
     shall--
       (i) utilize a single entity to host, support, manage, and 
     maintain software-based services, predictive models, and 
     solutions from a central location for the customers who 
     access the fraud prevention system;
       (ii) allow access through a secure private data connection 
     rather than the installation of software in multiple 
     information technology infrastructures (and data facilities);
       (iii) provide access to the best and latest software 
     without the need for upgrades, data security, and costly 
     installations;
       (iv) permit modifications to the software and system edits 
     in a rapid and timely manner;
       (v) ensure that all technology and decision components 
     reside within the module; and
       (vi) ensure that the third party host of the modular 
     solution is not a party, payer, or stakeholder that reports 
     claims data, accesses the results of the fraud prevention 
     systems analysis, or is otherwise required under this section 
     to verify, research, or investigate the risk of claims.
       (C) Processing, scoring, and storage.--The platform of the 
     fraud prevention system shall be a high volume, rapid, real-
     time information technology solution, which includes data 
     pooling, data storage, and scoring capabilities to quickly 
     and accurately capture and evaluate data from millions of 
     claims per day. Such platform shall be secure and have (at a 
     minimum) data centers that comply with Federal and State 
     privacy laws.
       (D) Data consortium.--The fraud prevention system shall 
     provide for the establishment of a centralized data file 
     (referred to as a ``consortium'') that accumulates data from 
     all government health insurance claims data sources. 
     Notwithstanding any other provision of law, Federal health 
     care payers shall provide to the consortium existing claims 
     data, such as Medicare's ``Common Working File'' and Medicaid 
     claims data, for the purpose of fraud and abuse prevention. 
     Such accumulated data shall be transmitted and stored in an 
     industry standard secure data environment that complies with 
     applicable Federal privacy laws for use in building medical 
     waste, fraud, and abuse prevention predictive models that 
     have a comprehensive view of provider activity across all 
     payers (and markets).
       (E) Market view.--The fraud prevention system shall ensure 
     that claims data from Federal health programs and all markets 
     flows through a central source so the waste, fraud, and abuse 
     system can look across all markets and geographies in health 
     care to identify fraud and abuse in Medicare, Medicaid, the 
     State Children's Health Program, TRICARE, and the Department 
     of Veterans Affairs, holistically. Such cross-market 
     visibility shall identify unusual provider and patient 
     behavior patterns and fraud and abuse schemes that may not be 
     identified by looking independently at one Federal payer's 
     transactions.
       (F) Behavior engine.--The fraud prevention system shall 
     ensure that the technology used provides real-time ability to 
     identify high-risk behavior patterns across markets, 
     geographies, and specialty group providers to detect waste, 
     fraud, and abuse, and to identify providers that exhibit 
     unusual behavior patterns. Behavior pattern technology that 
     provides the capability to compare a provider's current 
     behavior to their own past behavior and to compare a 
     provider's current behavior to that of other providers in the 
     same specialty group and geographic location shall be used in 
     order to provide a comprehensive waste, fraud, and abuse 
     prevention solution.
       (G) Predictive model.--The fraud prevention system shall 
     involve the implementation of a statistically sound, 
     empirically derived predictive modeling technology that is 
     designed to prevent (versus post-payment detect) waste, 
     fraud, and abuse. Such prevention system shall utilize 
     historical transaction data, from across all Federal health 
     programs and markets, to build and re-develop scoring models, 
     have the capability to incorporate external data and external 
     models from other sources into the health care predictive 
     waste, fraud, and abuse model, and provide for a feedback 
     loop to provide outcome information on verified claims so 
     future system enhancements can be developed based on previous 
     claims experience.
       (H) Change control.--The fraud prevention system platform 
     shall have the infrastructure to implement new models and 
     attributes in a test environment prior to moving into a 
     production environment. Capabilities shall be developed to 
     quickly make changes to models, attributes, or strategies to 
     react to changing patterns in waste, fraud, and abuse.
       (I) Scoring engine.--The fraud prevention system shall 
     identify high-risk claims by scoring all such claims on a 
     real-time capacity prior to payment. Such scores shall then 
     be communicated to the fraud management system provided for 
     under subparagraph (J).
       (J) Fraud management system.--The fraud prevention system 
     shall utilize a fraud management system, that contains 
     workflow management and workstation tools to provide the 
     ability to systematically present scores, reason codes, and 
     treatment actions for high-risk scored transactions. The 
     fraud prevention system shall ensure that analysts who review 
     claims have the capability to access, review, and research 
     claims efficiently, as well as decline or approve claims 
     (payments) in an automated manner. Workflow management under 
     this subparagraph shall be combined with the ability to 
     utilize principles of experimental design to compare and 
     measure prevention and detection rates between test and 
     control strategies. Such strategy testing shall allow for 
     continuous improvement and maximum effectiveness in keeping 
     up with ever changing fraud and abuse patterns. Such system 
     shall provide the capability to test different treatments or 
     actions randomly (typically through use of random digit 
     assignments).
       (K) Decision technology.--The fraud prevention system shall 
     have the capability to monitor consumer transactions in real-
     time and monitor provider behavior at different stages within 
     the transaction flow based upon provider, transaction and 
     consumer trends. The fraud prevention system shall provide 
     for the identification of provider and claims excessive usage 
     patterns and trends that differ from similar peer groups, 
     have the capability to trigger on multiple criteria, such as 
     predictive model scores or custom attributes, and be able to 
     segment transaction waste, fraud, and abuse into multiple 
     types for health care categories and business types.
       (L) Feedback loop.--The fraud prevention system shall have 
     a feedback loop where all Federal health payers provide pre-
     payment and post-payment information about the eventual 
     status of a claim designated as ``Normal'', ``Waste'', 
     ``Fraud'', ``Abuse'', or ``Education Required''. Such 
     feedback loop shall enable Federal health agencies to measure 
     the actual amount of waste, fraud, and abuse as well as the 
     savings in the system and provide the ability to retrain 
     future, enhanced models. Such feedback loop shall be an 
     industry file that contains information on previous fraud and 
     abuse claims as well as abuse perpetrated by consumers, 
     providers, and fraud rings, to be used to alert other payers, 
     as well as for subsequent fraud and abuse solution 
     development.
       (M) Tracking and reporting.--The fraud prevention system 
     shall ensure that the infrastructure exists to ascertain 
     system, strategy, and predictive model return on investment. 
     Dynamic model validation and strategy validation analysis and 
     reporting shall be made available to ensure a strategy or 
     predictive model has not degraded over time or is no longer 
     effective. Queue reporting shall be established and made 
     available for population estimates of what claims were 
     flagged, what claims received treatment, and ultimately what 
     results occurred. The capability shall exist to complete 
     tracking and reporting for prevention strategies and actions 
     residing farther upstream in the health care payment flow. 
     The fraud prevention system shall establish a reliable metric 
     to measure the dollars that are never paid due to 
     identification of fraud and abuse, as well

[[Page S2047]]

     as a capability to effectively test and estimate the impact 
     from different actions and treatments utilized to detect and 
     prevent fraud and abuse for legitimate claims. Measuring 
     results shall include waste and abuse.
       (N) Operating tenet.--The fraud prevention system shall not 
     be designed to deny health care services or to negatively 
     impact prompt-pay laws because assessments are late. The 
     database shall be designed to speed up the payment process. 
     The fraud prevention system shall require the implementation 
     of constant and consistent test and control strategies by 
     stakeholders, with results shared with Federal health program 
     leadership on a quarterly basis to validate improving 
     progress in identifying and preventing waste, fraud, and 
     abuse. Under such implementation, Federal health care payers 
     shall use standard industry waste, fraud, and abuse measures 
     of success.
       (2) Coordination.--The Secretary shall coordinate the 
     operation of the fraud prevention system with the Department 
     of Justice and other related Federal fraud prevention 
     systems.
       (3) Operation.--The Secretary shall phase-in the 
     implementation of the system under this subsection beginning 
     not later than 18 months after the date of enactment of this 
     Act, through the analysis of a limited number of Federal 
     health program claims. Not later than 5 years after such date 
     of enactment, the Secretary shall ensure that such system is 
     fully phased-in and applicable to all Federal health program 
     claims.
       (4) Non-payment of claims.--The Secretary shall promulgate 
     regulations to prohibit the payment of any health care claim 
     that has been identified as potentially ``fraudulent'', 
     ``wasteful'', or ``abusive'' until such time as the claim has 
     been verified as valid.
       (5) Application.--The system under this section shall only 
     apply to Federal health programs (all such programs), 
     including programs established after the date of enactment of 
     this Act.
       (6) Regulations.--The Secretary shall promulgate 
     regulations providing the maximum appropriate protection of 
     personal privacy.
       (b) Protecting Participation in Health Care Antifraud 
     Programs.--
       (1) In general.--Notwithstanding any other provision of 
     law, no person providing information to the Secretary under 
     this section shall be held, by reason of having provided such 
     information, to have violated any criminal law, or to be 
     civilly liable under any law of the United States or of any 
     State (or political subdivision thereof) unless such 
     information is false and the person providing it knew, or had 
     reason to believe, that such information was false.
       (2) Confidentiality.--The Secretary shall, through the 
     promulgation of regulations, establish standards for--
       (A) the protection of confidential information submitted or 
     obtained with regard to suspected or actual health care 
     fraud;
       (B) the protection of the ability of representatives the 
     Department of Health and Human Services to testify in private 
     civil actions concerning any such information; and
       (C) the sharing by the Department of Health and Human 
     Services of any such information related to the medical 
     antifraud programs established under this section.
       (c) Use of Savings.--Notwithstanding any other provision of 
     law, amounts remaining at the end of a fiscal year in the 
     account for any Federal health program to which this section 
     applies that the Secretary of Health and Human Services 
     determines are remaining as a result of the fraud prevention 
     activities applied under this section shall remain in such 
     account and be used for such program for the next fiscal 
     year.
       (d) Definition.--In this section, the term ``Federal health 
     program'' means any program that provides Federal payments or 
     reimbursements to providers of health-related items or 
     services, or suppliers of such items, for the provision of 
     such items or services to an individual patient.
       (e) Recission of Certain Stimulus Funds.--Notwithstanding 
     section 5 of the American Recovery and Reinvestment Act of 
     2009 (Public Law 111-5; 123 Stat. 116), from the amounts 
     appropriated or made available under division A of such Act 
     (other than under title X of such division A), there is 
     rescinded, of the remaining unobligated amounts as of the 
     date of the enactment of this Act, funds in the amount as may 
     be necessary to carry out this section. The Director of the 
     Office of Management and Budget shall report to each 
     congressional committee the amounts so rescinded within the 
     jurisdiction of such committee.
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