H.R. 3046

SUMMARY

The Toomey/Berkley/Bilirakis/Brown Medicare RACER Act aims to improve the management of the Medicare program and strengthen communications with beneficiaries and providers. The bill also improves the Medicare appeals process and grants the Secretary of Health and Human Services the authority to require Medicare fee-for-service contractors to meet new performance standards.

The intent of this title is to create some predictability in the issuance of Medicare regulations and implementation of program changes. The Secretary must establish a time frame for the publication of regulations from proposed to interim final to final regulations. Medicare providers must receive at least 30 days notice before program changes are implemented, and changes may not be applied retroactively. There are exceptions to these general rules when it is necessary to comply with statutory requirements or when application of the general rules would be contrary to the public interest.

This title includes improvements to several Medicare appeals processes. First, the Secretary would develop a plan to transfer the functions of the Administrative Law Judges (ALJs) who hear Medicare claims appeals from the Social Security Administration to the Department of Health and Human Services. This title authorizes additional appropriations in order to increase the number of Medicare ALJs so that appeals may be heard in a more timely manner.

A panel within the Department would certify cases that concern only constitutional and statutory issues and allow them to proceed to federal court, so that these cases would not have to complete an appeals process where the reviewers do not have the authority to decide the matter at hand. This expedited access to judicial review would apply to both Medicare claims appeals and provider agreement appeals, which generally involve nursing homes.

The Secretary would be required to expedite nursing home appeals in which a facility's participation in the Medicare program has been terminated, and new appropriations are authorized in order to decrease the backlog in nursing home appeals. Providers whose application for enrollment in Medicare has been denied would also have full appeal rights.

Finally, the bill improves the Medicare claims appeals process for beneficiaries by requiring that their cases be reviewed using good medical standards. Cases would be heard in a timely manner that takes into account the patient's medical needs. Individual beneficiaries would also be able to appeal for an exception to a Medicare national coverage decision on the grounds that the decision is inappropriate for his or her particular medical circumstances.

This title awards the Secretary the authority to contract on a competitive basis with the entities that process Medicare claims. The Secretary would be required to develop standards to measure the contractors' performance, and contractors would be required to establish information security programs to protect Medicare data.

This title increases funding for the Medicare Integrity Program by $35 million per year in order to improve provider education and training. Medicare contractors would be required to meet certain standards in responding to beneficiary and provider inquiries, and contractors would be evaluated based on the timeliness and accuracy of their responses. The Secretary would designate a specific person within the Department of Health and Human Services who would respond to complaints of inconsistent responses from Medicare contractors.

The Secretary would also establish deadlines for contractors to act on providers' applications for enrollment and re-enrollment, and contractors would be evaluated on their ability to meet these deadlines.

This title requires the Secretary to work with practicing physicians in conducting a number of pilot projects to test Medicare's new evaluation and management (E&M) documentation guidelines. A demonstration is also authorized that would place Medicare specialists at a limited number of Social Security offices to provide advice and assistance to Medicare beneficiaries.

This title is intended to develop consistency among Medicare contractors when they audit providers or notify them of overpayments. The Secretary would be required to establish standards for pre-payment review of claims that all contractors must follow. Providers who are subject to audits must receive a written notice from the contractor, and the contractor must provide an explanation of the finding of the audit once it is complete.

If a provider receives notice from a contractor that there is a potential overpayment, the provider would have additional time to provide information relating to the overpayment. The Secretary would establish standards for determining when providers are eligible for a repayment plan to return overpayments to the Medicare program. Providers who would like to appeal an alleged overpayment would not have to return the payment until the second level of appeal, which is a review by a Qualified Independent Contractor (QIC), has been completed.

The Secretary would develop a process under which claims with minor errors or omissions are returned to the provider instead of being automatically denied. Providers would have the opportunity to resubmit the completed claim without having to go through the appeals process.

Finally, this title includes a clarification that emergency care that meets the prudent layperson test is covered by the Medicare fee-for-service program.

This title outlines the process that the Secretary must follow in determining payment amounts and assigning codes to new lab tests. This process must include public meetings and allow for consideration of comments submitted by interested parties.

Prepared by the Democratic staff of the Energy and Commerce Committee
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