• PRIME Act: New Legislation to Curb Health Care Fraud
  • June 20, 2013 | Author: Brian P. Dunphy
  • Law Firm: Mintz, Levin, Cohn, Ferris, Glovsky and Popeo, P.C. - Boston Office
  • The United States Senate and House of Representatives recently introduced bipartisan legislation designed to reduce fraud, waste, and abuse in the Medicare and Medicaid programs. The legislation, entitled “Preventing and Reducing Improper Medicare and Medicaid Expenditures Act of 2013,” or PRIME Act (S. 1123, H.R. 2305), seeks to curb improper payments by: reducing Medicare overpayments; requiring the Secretary of the Department of Health and Human Services (HHS) to address vulnerabilities identified by Recovery Audit Contractors (RAC); and sharing certain data among state and federal programs and agencies.

    Specifically, the PRIME Act:

    • Prohibits prescription drug plan sponsors from paying prescription drugs claims that do not include a valid prescriber National Provider Identifier (NPI number);
    • Allows for the transfer of information to the Inspector General of HHS (OIG), including claim records, for claims missing valid NPI numbers;
    • Enacts stronger penalties for the illegal purchase, sale, or distribution of a Medicare, Medicaid, or CHIP “beneficiary identification number or billing privileges”;
    • Strengthens fraud, waste, and abuse prevention by requiring the HHS Secretary to address improper payment vulnerabilities identified by RACs and annually report to Congress how the Secretary is addressing the identified vulnerabilities;
    • Requires the Secretary to develop a plan to encourage individuals to report fraud and abuse in the Medicare program, including enhanced reporting incentives and expanded participation in Senior Medicare Patrols;
    • Incentivizes Medicare Administrative Contractors to reduce improper payments in their jurisdictions;
    • Enhances data sharing among state and federal agencies and programs, including permitting sharing of data from the National Directory of New Hires to determine eligibility for Medicare; and
    • Requires the Secretary to develop and implement a plan allowing state Medicaid agencies to access data on improper Medicare payments for health care items or services provided to dual eligible individuals.

    The PRIME Act is another example of the government’s intense, bipartisan focus on combating health care waste, fraud, and abuse. According to Representative Peter Roskam (R-Ill.), one of the bill’s sponsors:

    The problem of Medicare fraud is an urgent one - we cannot continue to allow these critical programs to be fleeced because of carelessness or criminals gaming the system. The program’s current pay-and-chase model pays out even suspicious Medicare claims, costing taxpayers billions of dollars. By combining 21st century technology and common sense solutions, the PRIME Act can help stop fraudsters in their tracks and make Medicare and Medicaid more financially stable for the long term.