Bill summaries are authored by CRS.

Shown Here:
Reported to House amended, Part I (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 final (including interim final) regulations to carry out Medicare only on one business day of every month. Allows the issuance of a final regulation on any other day, however, if that is necessary to comply with requirements under law, or the limitation to one business day per month is contrary to the public interest.

(Sec. 101) Directs the Secretary to establish a regular timeline for the publication of 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 Medicare regulations, manual instructions, interpretative rules, statements of policy, or guidelines of general applicability to items and services furnished before the effective date of the change, unless the Secretary determines that such retroactive application is necessary to comply with statutory requirements, or failure to apply the change retroactively would be contrary to the public interest. Prohibits such a substantive change from becoming effective before the end of the 30-day period that begins on the date that the Secretary has issued or published the substantive change, except as provided for in this Act.

(Sec. 103) Directs the Secretary to report to Congress on the administration of the Medicare program and areas of inconsistency or conflict among the various provisions under law and regulation.

(Sec. 104) Directs the Comptroller General to report to Congress on: (1) the accuracy of the sustainable growth rate for 2002 and succeeding years in accounting for regulatory costs imposed on physicians; (2) the extent to which group health plans or other third party payors require that claims for Medicare categorically excluded dental services be denied under the Medicare program before the plan or payor will make payment for such claim; and (3) Medicare beneficiaries' requests for dentists to submit claims for such categorically excluded services.

Title II: Appeals Process Reform - 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. 201) Provides for increased financial support for administrative law judges and the Departmental Appeals Board.

(Sec. 202) 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. 203) Directs the Secretary to develop and implement a process to expedite hearings on provider agreements in which the sanction of termination of participation has been imposed.

(Sec. 205) Authorizes a provider of services, physician, practitioner, facility, or supplier whose application to enroll (or, if applicable, to renew enrollment) under Medicare is denied to have a hearing and judicial review of such denial.

(Sec. 206) Requires the Secretary to permit a provider of services, physician, practitioner, facility, or supplier to appeal any determination of the Secretary under the Medicare program relating to services rendered under such program to an individual who subsequently dies, if there is no other party available to appeal such determination, so long as the estate of the individual, and the individual's family and heirs, are not liable for paying for the time or service and are not liable for any increased coinsurance or deductible amounts resulting from any decision increasing the reimbursement amount for the provider of services, physician, practitioner, facility, or supplier.

(Sec. 207) Directs the Secretary to establish a process whereby an individual with standing may request the Secretary to determine that a national coverage determination, which has the effect of denying Medicare coverage for items and services for the treatment of a serious or life-threatening condition of the individual, should not apply to the individual due to special medical circumstances that involve medical factors that were not considered during the national coverage determination decisionmaking procedure, and make the application of the national coverage determination inappropriate for the individual's particular case.

(Sec. 208) Provides that, with respect to a Medicare administrative contractor with a contract providing for 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: (1) a process for the collection of information on the instances in which an advance beneficiary notice has been provided and on instances in which a beneficiary indicates on such a notice that the beneficiary does not intend to seek or to have furnished the item or service that is the subject of the notice; and (2) a program of outreach and education for beneficiaries, 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 III: Contracting Reform - Amends SSA title XVIII to provide for increased flexibility in Medicare administration.

(Sec. 302) Outlines requirements for information security for Medicare administrative contractors and the general application of such requirements to fiscal intermediaries and carriers.

Title IV: Education and Outreach Improvements - Amends SSA title XVIII to require the Secretary to: (1) coordinate the educational activities provided through Medicare contractors to maximize the effectiveness of Federal education efforts for service providers, physicians, practitioners, facilities, and suppliers; and (2) implement a methodology to measure the specific claims payment error rates of such contractors in the processing or reviewing of Medicare claims to give Medicare administrative contractors an incentive to implement effective education and outreach programs for service providers, physicians, practitioners, facilities, and suppliers.

(Sec. 401) Authorizes appropriations to the Secretary for enhanced provider education and training.

Requires: (1) a Medicare contractor that conducts education and training activities to tailor such activities 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, physicians, practitioners, facilities, 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, physicians, practitioners, facilities, or suppliers under the Medicare programs.

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. 402) Directs the Secretary to develop a strategy for communications with beneficiaries and with service providers, physicians, practitioners, facilities, and suppliers under Medicare.

Requires each Medicare administrative contractor to: (1) provide timely general written responses to inquiries by service providers, physicians, practitioners, facilities, and suppliers which submit claims to the contractor for processing, and those beneficiaries with respect to which claims are submitted; (2) maintain, for such entities, a toll-free telephone number at which beneficiaries, providers, physicians, practitioners, facilities, and suppliers may obtain information regarding billing, coding, claims, coverage, and other appropriate information under Medicare; and (3) maintain a system for identifying who provides such information above and monitor the accuracy, consistency, and timeliness of the information so provided.

(Sec. 403) Prohibits the imposition of any penalty on a service provider, physician, practitioner, facility, or supplier for reasonably relying on written guidance provided by the Secretary or a Medicare contractor in response to a written inquiry with respect to the furnishing of an item or service or the submission of a claim, when the Secretary determines that: (1) the entity has accurately presented the circumstances relating to such item, service, and claim; (2) there is no fraud or abuse against Medicare; and (3) the guidance was in error.

(Sec. 404) Directs the Secretary to appoint an individual within HHS responsible for responding to complaints and grievances from service providers, physicians, practitioners, facilities, and suppliers under the Medicare program concerning inconsistent information or inquiry responses.

(Sec. 405) 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 such guidelines; (4) finds that the objectives for them will be met in their implementation; and (5) has established, and is implementing, a program to educate physicians on the use of such guidelines.

Directs the Secretary to conduct appropriate and representative pilot projects to test new evaluation and management documentation guidelines.

(Sec. 406) Requires the Secretary to establish a demonstration program under which Medicare specialists employed by HHS provide advice and assistance to Medicare beneficiaries at the location of existing offices of the Social Security Administration.

Directs the Comptroller General to study and report to Congress on the toll free 1-800 Medicare number.

(Sec. 407) Amends SSA title XVIII to require the Secretary to: (1) establish by regulation procedures under which there are deadlines for actions on applications for enrollment; and (2) monitor the performance of Medicare administrative contractors in meeting such deadlines.

Title V: Review, Recovery, and Enforcement Reform - Amends SSA title XVIII to: (1) provide that if a Medicare administrative contractor conducts a random prepayment review, the contractor may only conduct it in accordance with a standard protocol for random prepayment audits developed by the Secretary; and (2) provide for recovery of overpayments.

(Sec. 503) Directs the Secretary to develop a process whereby a service provider, physician, practitioner, facility, or supplier is given an opportunity to correct minor errors or omissions detected in the submission of Medicare claims without the need to initiate an appeal.

(Sec. 504) Amends SSA titles XI and XIX to make certain technical changes to program and payment exclusions provisions.

Title VI: EMTALA Improvements - Amends SSA title XVIII with respect to determinations for payment for Emergency Medical Treatment and Active Labor Act (EMTALA) mandated screening and stabilization services.

(Sec. 602) Directs the Secretary to establish the Emergency Medical Treatment and Active Labor Act Task Force to: (1) review EMTALA regulations; (2) provide advice and recommendations with respect to those regulations and their application to hospitals and physicians; (3) solicit comments and recommendations from hospitals, physicians, and the public regarding the implementation of such regulations; and (4) disseminate information on the application of such regulations to hospitals, physicians, and the public.

(Sec. 603) Requires the Secretary to establish a procedure to notify hospitals and physicians when an EMTALA investigation is closed.

(Sec. 604) Directs the Secretary to request a prior review by peer review organizations in EMTALA cases involving termination of a hospital's participation under Medicare except in certain cases.

Title VII: Miscellaneous Improvements - Directs the Secretary to establish by regulation procedures for determining the basis for, and amount of, payment under Medicare 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. 702) Amends part C (Medicare+Choice) of SSA title XVIII to provide a one-year delay in lock-in procedures for Medicare+Choice plans.