42 USC 1396u-6 - Medicaid Integrity Program

U.S Code last checked for updates: Oct 16, 2024

§ 1396u–6.

Medicaid Integrity Program

(a)

In general

(b)

Activities described

Activities described in this subsection are as follows:

(1)

Review of the actions of individuals or entities furnishing items or services (whether on a fee-for-service, risk, or other basis) for which payment may be made under a State plan approved under this subchapter (or under any waiver of such plan approved under section 1315 of this title) to determine whether fraud, waste, or abuse has occurred, is likely to occur, or whether such actions have any potential for resulting in an expenditure of funds under this subchapter in a manner which is not intended under the provisions of this subchapter.

(2)

Audit of claims for payment for items or services furnished, or administrative services rendered, under a State plan under this subchapter, including—

(A)

cost reports;

(B)

consulting contracts; and

(C)

risk contracts under section 1396b(m) of this title.

(3)

Identification of overpayments to individuals or entities receiving Federal funds under this subchapter.

(4)

Education or training, including at such national, State, or regional conferences as the Secretary may establish, of State or local officers, employees, or independent contractors responsible for the administration or the supervision of the administration of the State plan under this subchapter, providers of services, managed care entities, beneficiaries, and other individuals with respect to payment integrity and quality of care.

(c)

Eligible entity and contracting requirements

(1)

In general

(2)

Eligibility requirements

The requirements of this paragraph are the following:

(A)

The entity has demonstrated capability to carry out the activities described in subsection (b).

(B)

In carrying out such activities, the entity agrees to cooperate with the Inspector General of the Department of Health and Human Services, the Attorney General, and other law enforcement agencies, as appropriate, in the investigation and deterrence of fraud and abuse in relation to this subchapter and in other cases arising out of such activities.

(C)

The entity complies with such conflict of interest standards as are generally applicable to Federal acquisition and procurement.

(D)

The entity agrees to provide the Secretary and the Inspector General of the Department of Health and Human Services with such performance statistics (including the number and amount of overpayments recovered, the number of fraud referrals, and the return on investment of such activities by the entity) as the Secretary or the Inspector General may request.

(E)

The entity meets such other requirements as the Secretary may impose.

(3)

Contracting requirements

The entity has contracted with the Secretary in accordance with such procedures as the Secretary shall by regulation establish, except that such procedures shall include the following:

(A)

Procedures for identifying, evaluating, and resolving organizational conflicts of interest that are generally applicable to Federal acquisition and procurement.

(B)

Competitive procedures to be used—

(i)

when entering into new contracts under this section;

(ii)

when entering into contracts that may result in the elimination of responsibilities under section 202(b) of the Health Insurance Portability and Accountability Act of 1996; and

(iii)

at any other time considered appropriate by the Secretary.

(C)

Procedures under which a contract under this section may be renewed without regard to any provision of law requiring competition if the contractor has met or exceeded the performance requirements established in the current contract.

The Secretary may enter into such contracts without regard to final rules having been promulgated.

(4)

Limitation on contractor liability

(d)

(1)

5-year plan

(2)

Consultation

(e)

Appropriation

(1)

In general

Out of any money in the Treasury of the United States not otherwise appropriated, there are appropriated to carry out the Medicaid Integrity Program under this section (including the costs of equipment, salaries and benefits, and travel and training), without further appropriation—

(A)

for fiscal year 2006, $5,000,000;

(B)

for each of fiscal years 2007 and 2008, $50,000,000;

(C)

for each of fiscal years 2009 and 2010, $75,000,000; and

(D)

for each fiscal year after fiscal year 2010, the amount appropriated under this paragraph for the previous fiscal year, increased by the percentage increase in the consumer price index for all urban consumers (all items; United States city average) over the previous year.

(2)

Availability; authority for use of funds

(A)

Availability

(B)

Authority for use of funds for transportation and travel expenses for attendees at education, training, or consultative activities

(i)

In general

(ii)

Public disclosure

The Secretary shall make available on a website of the Centers for Medicare & Medicaid Services that is accessible to the public—

(I)

the total amount of funds expended for each conference conducted under the authority of subsection (b)(4); and

(II)

the amount of funds expended for each such conference that were for transportation and for travel expenses.

(3)

Increase in CMS staffing devoted to protecting Medicaid program integrity

(4)

Evaluations

(5)

Annual report

Not later than 180 days after the end of each fiscal year (beginning with fiscal year 2006), the Secretary shall submit a report to Congress which identifies—

(A)

the use of funds appropriated pursuant to paragraph (1); and

(B)

the effectiveness of the use of such funds.

(Aug. 14, 1935, ch. 531, title XIX, § 1936, as added Pub. L. 109–171, title VI, § 6034(a)(2), Feb. 8, 2006, 120 Stat. 74; amended Pub. L. 110–379, § 5(a)(1), (b)(1), Oct. 8, 2008, 122 Stat. 4078; Pub. L. 111–148, title VI, § 6402(j)(2), Mar. 23, 2010, 124 Stat. 762; Pub. L. 111–152, title I, § 1303(b), Mar. 30, 2010, 124 Stat. 1058; Pub. L. 114–115, § 6, Dec. 28, 2015, 129 Stat. 3133.)

cite as: 42 USC 1396u-6