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S. 2368 (114th): Audit & Appeals Fairness, Integrity, and Reforms in Medicare Act of 2015

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The summary below was written by the Congressional Research Service, which is a nonpartisan division of the Library of Congress, and was published on Dec 8, 2015.


(This measure has not been amended since it was introduced. The summary has been expanded because action occurred on the measure.)

Audit & Appeals Fairness, Integrity, and Reforms in Medicare Act of 2015 or the AFIRM Act

(Sec. 2) This bill requires the Department of Health and Human Services (HHS) to provide for the annual transfer, from the Federal Hospital Insurance Trust Fund and the Federal Supplementary Insurance Trust Fund, of specified additional funding for Medicare hearings and appeals.

The Government Accountability Office (GAO) shall study whether the availability of such funds led to any improvements in the Medicare appeals program.

(Sec. 3) The bill amends title XVIII (Medicare) of the Social Security Act to require HHS to establish, within the Office of Medicare Hearings and Appeals, decision-making officials to be known as Medicare magistrates.

(Sec. 4) With specified exceptions, Medicare appeals shall be remanded to the redetermination level when a party to the appeal introduces new evidence.

(Sec. 5) HHS shall establish by regulation and implement processes authorizing an administrative law judge (ALJ) to, in specified cases: (1) issue a decision on the record, or (2) certify an appeal for expedited process to judicial review.

(Sec. 6) If specified requirements are met, the adjudicator of a Medicaid appeal may consolidate pending requests for review into a single action and may issue either a single decision or separate decisions.

With the consent of the appellant, an adjudicator may use statistical sampling and extrapolation in reaching a decision with respect to a Medicare appeal.

(Sec. 7) HHS shall establish and implement a process for the referral of cases in which there is a credible suspicion of fraudulent activity to relevant specified agencies.

(Sec. 8) HHS must study the feasibility of increasing the participation of specified entities in Medicare appeals hearings.

(Sec. 9) The bill extends training requirements for ALJs to Medicare magistrates and establishes additional training for both types of adjudicator.

HHS shall: (1) annually publish on its website specified data regarding Medicare appeals, (2) establish and implement a process for identifying inconsistent interpretations of policies in Medicare appeals, and (3) study whether the specialization of ALJs would lead to more consistent decisions.

GAO must study the consistency of Medicare appeals decisions.

HHS shall establish one or more optional alternative dispute resolution (ADR) process for redeterminations and reconsiderations. There shall be no judicial review of an ADR settlement.

(Sec. 10) HHS must: (1) establish guidelines for reviewing claims for payment submitted by providers; (2) designate a point of contact to oversee and undertake several Medicare program integrity initiatives; and (3) establish a secure system through which a provider may track the status of a claim for payment that is being audited or processed as an appeal.

(Sec. 11) HHS shall appoint a Medicare Reviews and Appeals Ombudsman.

(Sec. 12) The bill limits the audit and recovery period for reviews of an individual's classification as an inpatient or an outpatient for purposes of hospital claims for payment. HHS shall study the impact of shortening such period with respect to different types of reviews.

(Sec. 13) HHS shall establish a compliance incentive program consisting of: (1) a system through which a provider that has achieved a low rate of payment claim denials shall, for one year, be exempt from a post-payment review of payment claims; and (2) an established process for conditioning the number of medical records that a review contractor may request from a provider on the quality of that review contractor's performance over a specified period.