Bill > HR3996

This bill establishes a two-year pilot program within the Medicare system to test a predictive risk-scoring algorithm designed to help prevent fraud in durable medical equipment (DME) and clinical diagnostic laboratory tests. The pilot program will be voluntary for Medicare beneficiaries who opt-in to receive electronic Medicare Summary Notices and participate in the program. The predictive algorithm will score transactions on a risk scale from 1 (least risky) to 99 (most risky), considering factors such as new provider-patient relationships, unusual billing patterns, electronic fund transfer changes, and provider ownership changes. If a transaction is flagged as high-risk, the system will trigger a review process where the beneficiary will be notified electronically and given an opportunity to confirm or challenge the transaction. The Secretary of Health and Human Services will collaborate with industry representatives in developing the algorithm, ensure thorough testing and evaluation, and establish communication methods with the Office of the Inspector General. Importantly, any transaction suspension will require human review, and the algorithm is intended to assist—not replace—human oversight. The program aims to provide an additional layer of protection against potential Medicare fraud while maintaining beneficiary privacy and offering transparency in the review process.

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https://www.congress.gov/bill/119th-congress/house-bill/3996/all-info