(2) entities serving as qualified independent contractors under section 1869(c) of the Social Security Act (42 U.S.C. 1395ff(c));

(3) entities serving as medicare administrative contractors under section 1874A of such Act (42 U.S.C. 1395kk–1);

(4) entities serving as recovery audit contractors under section 1893(h) of such Act (42 U.S.C. 1395ddd(h)); and

(5) other Medicare claims review entities determined appropriate by the Secretary.

(b) Report.—Not later than 2 years after the date of the enactment of this Act, the Secretary of Health and Human Services shall publish a report containing the results of the study required under subsection (a) on the Internet website of the Department of Health and Human Services.

(a) Training for ALJs and Medicare magistrates.—Section 1869(e)(3) of the Social Security Act (42 U.S.C. 1395ff(e)(3)) is amended—

(1) in the paragraph heading, by striking “and administrative law judges” and inserting “, administrative law judges, and Medicare magistrates; Annual training for administrative law judges and Medicare magistrates”;

(2) by striking “The Secretary” and inserting the following:

“(A) CONTINUING EDUCATION REQUIREMENT.—The Secretary”;

(3) by inserting “and, beginning in 2020, to Medicare magistrates” after “administrative law judges” the first place it appears;

(4) by striking “and administrative law judges” and inserting “, administrative law judges, and Medicare magistrates”; and

(5) by adding at the end the following new subparagraph:

“(B) ANNUAL TRAINING.—Beginning with calendar year 2020, each calendar year the Secretary shall provide to each administrative law judge and Medicare magistrate within the Office of Medicare Hearings and Appeals training on Medicare policies, including any policies that were changed or instituted in the previous year.”.

(b) Publication of appeals information.—Section 1869(e) of the Social Security Act (42 U.S.C. 1395ff(e)) is amended by adding at the end the following new paragraph:

“(5) PUBLICATION OF APPEALS INFORMATION.—Not later than January 1, 2020, and annually thereafter, the Secretary of Health and Human Services shall publish and maintain on the Internet website of the Department of Health and Human Services the following information regarding appeals heard by the Office of Medicare Hearings and Appeals for each fiscal year:

“(A) The percentage of appeals that received fully favorable, partially favorable, and unfavorable decisions.

“(B) For each type of service, the percentage of appeals that received fully favorable, partially favorable, and unfavorable decisions.

“(C) The average length of time elapsed between the initial request for review and a final decision.

“(D) Such other information as the Secretary determines necessary to ensure greater transparency for the Office of Medicare Hearings and Appeals.”.

(a) In general.—Section 1893 of the Social Security Act (42 U.S.C. 1395ddd) is amended—

(1) in subsection (b), by adding at the end the following new paragraph:

“(7) The review program improvements described in subsection (k).”; and

(2) by adding at the end the following new subsection:

“(k) Review program improvements.—

“(1) IN GENERAL.—

“(A) GUIDELINES.—

“(i) IN GENERAL.—To promote uniformity and consistency in initial determinations and appeals decisions relating to the appropriateness of payment with respect to items or services furnished under this title, the Secretary shall establish claim review guidelines for review contractors for reviewing claims for payment submitted by providers of services and suppliers.

“(ii) REQUIREMENTS.—Prior to the implementation of the claim review guidelines described in subparagraph (A)(i), the Secretary shall—

“(I) approve the claim review guidelines;

“(II) make the claim review guidelines publicly available as described in subparagraph (B); and

“(III) ensure that review contractors, Medicare magistrates, administrative law judges, and appropriate members of the Departmental Appeals Board are trained in the application of the claim review guidelines.

“(iii) TRANSITION PERIOD.—The Secretary may provide for or establish one or more transition periods, during which the use of existing claim review guidelines for reviewing claims submitted by providers of services and suppliers shall be permitted to continue until such time as the Secretary is able to review and approve the claim review guidelines established under this subparagraph.

“(B) TRANSPARENCY.—

“(i) IN GENERAL.—The Secretary shall ensure that the information described in clause (iii)—

“(I) is published on the Internet website of the Department of Health and Human Services for not less than 30 days prior to its implementation;

“(II) remains available on such Internet website after such publication; and

“(III) is updated at least annually.

“(ii) EXPEDITED PROCESS.—The Secretary of Health and Human Services may expedite the process described in clause (i) for claims review guidelines that are expected to impact the improper payment rate, frequency of denials of payment, or costs to the Medicare program.

“(iii) INFORMATION DESCRIBED.—The information described in this clause is the following:

“(I) Subject to clause (ii) and subparagraph (A), any new claim review guideline approved for use under this paragraph.

“(II) Any updates or revisions to existing claim review guidelines.

“(C) LIMITATION.—Nothing in this section is intended to—

“(i) delineate sample size or how claims are to be selected for review;

“(ii) require the publication of algorithms or methodologies used for claim selection; or

“(iii) require the publication of information that could promote fraud or potential gaming.

“(D) REVIEW CONTRACTOR DEFINED.—In this subsection, the term ‘review contractor’ means—

“(i) a medicare administrative contractor (as defined in section 1874A(a)(3)(A)) with a contract to conduct prepayment or post-payment reviews of claims for payment by providers of services or suppliers;

“(ii) a recovery audit contractor with a contract under subsection (h); or

“(iii) any other contractor the Secretary determines appropriate.

“(2) PROGRAM INTEGRITY INITIATIVES.—To improve existing and future Medicare program integrity initiatives, and to limit unnecessary burdens on providers of services and suppliers, the Secretary shall designate a point of contact to oversee and undertake the following:

“(A) Develop a comprehensive strategy for claim review determinations made on a prepayment, post-payment, or prior-authorization basis that—

“(i) focuses on identifying and reducing those claim errors that have the largest impact on the improper payment rate, pose the greatest risk to the Federal Hospital Insurance Trust Fund under section 1817 or the Federal Supplementary Medical Insurance Trust Fund under section 1841, or are likely to negatively affect quality of care;

“(ii) reduces unnecessary burden on providers of services and suppliers and minimizes any negative effects on Medicare beneficiaries; and

“(iii) utilizes data and other sources, including claims data, improper payment rate data, and reports from the Office of the Inspector General of the Department of Health and Human Services, the General Accountability Office, and the Medicare Payment Advisory Commission.

“(B) Develop methods designed to minimize, using available data, unnecessary duplicate reviews by review contractors.

“(C) To the extent possible given the specific mission of each entity that has contracted with the Secretary, work with all review contractors to develop a uniform, consistent, and transparent review process to reduce the burden on providers of services and suppliers, including a uniform approach for such entities to notify parties of pending reviews and to request medical documentation, improved communication with providers of services and suppliers, better refinement of audits to target claims that are at the highest risk for improper payments or other errors, and any other areas in which the Secretary determines that the burden on providers of services and suppliers may be decreased.

“(D) To the extent practicable, identify local coverage determinations, national coverage determinations, regulations, and program instructions issued by the Centers for Medicare & Medicaid Services for the Medicare program that need updating or that inappropriately conflict with other Medicare policies and make modifications where appropriate, and, if necessary, establish new policies or claim review guidelines with input from stakeholders as appropriate.

“(E) Publish on the Internet website of the Department of Health and Human Services the volume and type of prepayment and post-payment claim reviews performed by medicare administrative contractors under section 1874A and recovery audit contractors under subsection (h).

“(F) Coordinate with the Office of Medicare Hearings and Appeals and the Departmental Appeals Board of the Department of Health and Human Services in the implementation of the improved claim review guidelines and evidentiary standards established by the provisions of, and the amendments made by, the Audit & Appeals Fairness, Integrity, and Reforms in Medicare Act of 2019, such as the decision to remand an appeal.

“(G) Ensure that providers of services and suppliers subject to post-payment review by a medicare administrative contractor are granted a discussion period with the contractor of at least 30 days from the letter from the contractor regarding the result of the review.

“(H) Develop qualification standards for review contractors that require prepayment and post-payment reviews of claims for payment submitted by providers of services or suppliers be overseen by a medical director of the review contractor who has knowledge of relevant Medicare laws, regulations, and program instruction, as appropriate.

“(I) Undertake verification methods, such as sampling, to determine whether decisions by review contractors are consistent with Medicare laws, regulations, and program instruction (taking into account geographical variations that are a result of local coverage determinations).

“(J) Determine whether punitive actions against ineffective review contractors could be taken and what, if any, financial incentives or disincentives could be used to promote the accuracy of a review contractor's reviews.”.

(b) Annual RAC report.—Section 1893(h)(8) of the Social Security Act (42 U.S.C. 1395ddd(h)(8)) is amended by inserting “, and, with respect to reports submitted after the date of the enactment of the Audit & Appeals Fairness, Integrity, and Reforms in Medicare Act of 2019, the number of claims corrected in the discussion period, the percentage of appeals of determinations by recovery audit contractors that were ultimately successful, a careful description of the denominator of total audits and appeals (given the likelihood that many appeals in a given year will not have a decision in that year), and separate reports on complex Medicare part A, complex Medicare part B, semiautomated, and automated reviews” before the period at the end.

(c) Independence of adjudicators.—Nothing in this section or the amendments made thereby shall be construed as authorizing the Secretary of Health and Human Services to limit the authority or decisional independence of Medicare magistrates, administrative law judges, or the Departmental Appeals Board of the Department of Health and Human Services.

“(2) DUTIES.—The Medicare Reviews and Appeals Ombudsman shall—

“(A) identify, investigate, and assist in the resolution of complaints and inquiries related to the Medicare audits and appeals process from providers of services or suppliers with respect to benefits under part A or B;

“(B) identify trends in complaints and inquiries regarding the current Medicare review and appeals systems to provide recommendations for improvements to the Secretary that would improve the efficacy and efficiency of claim review and appeals systems, as well as communication to beneficiaries, providers of services, and suppliers;

“(C) design a system by which to objectively measure and evaluate reviewer responsiveness to addressing inquiries from providers of services and suppliers and inquiries from the Ombudsman;

“(D) provide assistance to appellants and those considering an appeal;

“(E) publish data regarding the number of review determinations appealed, each appeal's outcome, and aggregate appeal statistics—

“(i) for each medicare administrative contractor conducting redeterminations under section 1869(a)(3);

“(ii) for each qualified independent contractor conducting reconsiderations under section 1869(c);

“(iii) for each recovery audit contractor conducting reviews under section 1893(h);

“(iv) by type of provider of services; and

“(v) by type of supplier;

“(F) assist in education and training efforts for providers of services, suppliers, and review contractors (as defined in section 1893(k)(1)(D));

“(G) communicate with the Medicare Beneficiary Ombudsman to assist with the identification, investigation, and resolution of beneficiary-related complaints, including those that overlap with requests for review and appeals submitted by providers of services or suppliers; and

“(H) perform such other duties as determined appropriate by the Secretary.”.

(a) In general.—Section 1893(h)(4) of the Social Security Act (42 U.S.C. 1395ddd(h)(4)) is amended—

(1) by redesignating subparagraphs (A) and (B) as clauses (i) and (ii), respectively, and moving such clauses 2 ems to the right;

(2) by striking “Each such” and inserting the following:

“(A) IN GENERAL.—Except as provided in subparagraph (B), each such”; and

(3) by adding at the end the following new subparagraph:

“(B) LIMITATION.—

“(i) IN GENERAL.—With respect to the classification of an individual entitled to benefits under part A or enrolled under part B, or both, as an inpatient or an outpatient for purposes of hospital claims for payment for items or services furnished to such individual under this title, such contracts shall provide that a recovery audit contractor shall only send additional documentation requests related to the appropriateness of such classification in the first 6 months after the date on which such items or services were furnished.

“(ii) EXCEPTION.—The limitation described in clause (i) shall not apply where a claim for payment is submitted more than 3 months after the date on which such items or services were furnished.”.

(b) Study on shortening the audit and recovery period for other reviews.—

(1) STUDY.—The Secretary of Health and Human Services shall conduct a study to assess—

(A) the potential burden on providers of services (as defined in subsection (u) of section 1861 of the Social Security Act (42 U.S.C. 1395x)) and suppliers (as defined in subsection (d) of such section) under the Medicare program of the audit and recovery period applicable to audit and recovery activities conducted by recovery audit contractors under section 1893(h)(4) of such Act (42 U.S.C. 1395ddd(h)(4)); and

(B) the impact of shortening such period with respect to different types of reviews.

(2) REPORT.—Not later than 1 year after the date of the enactment of this Act, the Secretary of Health and Human Services shall publish a report containing the results of the study required under paragraph (1) on the Internet website of the Department of Health and Human Services.

(c) Authority To implement shorter audit and recovery period.—Section 1893(h)(4) of the Social Security Act (42 U.S.C. 1395ddd(h)(4)), as amended by subsection (a), is further amended—

(1) in subparagraph (A), by striking “subparagraph (B)” and inserting “subparagraphs (B) and (C)”; and

(2) by adding at the end the following new subparagraph:

“(C) AUTHORITY TO IMPLEMENT SHORTER AUDIT AND RECOVERY PERIOD.—Notwithstanding subparagraph (A)(ii), with respect to payments made under this title for specific categories of services, the Secretary may enter into contracts under paragraph (1) that provide for a retrospective period during which audit and recovery activities may be conducted of not more than 3 years.”.

(d) Report on RAC payment structure.—Not later than 6 months after the date of the enactment of this Act, the Secretary of Health and Human Services shall submit to Congress a report on ways to change, in a budget neutral manner, the payment structure for recovery audit contractors under section 1893(h)(1) of the Social Security Act (42 U.S.C. 1395ddd(h)(1)) from an incentive-based model to a non-incentive based approach that does not impose additional financial burdens on providers.

“(B) entities that have entered into contracts with the Secretary under subsection (h) (referred to in this subsection as ‘review contractors’) to conduct reviews under this section in a manner that is consistent with the provisions of this title and the claim review guidelines, regulations, and program instructions promulgated thereunder, as well as any applicable national or local coverage determinations.

“(2) COMPLIANCE WITH CLAIM PROCEDURES BY PROVIDERS OF SERVICES AND SUPPLIERS.—

“(A) IN GENERAL.—Not later than 6 months after the date of enactment of this subsection, the Secretary shall establish a system through which a provider of services or supplier that has achieved a low rate of denials of claims for payment subject to additional documentation requests over a 2-year period, as determined by the Secretary, shall be exempt for a period of 1 year from any post-payment review of claims for payment conducted by review contractors.

“(B) LIMITATION.—The Secretary shall not exempt or shall rescind an exemption granted to a provider of services or supplier under subparagraph (A) if the Secretary determines that there is a reasonable basis to suspect gaming, fraud, abuse, or delay in the provision of services or items by such provider or services or supplier.

“(3) COMPLIANCE WITH REVIEW PROCEDURES BY MEDICARE CONTRACTORS.—

“(A) IN GENERAL.—Not later than 6 months after the date of enactment of this subsection, the Secretary shall establish a process, which may include the use of sampling, for determining the frequency with which the decisions made by a review contractor with respect to reviews conducted under this section are consistent with the provisions of this title and the policies, regulations, and program instructions promulgated thereunder, as well as any applicable national or local coverage determinations. The results of this process shall be made available to the public on the Internet website of the Department of Health and Human Services.

“(B) ACCESS TO MEDICAL RECORDS BY REVIEW CONTRACTORS.—

“(i) ACCESS TO RECORDS BASED ON PERFORMANCE REVIEW.—Not later than 6 months after the date of enactment of this Act, the Secretary shall establish a system under which, in addition to any other adjustments that the Secretary may make to the number of medical records that a review contractor may request, for any incentive period—

“(I) the number of medical records that a review contractor that was a high-performing review contractor in the performance review period associated with such incentive period may request from a provider of services or supplier in carrying out activities under this section may be increased (on a sliding scale); and

“(II) the number of medical records that a review contractor that was a low-performing review contractor in the performance review period associated with such incentive period may request from a provider of services or supplier in carrying out activities under this section may be decreased (on a sliding scale).

“(ii) DEFINITIONS.—In this subparagraph:

“(I) HIGH-PERFORMING REVIEW CONTRACTOR.—The term ‘high-performing review contractor’ means a review contractor that, for a given performance review period, makes decisions with respect to reviews conducted under this section of the activities of providers of services and suppliers that are consistent with the provisions of this title and the policies, regulations, and program instructions promulgated thereunder, as well as any applicable national or local coverage determinations, at a rate that is equal to or greater than 95 percent.

“(II) INCENTIVE PERIOD.—The term ‘incentive period’ means, with respect to a performance review period, a period of time (to be determined by the Secretary) following such performance review period during which the number of medical records that a review contractor may request from a provider of services or supplier may be increased or decreased based on such contractor’s status as a high-performing review contractor or a low-performing review contractor for such performance review period.

“(III) LOW-PERFORMING REVIEW CONTRACTOR.—The term ‘low-performing review contractor’ means a review contractor that, for a given performance review period, is not described in subclause (I).

“(IV) PERFORMANCE REVIEW PERIOD.—The term ‘performance review period’ means a period of time (to be determined by the Secretary) during which a review contractor’s decisions with respect to reviews conducted under this section are evaluated to determine if such review contractor is a high-performing contractor or a low-performing contractor for such period.”.