
From the U.S. Code Online via GPO Access
[wais.access.gpo.gov]
[Laws in effect as of January 23, 2000]
[Document not affected by Public Laws enacted between
  January 23, 2000 and December 4, 2001]
[CITE: 42USC1395ddd]

 
                 TITLE 42--THE PUBLIC HEALTH AND WELFARE
 
                       CHAPTER 7--SOCIAL SECURITY
 
        SUBCHAPTER XVIII--HEALTH INSURANCE FOR AGED AND DISABLED
 
                    Part D--Miscellaneous Provisions
 
Sec. 1395ddd. Medicare Integrity Program


(a) Establishment of Program

    There is hereby established the Medicare Integrity Program (in this 
section referred to as the ``Program'') under which the Secretary shall 
promote the integrity of the Medicare program by entering into contracts 
in accordance with this section with eligible entities to carry out the 
activities described in subsection (b) of this section.

(b) Activities described

    The activities described in this subsection are as follows:
        (1) Review of activities of providers of services or other 
    individuals and entities furnishing items and services for which 
    payment may be made under this subchapter (including skilled nursing 
    facilities and home health agencies), including medical and 
    utilization review and fraud review (employing similar standards, 
    processes, and technologies used by private health plans, including 
    equipment and software technologies which surpass the capability of 
    the equipment and technologies used in the review of claims under 
    this subchapter as of August 21, 1996).
        (2) Audit of cost reports.
        (3) Determinations as to whether payment should not be, or 
    should not have been, made under this subchapter by reason of 
    section 1395y(b) of this title, and recovery of payments that should 
    not have been made.
        (4) Education of providers of services, beneficiaries, and other 
    persons with respect to payment integrity and benefit quality 
    assurance issues.
        (5) Developing (and periodically updating) a list of items of 
    durable medical equipment in accordance with section 1395m(a)(15) of 
    this title which are subject to prior authorization under such 
    section.

(c) Eligibility of entities

    An entity is eligible to enter into a contract under the Program to 
carry out any of the activities described in subsection (b) of this 
section if--
        (1) the entity has demonstrated capability to carry out such 
    activities;
        (2) 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;
        (3) the entity complies with such conflict of interest standards 
    as are generally applicable to Federal acquisition and procurement; 
    and
        (4) the entity meets such other requirements as the Secretary 
    may impose.

In the case of the activity described in subsection (b)(5) of this 
section, an entity shall be deemed to be eligible to enter into a 
contract under the Program to carry out the activity if the entity is a 
carrier with a contract in effect under section 1395u of this title.

(d) Process for entering into contracts

    The Secretary shall enter into contracts under the Program in 
accordance with such procedures as the Secretary shall by regulation 
establish, except that such procedures shall include the following:
        (1) Procedures for identifying, evaluating, and resolving 
    organizational conflicts of interest that are generally applicable 
    to Federal acquisition and procurement.
        (2) Competitive procedures to be used--
            (A) when entering into new contracts under this section;
            (B) when entering into contracts that may result in the 
        elimination of responsibilities of an individual fiscal 
        intermediary or carrier under section 202(b) of the Health 
        Insurance Portability and Accountability Act of 1996; and
            (C) at any other time considered appropriate by the 
        Secretary,

    except that the Secretary may continue to contract with entities 
    that are carrying out the activities described in this section 
    pursuant to agreements under section 1395h of this title or 
    contracts under section 1395u of this title in effect on August 21, 
    1996.
        (3) 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.

(e) Limitation on contractor liability

    The Secretary shall by regulation provide for the limitation of a 
contractor's liability for actions taken to carry out a contract under 
the Program, and such regulation shall, to the extent the Secretary 
finds appropriate, employ the same or comparable standards and other 
substantive and procedural provisions as are contained in section 1320c-
6 of this title.

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1893, as added Pub. L. 104-
191, title II, Sec. 202(a), Aug. 21, 1996, 110 Stat. 1996.)

                       References in Text

    Section 202(b) of the Health Insurance Portability and 
Accountability Act of 1996, referred to in subsec. (d)(2)(B), is section 
202(b) of Pub. L. 104-191, which amended sections 1395h and 1395u of 
this title.

                  Section Referred to in Other Sections

    This section is referred to in sections 1395h, 1395i, 1395u of this 
title.
