Enhancing Certain Program Integrity Requirements for Dme under Medicare
Section 6212 · Sec. 6212 ·
What this chapter is about
This part adds a new billing warning sign for medical equipment. From January 1, 2029, an item ordered by a provider who has not treated the patient before can be flagged. It also orders a fraud report on lab tests and puts $1,200,000 behind the work.
The document says “shall”Who acts: Secretary of Health and Human ServicesHow: statuteSec. 6212 in the PDF
What the document says
“the Secretary shall also treat an item for which payment may be made under this subsection as having such an aberrant billing pattern if the Secretary determines that, without explanatory contributing factors (such as furnishing emergent care services), a substantial number of claims for such items under this subsection are for such items ordered by a physician or practitioner who has not previously”
Section 6212 adds a new paragraph (23) to section 1834(a) of the Social Security Act. From January 1, 2029, for the Master List described in section 414.234(b) of title 42 of the Code of Federal Regulations, the Secretary must also treat an item as having an aberrant billing pattern where a substantial number of claims are for items ordered by a physician or practitioner who has not, in a period of at least 24 months as the Secretary sets, furnished the patient any item or service payable under the Medicare title, and there are no explanatory contributing factors such as emergent care.
What the document actually says
“the Secretary shall also treat an item for which payment may be made under this subsection as having such an aberrant billing pattern if the Secretary determines that, without explanatory contributing factors (such as furnishing emergent care services), a substantial number of claims for such items under this subsection are for such items ordered by a physician or practitioner who has not previously”
That sentence, in plain words
The health chief must flag an item. That happens when many claims for it come from one kind of source. The source is a provider who has not treated that patient.
What this is about
The list names items that get extra checks. A new sign is added to it. The sign is a provider ordering gear for someone they do not treat.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “can”Who acts: Secretary of Health and Human ServicesHow: statuteSec. 6212 in the PDF
What the document says
“``(B) Claim review.--With respect to items furnished on or after January 1, 2029, that are included on the Master List pursuant to subparagraph (A), if such an item is not subject to a determination of coverage in advance pursuant to paragraph (15)(C), the Secretary may conduct prepayment review of claims for payment for such item.''.”
The new paragraph lets the Secretary conduct prepayment review of claims for an item furnished on or after January 1, 2029 that is on the Master List under the new rule, where the item is not already subject to an advance coverage determination under paragraph (15)(C).
What the document actually says
“``(B) Claim review.--With respect to items furnished on or after January 1, 2029, that are included on the Master List pursuant to subparagraph (A), if such an item is not subject to a determination of coverage in advance pursuant to paragraph (15)(C), the Secretary may conduct prepayment review of claims for payment for such item.''.”
That sentence, in plain words
Say an item is on the list and is given on or after January 1, 2029. The health chief may check the claim before paying it.
What this is about
Most claims are paid first and checked later. A check before payment is slower. It is used where the risk looks higher.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall apply”Who acts: Secretary of Health and Human ServicesHow: statuteSec. 6212 in the PDF
What the document says
“``, and paragraph (23) of subsection (a) shall apply to prosthetic devices, orthotics, and prosthetics in the same manner as such provision applies to items for which payment may be made under such subsection''”
Paragraph (2) of subsection (a) amends section 1834(h)(3) of the Social Security Act so that the new paragraph (23) applies to prosthetic devices, orthotics and prosthetics in the same way it applies to durable medical equipment.
What the document actually says
“``, and paragraph (23) of subsection (a) shall apply to prosthetic devices, orthotics, and prosthetics in the same manner as such provision applies to items for which payment may be made under such subsection''”
That sentence, in plain words
The new rule also covers limb devices, braces and other such gear. It works the same way for them.
What this is about
A conforming change keeps two sets of gear under one rule. Without it, the new check would cover only some items.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall”Who acts: Inspector General of the Department of Health and Human ServicesHow: statuteSec. 6212 in the PDF
What the document says
“Not later than January 1, 2028, the Inspector General of the Department of Health and Human Services shall submit to”
Subsection (b) of section 6212 requires the Inspector General of the Department of Health and Human Services to submit to Congress, by January 1, 2028, a report assessing fraud risks for clinical diagnostic laboratory tests payable under section 1834A of the Social Security Act and effective tools for reducing fraudulent claims. The report may, at the Inspector General's discretion, identify high risk tests, set out amounts payable and volumes, note whether orders came from providers without a prior relationship with the patient, count how often code 59 or 91 was used, and suggest strategies including outlier monitoring and targeted education.
What the document actually says
“Not later than January 1, 2028, the Inspector General of the Department of Health and Human Services shall submit to”
That sentence, in plain words
There is a watchdog office inside the health department. By January 1, 2028 it must send in a report.
What this is about
The report is about lab tests that carry a high risk of false claims. It goes to Congress. Much of what it holds is left to the watchdog.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall”Who acts: Inspector General of the Department of Health and Human ServicesHow: statuteSec. 6212 in the PDF
What the document says
“In addition to amounts otherwise available, there is appropriated to the Inspector General of the Department of Health and Human Services, out of any money in the Treasury not otherwise appropriated, $1,200,000 for fiscal year 2026, to remain available until expended, to carry out this section.”
Subsection (c) of section 6212 appropriates $1,200,000 to the Inspector General of the Department of Health and Human Services for fiscal year 2026, in addition to amounts otherwise available, to remain available until expended, to carry out the section.
What the document actually says
“In addition to amounts otherwise available, there is appropriated to the Inspector General of the Department of Health and Human Services, out of any money in the Treasury not otherwise appropriated, $1,200,000 for fiscal year 2026, to remain available until expended, to carry out this section.”
That sentence, in plain words
The sum of $1,200,000 goes to the department watchdog for 2026. It may be held until it is spent.
What this is about
The report takes staff time and data work. This money pays for it. Funds that stay available do not lapse at year end.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The main things the section does: add a new paragraph (23) to section 1834(a) of the Social Security Act covering Master List inclusion and prepayment claim review, apply it to prosthetic devices, orthotics and prosthetics, require an Inspector General report on lab test fraud risk, and appropriate funding.
The items the report may include, listed one by one. They are recorded in summary.
The section amends the Social Security Act and points at a section of the Code of Federal Regulations. Neither is indexed here, so what the Master List and the advance coverage determination process otherwise involve is not recorded on this site.
