H.R. 1785: Preventing Medicare Telefraud Act

The Preventing Medicare Telefraud Act aims to amend existing laws regarding Medicare coverage for certain high-cost durable medical equipment and laboratory tests when ordered via telehealth. Here is a breakdown of the key provisions of the bill:

High-Cost Durable Medical Equipment

Under the new rules for high-cost durable medical equipment:

• Payment Restrictions: Medicare will not cover high-cost durable medical equipment ordered by a healthcare provider through telehealth unless the provider has seen the patient in person at least once in the six months prior to the equipment order. This provision will go into effect 180 days after the bill is enacted.
• Definition and Standards: The bill requires the Centers for Medicare & Medicaid Services (CMS) to define what constitutes high-cost durable medical equipment and to list specific items that fall under this category.
• Audits: Medicare contractors will perform audits on providers who prescribe a significant majority of their durable medical equipment via telehealth to ensure compliance with the new rules. Specifically, audits will target those who prescribed 90% or more of their durable medical equipment through telehealth during a specified time frame.

High-Cost Laboratory Tests

Similar to the provisions for durable medical equipment, the bill also addresses high-cost laboratory tests:

• Payment Restrictions: Medicare will restrict payment for high-cost laboratory tests ordered via telehealth, requiring an in-person visit within the preceding six months before ordering the test. This will also take effect 180 days after the bill is enacted.
• Definition and Standards: CMS will define high-cost laboratory tests and specify which tests are included in this definition.
• Audits: Periodic reviews will also be conducted on laboratory test claims for compliance, specifically targeting providers who mostly order tests through telehealth.

Provider Identification

The bill introduces a requirement for providers submitting claims for separately billable telehealth services:

• NPI Submission: Providers must submit claims under their national provider identification (NPI) number for telehealth services to receive payment. This requirement will apply to claims made 180 days after the enactment of this bill.

Overall Impact

This legislation is primarily focused on reducing potential telehealth-related fraud in the Medicare system related to high-cost medical items and services. It aims to ensure that patients have received appropriate in-person medical consultations before costly items or tests are ordered through telehealth services.

Relevant Companies

• ABC - Some durable medical equipment suppliers may be affected as the bill imposes stricter rules on telehealth prescriptions.
• XYZ - Providers of high-cost laboratory tests might need to adjust their operating procedures to comply with new in-person visit requirements.