Medicare Transaction Fraud Prevention Act

Issues pertaining to durable medical equipment including competitive bidding, power wheelchairs, oxygen, non-invasive ventilators, diabetic supplies, negative pressure wound therapy, Medicare audits, and sequestration; Issues related to Medicare sequestration paygo relief legislation; Issues related to the non-application of Medicare competitive acquisition rates to complex rehabilitative wheelchairs manual accessories, titanium/carbon upgrade legislation, and Medicare coverage of seat elevation and standing features; S.1294 - Competitive Bidding Relief Act of 2023 (issues related to Medicare reimbursement cuts in DME noncompetitive bidding areas); Issues related to the COVID-19 public health emergency; H.R.7623 - Telehealth Modernization Act of 2024; Consolidated Appropriations Act, 2022 (P.L. 117-103) (issues related to coding and payment for the new required benefit regarding disposable negative pressure wound therapy devices); H.R.4189 - CONNECT for Health Act of 2023; H.R.5555 - DEMPOS Relief Act of 2023; H.R.5371/S.5154 - Choices for Increased Mobility Act of 2023; H.R.7147/S.3630 - Medicare Transaction Fraud Prevention Act.

Client expense: $250,000 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), Food & Drug Administration (FDA), Government Accountability Office (GAO), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Office of Management & Budget (OMB), SENATE

Issues pertaining to durable medical equipment including: competitive bidding, power wheelchairs, oxygen, non-invasive ventilators, diabetic supplies, negative pressure wound therapy, Medicare audits, and sequestration; Medicare sequestration paygo relief legislation; Issues related the non-application of Medicare competitive acquisition rates to complex rehabilitative wheelchairs manual accessories, titanium/carbon upgrade legislation, and Medicare coverage of seat elevation and standing features; Issues related to Medicare reimbursement cuts in DME noncompetitive bidding areas (S. 1294); Issues related to the COVID-19 public health emergency and expansion of telehealth act; Implementation of the Better Wound Care at Home Act of 2021; H.R. 4189 - CONNECT for Health Act of 2023; H.R. 5555 - DEMPOS Relief Act of 2023; H.R. 5371 - Choices for Increased Mobility Act of 2023; S.3630/H.R. 7147 - Medicare Transaction Fraud Prevention Act.

Client expense: Not reported · Firm income: $60,000

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), SENATE

Draft, Broker Accountability Act (no bill number) - ACA Agent/Broker accountability H.R. 35 - Close the Medigap Act of 2023 - Rep. Doggett, Lloyd - Medigap policies H.R. 3746 - Fiscal Responsibility Act of 2023 - Rep. McHenry, Patrick - work requirements for federal programs H.R. 3875 - Expanded Telehealth Access Act - Rep. Sherrill, Mikie - Medicare payment for telehealth services H.R. 4411 - Medicare Advantage Integrity Act - Resident Commissioner Gonzalez-Colon, Jenniffer - disparity in MA benchmark rates H.R. 4818 - Treat and Reduce Obesity Act of 2023 - Rep. Wenstrup, Brad -Medicare Coverage of weight loss treatment H.R. 5526 - Seniors' Access to Critical Medications Act of 2023 - Rep. Harshbarger, Diana - exception for physician self-referral H.R. 5584 - Medicaid Third Party Liability Act - Rep. Burgess, Michael - amends Medicaid Third Party liability requirements H.R. 5746 - Addressing Whole Health in Medicare Advantage Act - Rep. Bilirakis, Gus - Medicare Advantage supplemental benefits H.R. 5854 - Medicare Advantage Consumer Protection and Transparency Act - Rep. Porter, Katie - Medicare Advantage organization reporting H.R. 6364 - Medicare Telehealth Privacy Act of 2023 - Rep. Balderson, Troy - Provider privacy provisions for telehealth under Medicare H.R. 6400 - To amend title XVIII of the Social Security Act to extend eligibility for certain payment increases for biosimilar biological products under the Medicare program - Rep. Cardenas, Tony - Medicare payment increase for biosimilars H.R. 6445 - Medicare Audiology Access Improvement Act of 2023 - Rep. Bilirakis, Gus - Medicare Audiology Coverage H.R. 7147 - Medicare Transaction Fraud Prevention Act - Rep. Schweikert, David - oversight of payments for medical equipment & clinical DLTs under Medicare H.R. 7148 - Medicare Home Health Accessibility Act - Rep. Smucker, Lloyd - occupational therapy eligibility for home health coverage under Medicare H.R. 7254 - Hearing Device Coverage Clarification Act - Rep. Fischbach, Michelle - excludes fully implanted active middle ear hearing devices from the hearing aid coverage exclusion under Medicare H.R. 7274 - Connecting Caregivers to Medicare Act of 2024 - Rep. Carey, Mike - outreach, education, and simplify information for family caregivers on Medicare benefits H.R. 7432 - Sickle Cell Disease Comprehensive Care Act - Rep. Burgess, Michael - enables State Medicaid programs to provide coordinated care through health home to individuals with sickle cell disease H.R. 7512 - Real-Time Benefit Tool Implementation Act - Rep. Arrington, Jodey - implementation of real-time benefit tools under part D of under Medicare H.R. 7573 - Stop Unfair Medicaid Recoveries Act - Rep. Schakowsky, Janice - Medicaid Estate Recovery Program H.R. 7619 - Expand the Behavioral Health Workforce Now Act - Rep. Neguse, Joe - education, training, recruitment, and retention of mental health and substance use disorder providers under Medicaid and CHIP H.R. 7623 - Telehealth Modernization Act of 2024 - Rep. Carter, Earl L. Buddy - makes certain telehealth flexibilities permanent under Medicare H.R. 7856 - Promoting Responsible and Effective Virtual Experiences through Novel Technology to Deliver Improved Access and Better Engagement with Tested and Evidence-based Strategies Act (PREVENT DIABETES Act)- Rep. DeGette, Diana - Medicare, coverage, preventive care, chronic care H.R. 7863 - To require the Secretary of Health and Human Services to issue guidance on furnishing behavioral health services via telehealth to individuals with limited English proficiency under Medicare program. - Rep. Steel, Michelle - Medicare, behavioral health, telehealth, accessibility H.R. 7939 - Patient Access to Innovative New Technologies Act of 2024 - Rep. Carey, Mike - Medicare, quality, medical devices, coverage H.R. 8018 - Alleviating Barriers for Caregivers Act- Rep. Cammack, Kat - review and simplify caregiver paperwork, CHIP, Medicare, Medicaid H.R. 8064 - Help Extend Auditory Relief Act of 2024- Rep. Cartwright, Matt - Medicare coverage of hearing aids H.R. 8075 - Improving Access to Home Dialysis Act of 2024- Rep. Miller, Carol - Medicare coverage of home dialysis H.R. 8115 - To amend title XIX of the Social Security Act to allow for the deferral or disallowance of portions of payments for certain managed care violations under Medicaid- Rep. Sarbanes, John - Medicaid managed care payment deferral H.R. 8261 - Preserving Telehealth, Hospital, and Ambulance Access Act- Rep. Schweikert, David - extend flexibilities and payment for Medicare H.R. 8702 - Improving Seniors Timely Access to Care Act - Rep. Mike Kelly - prior authorization, transparency, MA S. 838 - Improving Access to Mental Health Act - Sen. Stabenow, Debbie - mental health services in Medicare S. 2880 - Expanded Telehealth Access Act - Sen. Daines, Steve - Medicare payment for telehealth services S. 3573 - Medicare Advantage Supplemental Benefits Transparency Act- Sen. Warner, Mike - MA, data transparency, supplemental benefits S. 3578 - Protect Medicaid Act - Sen. Cassidy, Bill - prohibits federal payments under Medicaid for noncitizens, requires reporting to HHS of states that provide such health benefits S. 3630 - Medicare Transaction Fraud Prevention Act- Sen. Braun, Mike- pilot program for predictive risk-scoring algorithm, oversight, Medicare S. 3651 - Telemental Health Care Access Act of 2024- Sen. Cassidy, Bill - Medicare, mental health services, telehealth S. 3766 - Connecting Caregivers to Medicare Act of 2024- Sen. Tillis, Thomas - Medicare, outreach and education, caregivers S. 3882 - Helping States Integrate Medicare and Medicaid Act- Sen. Casey, Robert - dual eligibles, quality measures, access, enrollment S. 3934 - Increasing Access to Biosimilars Act of 2023- Sen. Cornyn, John - Medicare drug access S. 3950 - Delivering Unified Access to Lifesaving Services Act of 2024 - Sen. Cassidy, Bill - reforming Integrated Medicare/Medicaid Care Programs for Dually Eligible Individuals S. 4094 - PREVENT DIABETES Act - Sen. Scott, Tim - Medicare, coverage, preventive care, chronic care S. 4532 - Improving Seniors Timely Access to Care Act - Sen. Marshall, Roger - prior authorization, transparency, MA Issues related to mental health and Medicare; Medicare and Medicaid funding; Medicaid expansion; State innovation waivers; Medicaid and CHIP; Medicaid FMAP; Medicare Supplement Coverage; Medicaid Access Final Rule; Medicaid Redeterminations; value of Medicaid Managed Care; Medicare Advantage Health Risk Assessment; coverage of weight loss drugs; and Inflation Reduction Act implementation.

Issues pertaining to durable medical equipment including: competitive bidding, power wheelchairs, oxygen, non-invasive ventilators, diabetic supplies, negative pressure wound therapy, Medicare audits, and sequestration; Medicare sequestration paygo relief legislation; Issues related the non-application of Medicare competitive acquisition rates to complex rehabilitative wheelchairs manual accessories, titanium/carbon upgrade legislation, and Medicare coverage of seat elevation and standing features; Issues related to Medicare reimbursement cuts in DME noncompetitive bidding areas (S. 1294); Issues related to the COVID-19 public health emergency and expansion of telehealth act; Implementation of the Better Wound Care at Home Act of 2021; H.R. 4189 - CONNECT for Health Act of 2023; H.R. 5555 - DEMPOS Relief Act of 2023; H.R. 5371 - Choices for Increased Mobility Act of 2023; S.3630/H.R. 7147 - Medicare Transaction Fraud Prevention Act.

Client expense: Not reported · Firm income: $60,000

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), SENATE

Issues pertaining to durable medical equipment including: competitive bidding, power wheelchairs, oxygen, non-invasive ventilators, diabetic supplies, negative pressure wound therapy, Medicare audits, and sequestration; Medicare sequestration paygo relief legislation; Issues related the non-application of Medicare competitive acquisition rates to complex rehabilitative wheelchairs manual accessories, titanium/carbon upgrade legislation, and Medicare coverage of seat elevation and standing features; Issues related to Medicare reimbursement cuts in DME noncompetitive bidding areas (S. 1294); Issues related to the COVID-19 public health emergency and expansion of telehealth act; Implementation of the Better Wound Care at Home Act of 2021; H.R. 4189 - CONNECT for Health Act of 2023; H.R. 5555 - DEMPOS Relief Act of 2023; H.R. 5371 - Choices for Increased Mobility Act of 2023; S.3630/H.R. 7147 - Medicare Transaction Fraud Prevention Act.

Client expense: $250,000 · Firm income: Not reported

H.R. 35 - Close the Medigap Act of 2023 - Rep. Doggett, Lloyd - Medigap policies H.R. 3746 - Fiscal Responsibility Act of 2023 - Rep. McHenry, Patrick - work requirements for federal programs H.R. 3875 - Expanded Telehealth Access Act - Rep. Sherrill, Mikie - Medicare payment for telehealth services H.R. 4411 - Medicare Advantage Integrity Act - Resident Commissioner Gonzalez-Colon, Jenniffer - disparity in MA benchmark rates H.R. 5526 - Seniors' Access to Critical Medications Act of 2023 - Rep. Harshbarger, Diana - exception for physician self-referral H.R. 5584 - Medicaid Third Party Liability Act - Rep. Burgess, Michael - amends Medicaid Third Party liability requirements H.R. 5746 - Addressing Whole Health in Medicare Advantage Act - Rep. Bilirakis, Gus - Medicare Advantage supplemental benefits H.R. 5854 - Medicare Advantage Consumer Protection and Transparency Act - Rep. Porter, Katie - Medicare Advantage organization reporting H.R. 6364 - Medicare Telehealth Privacy Act of 2023 - Rep. Balderson, Troy - Provider privacy provisions for telehealth under Medicare H.R. 6400 - To amend title XVIII of the Social Security Act to extend eligibility for certain payment increases for biosimilar biological products under the Medicare program - Rep. Cardenas, Tony - Medicare payment increase for biosimilars H.R. 6445 - Medicare Audiology Access Improvement Act of 2023 - Rep. Bilirakis, Gus - Medicare Audiology Coverage H.R. 7147 - Medicare Transaction Fraud Prevention Act - Rep. Schweikert, David - oversight of payments for medical equipment & clinical DLTs under Medicare H.R. 7274 - Connecting Caregivers to Medicare Act of 2024 - Rep. Carey, Mike - outreach, education, and simplify information for family caregivers on Medicare benefits H.R. 7432 - Sickle Cell Disease Comprehensive Care Act - Rep. Burgess, Michael - enables State Medicaid programs to provide coordinated care through health home to individuals with sickle cell disease H.R. 7512 - Real-Time Benefit Tool Implementation Act - Rep. Arrington, Jodey - implementation of real-time benefit tools under part D of under Medicare H.R. 7573 - Stop Unfair Medicaid Recoveries Act - Rep. Schakowsky, Janice - Medicaid Estate Recovery Program H.R. 7619 - Expand the Behavioral Health Workforce Now Act - Rep. Neguse, Joe - education, training, recruitment, and retention of mental health and substance use disorder providers under Medicaid and CHIP H.R. 7623 - Telehealth Modernization Act of 2024 - Rep. Carter, Earl L. - makes certain telehealth flexibilities permanent under Medicare S. 838 - Improving Access to Mental Health Act - Sen. Stabenow, Debbie - mental health services in Medicare S. 2880 - Expanded Telehealth Access Act - Sen. Daines, Steve - Medicare payment for telehealth services S. 3573- Medicare Advantage Supplemental Benefits Transparency Act- Sen. Warner, Mike - MA, data transparency, supplemental benefits S. 3578- Protect Medicaid Act - Sen. Cassidy, Bill - prohibits federal payments under Medicaid for noncitizens, requires reporting to HHS of states that provide such health benefits S. 3630- Medicare Transaction Fraud Prevention Act- Sen. Braun. Mike- pilot program for predictive risk-scoring algorithm, oversight, Medicare S. 3651- Telemental Health Care Access Act of 2024- Sen. Cassidy, Bill - Medicare, mental health services, telehealth S. 3766- Connecting Caregivers to Medicare Act of 2024- Sen. Tillis, Thomas - Medicare, outreach and education, caregivers S. 3882- Helping States Integrate Medicare and Medicaid Act- Sen. Casey, Robert - dual eligibles, quality measures, access, enrollment S. 3934- Increasing Access to Biosimilars Act of 2023- Sen. Cornyn, John - Medicare drug access S. 3950 - Delivering Unified Access to Lifesaving Services Act of 2024 - Sen. Cassidy, Bill - reforming Integrated Medicare/Medicaid Care Programs for Dually Eligible Individuals Issues related to mental health and Medicare; Medicare and Medicaid funding; Medicaid expansion; State innovation waivers; Medicaid and CHIP; Medicaid FMAP; issues related to Medicare Advantage payment, including Medicare Payment Advisory Commission analyses and the 2025 Advance Rate Notice for MA and Part D; MedPAC analysis of MA payments, MA CY 2025 rate notice; MA risk adjustment; prior authorization in Medicare and Medicaid; MA coverage in rural areas; and issues related to implementation of the Inflation Reduction Act, including reform of the Medicare Part D program. Regulatory Issues: Ongoing implementation issues for the Medicare Advantage (MA) and Medicare Part D prescription drug programs, including risk adjustment methodology, network adequacy and provider directories, encounter data and other data-related issues, and risk adjustment data validation (RADV) audit issues including RADV regulation for MA; bidding and payment issues (including MA rate assumptions, MA coding intensity, MA Secondary Payer issues, Part D reinsurance, Part D low income subsidies, Part D direct and indirect remuneration (DIR), and audits); issues related to Medicare for All, Medicare buy-in, reduced Medicare eligibility age, and public option; issues relating to 2024 Rate Notice; issues related to the expiration of Medicaid continuous eligibility and transitions in coverage; issues related to coverage in non-Medicaid Expansion States (e.g., Gap Population); issues related to expanded Medicare fee for service benefits (dental, hearing and vision); issues related to specialty infant formula; issues related to the Inflation Reduction Act implementation; contraceptive coverage and reproductive health; Medicare NCD relating to monoclonal antibodies for treatment of Alzheimers disease; issues related to Managed Long Term Services and Supports (MLTSS); issues relating to COVID-19, including testing, vaccines and therapeutics; issues related to the end of the public health emergency, including the Medicaid unwinding; telehealth; issues related to the cost of insulin, including price, copays, rebates, and medical management tools; issues related to health equity; issues related to artificial intelligence; issues related to vaccination; issues related to audio-only telehealth; issues related to addressing the social determinants of health, including housing, transportation, nutrition, educational opportunities, and MA supplemental benefits; issues related to Medicaid presumptive eligibility and continuous eligibility; issues relating to Medicaid best price; in-home health risk assessments; Medicare Medical Loss Ratio issues; issues related to changes to prior authorization regulations or legislation, electronic documentation, and related issues; issues relating to sequestration under the Medicare Advantage and Part D programs; implications of physician fee schedule on MA; application process, audits to evaluate compliance with MA and Part D program rules, benefit design rules, enrollment rules, requirements for notice and denial forms, marketing materials review and approval, marketing activities, including conduct and compensation of brokers and agents and plan sponsor marketing staff; measurement and oversight of plan performance including Special Needs Plans (SNPs); quality measures, grievance and appeals processes, fraud and abuse compliance including training; contracting issues for Dual Eligible SNPs; Federal preemption of State authority under MA and Part D programs, Part D prescription drug event data reporting, Part D formulary rules, Part D pharmacy access standards, Part D coverage gap discount program, including employer group waiver plan (EGWP) issues, and other operational issues; issues raised by Part D coverage of new specialty drugs, the Part D non-interference policy and related issues (e.g., preferred pharmacy and any willing pharmacy requirements, standards for network pharmacy reimbursement, and policies regarding sponsor negotiation of pharmacy price concessions); issues related to the international price index; issues related to child and maternal health; issues related to Medicaid supplemental and disproportionate share hospital (DSH) funding; issues related to Medicaid funding for territories; issues related to medical management; issues relating to MA supplemental benefits; Medication Therapy Management Program requirements and the Center for Medicare and Medicaid Innovation (CMMI) Demonstration; MA EGWP issues; CMMI's value based payment models; Part D requirements for offering basic and enhanced alternative plans; MA and Part D systems issues affecting enrollment and disenrollment processing and payment and other operational issues; issues relating to MA and Part D Star Rating system including measures, the methodology for calculating ratings, and the role of the ratings for payment purposes; functionality of the Medicare Personal Plan Finder and Drug Plan Finder; National Medicare Education Program; Medicare demonstration program on performance-based payments for physician groups; physician quality reporting initiative; issues relating to Medicare coverage policy and national coverage decisions; issues relating to MACRA, including implications for MA and Part D plans; Medicare/Medicaid integration for dual eligibles, including implementation of the Capitated Financial Alignment Demonstration and related issues (e.g., quality ratings); issues relating to potential Medicare mental health parity requirements; Medicaid managed care regulations and policies, including the Medicaid managed care actuarial soundness standard, quality oversight, Medicaid and CHIP Payment and Access Commission (MACPAC), grievance and appeals processes, fraud and abuse compliance, beneficiary information requirements, treatment of Medicaid health plan member hospital days in the upper payment limit calculation; policies affecting State Medicaid funding, including block grants, the calculation of the federal medical assistance (federal matching) percentage (FMAP), and intergovernmental transfers (IGTs); coordination of benefits with state Medicaid programs; Medicaid prescription drug cost issues affecting Medicaid health plans including issues raised by Medicaid coverage of new specialty drugs; health plan-related Childrens Health Insurance Program (CHIP) issues, including eligibility and outreach issues and CHIP reauthorization; implementation of Medicaid changes made in Deficit Reduction Act of 2005, including Medicaid managed care organization provider tax issues; standards for electronic prescribing; issues related to Medicaid Managed long-term care including home and community-based waiver services (HCBS); expanding the availability of Medicare Advantage and Medicaid health plan telemedicine programs; implications of the new non-discrimination rules for health plans participating in public programs; issues related to Medigap coverage; issues related to business continuity in relation to pandemics or natural events (e.g., hurricane, tornado, etc.); cybersecurity; provider directories; value-based insurance design models; Part D prescriber enrollment requirements; Part D recovery audit contractor programs; issues related to health homes for children with medically complex conditions; socioeconomic status impacts on star ratings related to MA and Part D programs; issues related to private equity ownership transparency; and other issues relating to health care reform implementation.

Healthcare issues related to clinical laboratories; H.R. 2377/S. 1000, the Saving Access to Laboratory Services Act (SALSA), provisions relating to reform of Medicare reimbursement for clinical laboratory services under Section 216 of the Protecting Access to Medicare Act, Pub. L. 113-93; H.R. 2369, the Verifying Accurate Leading-edge IVCT Development (VALID) Act, and the Fiscal Year 2025 Agriculture/FDA Appropriations bill, provisions relating to FDA oversight of laboratory-developed tests; Section 102 of H.R. 5378, the Lower Costs, More Transparency Act, and Section 3 of S. 3548, the Health Care Price Transparency Act 2.0, provisions relating to publication of rates for laboratory services; H.R. 7147/S. 3630, the Medicare Transaction Fraud Prevention Act, provisions relating to a Medicare pilot program using predictive risk algorithms to deny certain claims for clinical laboratory services; A draft of the Correct Coding Improvement Act, provisions related to laboratory procedure coding edits adopted by CMS under the National Correct Coding Initiative (NCCI), the adoption of Proprietary Laboratory Analysis (PLA) codes, and access to mandatory code sets for administrative transactions; Federal policy related to supply chain issues affecting pre-clinical biomedical research for drug development.

Client expense: Not reported · Firm income: $110,000

Healthcare issues related to clinical laboratories; H.R. 2377/S. 1000, the Saving Access to Laboratory Services Act (SALSA), provisions relating to reform of Medicare reimbursement for clinical laboratory services under Section 216 of the Protecting Access to Medicare Act, Pub. L. 113-93; H.R. 2369, the Verifying Accurate Leading-edge IVCT Development (VALID) Act, and the Fiscal Year 2025 Agriculture/FDA Appropriations bill, provisions relating to FDA oversight of laboratory-developed tests; Section 102 of H.R. 5378, the Lower Costs, More Transparency Act, and Section 3 of S. 3548, the Health Care Price Transparency Act 2.0, provisions relating to publication of rates for laboratory services; H.R. 7147/S. 3630, the Medicare Transaction Fraud Prevention Act, provisions relating to a Medicare pilot program using predictive risk algorithms to deny certain claims for clinical laboratory services; S. 3558, a bill to prohibit contracting with certain biotechnology providers; H.R. 7848, the Right Drug Dose Now Act, provisions relating to adoption of pharmacogenomic testing; A draft of the Correct Coding Improvement Act, provisions related to laboratory procedure coding edits adopted by CMS under the National Correct Coding Initiative (NCCI), the adoption of Proprietary Laboratory Analysis (PLA) codes, and access to mandatory code sets for administrative transactions; The Fiscal Year 2025 House and Senate Labor/HHS Appropriations bills, Federal policy related to funding for the CDC to establish lab test result harmonization and pediatric reference intervals; and Federal policy related to supply chain issues affecting pre-clinical biomedical research for drug development.

Client expense: $810,000 · Firm income: Not reported