in a range of residency programs, including primary care and other specialties; and have the appropriate faculty expertise to teach the topics required to achieve such goals. A report on the results of the study would be submitted to Congress no later than 18 months after the date of the enactment. The study would include recommendations with respect to the development of curriculum requirements and an assessment of the accreditation processes of the Accreditation Council for Graduate Medical Education (ACGME) and the American Osteopathic Association (AOA) and effectiveness of these processes in meeting the residency program goals established in this section. Reason for Change MedPAC recommends that the residency training experience should encourage physicians to increase care coordination and assume greater accountability for quality of care. Graduate medical education should train a future physician workforce exposed to innovative delivery models that would support more integration. A MedPAC-sponsored study conducted by RAND pointed out that the curricula of residency training programs fall short of recommendations by the Institute of Medicine and other experts on items such as formal training or experience in multidisciplinary teamwork, cost-awareness in clinical decision-making, comprehensive health information technology, and patient care in nonhospital settings. Residents should be trained in innovative delivery systems that will support coordinated care and enhance an integrated approach. The Accreditation Council for Graduate Medical Education has also included similar goals for residency programs to improve the training of residents. The COGME report calls for "making accountability for the public's health the driving force for graduate medical education." The report further states that the $10 billion spent annually on GME should have parameters on how our physician workforce should be trained and the type of training residents should receive. This policy is intended to highlight broad goals, consistent with MedPAC recommendations, for residency programs to improve their accountability. The Comptroller General will undertake a study to assess: (1) the extent to which residency programs are meeting these goals and (2) the accreditation processes of ACGME and AOA and effectiveness of these processes in promoting the workforce goals established in this section. TITLE VI-PROGRAM INTEGRITY Subtitle A-Increased Funding to Fight Fraud, Waste, and Abuse Sec. 1601. Increased funding and flexibility to fight fraud and abuse Current Law The Health Care Fraud and Abuse Control (HCFAC) account funds activities to fight healthcare fraud. The HCFAC program along with the Medicare Integrity Program (MIP) were both established by the Health Insurance Portability and Accountability Act of 1996 (HIPAA, P.L. 104–191), which sought to increase and stabilize federal funding for healthcare anti-fraud activities. Specifically, HCFAC funds are directed to the enforcement and prosecu tion of healthcare fraud. MIP funding supports the program integrity activities undertaken by CMS contractors. For HCFAC, HIPAA appropriated funds to the Department of Health and Human Services, the Department of Justice (DOJ), and the Federal Bureau of Investigation (FBI) for anti-fraud activities undertaken for fiscal years 1997 through 2003. Funds are appropriated to the Account from the Medicare Part A Trust Fund in amounts as the Secretary and the Attorney General certify are necessary to support audits, investigations, evaluations, and prosecutions related to healthcare fraud. For HHS and DOJ, the legislation authorized an amount, beginning at $104 million for FY1997, equal to the limit for the preceding year increased by 15%. Within this amount, the legislation authorized minimum and maximum appropriations for the HHS OIG. The maximum OIG appropriation increased from $70 million in FY1997 to $160 million in FY2003. For each fiscal year after 2003, the amount was capped at the 2003 level. In December 2006, Congress passed the Tax Relief and Health Care Act of 2006 (TRHCA, P.L. 109-432), which extended the mandatory annual appropriation for HCFAC to 2010. For fiscal years 2007 through 2010, the mandatory annual appropriation is the limit for the preceding year plus the percentage increase in the consumer price index for all urban consumers (CPI-U). For years after FY2010, the annual appropriation remains at the FY2010 level. The MIP program authorizes the Secretary of HHS to enter into contracts with private organizations to conduct program integrity activities such as provider audits and medical review of claims. The largest share of the HIPAA appropriation was dedicated to the MIP program. Funding for MIP increased from $440 million in FY1997 to $720 million in FY2003. For fiscal years 2004 and 2005, the annual MIP appropriation remained at the FY2003 level. In 2005, Congress passed the Deficit Reduction Act (DRA, P.L. 109–171), which raised funding for the MIP program by $112 million for FY2006 to implement program integrity and oversight activities for the Medicare prescription drug benefit. This increased the annual MIP appropriation from $720 million to $832 million for FY2006 only. Congress did not increase funding for MIP in TRHCA. Therefore the mandatory annual appropriation for MIP remains at $720 million. Proposed Law The Congressional Budget Office has estimated that every dollar of increased funding for HCFAC results in a $1.75 return on investment. The provision would increase funding for HCFAC by $100 million annually beginning with FY2011, to allow for the implementation of new provisions in the legislation and providing new tools for CMS under current laws. Funding would be appropriated to HHS, DOJ, and MIP in the same manner as is currently appropriated in statute. Funding allocated to MIP would be authorized for HCFAC activities as well as MIP activities, ending the requirement that such funding be distributed solely to private organizations to conduct program integrity activities. Funding for both HCFAC and MIP would be available without further appropriation until expended. Subtitle B-Enhanced Penalties for Fraud and Abuse Sec. 1611. Enhanced penalties for false statements on provider or supplier enrollment applications Current Law Medicare statute provides the Secretary with general authority to prescribe regulations for the efficient administration of the Medicare program. Under this authority, the Center for Medicare and Medicaid Services (CMS) has implemented regulations requiring Medicare providers and suppliers to submit an application to enroll in the Medicare program and receive billing privileges. Providers and suppliers must resubmit and recertify the accuracy of their enrollment information every 5 years. Private contractors handle Medicare enrollment activities such as processing and reviewing applications. CMS may deny enrollment of a provider or supplier in Medicare or revoke a provider's billing privileges for the following reasons: non-compliance with enrollment requirements, exclusion from participation in federal health care programs, conviction of a felony, or the submission of false or misleading information on the enrollment application. Medicaid statute delegates the administration of the Medicaid program to the states. There is considerable variation in how states administer their provider enrollment processes. State Medicaid agencies determine whether a provider or supplier is eligible to participate in the Medicaid program by providing for written agreements with providers and suppliers. Written agreements require that providers and suppliers maintain specific records, disclose certain ownership information, and grant access to federal and state auditors to books and records. Section 1128A(a) of the Social Security Act (SSA) authorizes the imposition of Civil Monetary Penalties (CMPs) and assessments on a person, including an organization, agency, or other entity, who engages in various types of improper conduct with respect to federal health care programs. Under section 1128A(a)(1)(D) of the Act, a person who knowingly presents or causes to be presented a claim to federal or state agencies that the Secretary determines is for an item or service furnished during a period when the person was excluded from participation in the federal health care program under which the claim was made is subject to a civil monetary penalty of up to $10,000 for each item or service furnished, and an assessment of up to three times the amount claimed for each item or service. Proposed Law This provision would subject providers and suppliers applying to enroll or renewing enrollment in federal health care programs to CMPs for providing false information on an enrollment application. Medicaid managed care plans, MA plans, and PDP plans would also be subject to CMPS for providing false information on applications to participate in federal health care programs. Specifically, the provision would provide that a person who knowingly makes or causes to be made any false statement, omission, or misrepresentation of a material fact on an application, agreement, bid, or contract to participate or enroll as a provider of serv ices or supplier under a federal health care program would be subject to a CMP of $50,000 for each violation. In addition to providers and suppliers, the provision would also apply to Medicaid managed care organizations, Medicare Advantage (MA) organizations and MA plans, Prescription Drug Plan (PDP) sponsors and plans, and providers and suppliers that participate in these Medicare or Medicaid plans. In addition, such a person may be subject to an assessment of not more than three times the amount claimed as the result of the false statement, omission, or misrepresentation. The provision would also eliminate the requirement for a determination by the Secretary when a person knowingly presents or causes to be presented a claim for an item or service furnished during a period when the person was excluded under federal law from the federal health care program under which the claim was made. Sec. 1612. Enhanced penalties for submission of false statements material to a false claim Current Law Section 1128A(a) of the Social Security Act authorizes the imposition of CMPs and assessments on a person, including an organization, agency, or other entity, who engages in various types of improper conduct with respect to federal health care programs. This penalty authority includes penalties against a person who knowingly presents or causes to be presented false or fraudulent claims. This section generally provides for CMPs of up to $10,000 for each item or service claimed, $15,000 or $50,000 under other circumstances, and an assessment of up to three times the amount claimed. Proposed Law The bill would create a new SSA section 1128A(a)(9) providing that persons who knowingly make, use, or cause to be made or used any false statement or record material to a false or fraudulent claim submitted for payment to a federal health care program would be subject to a civil monetary penalty of not more than $50,000 for each violation. Sec. 1613. Enhanced penalties for delaying inspections Current Law The Secretary is required to provide for the annual auditing of the financial records of at least 3 of MA plans. Each contract with a MA plan is required to provide that the Secretary have the right to inspect or evaluate the quality, appropriateness and timeliness of services performed under the contract. Contracts must also provide the Secretary with right to audit any plan's books and records related to the plan's ability to bear risk or to the services performed, including determinations of amounts payable under the contract. Proposed Law The bill would create a new SSA section 1128A(a)(10) providing that persons who fail to grant timely access, upon reasonable request (as defined by the Secretary in regulations), to the Office of the Inspector General (OIG), for the purpose of audits, investiga tions, evaluations, or other statutory functions of the OIG, be subject to CMPs of $15,000 for each day of failure. The provision would also modify the contractual requirements for MA plans to allow the Secretary to conduct timely audits and inspections of MA plans. These provisions are designed to facilitate more timely and efficient audits, investigations, and evaluations by the OIG, and more rapid and enhanced audits of MA plans by the Secretary. Sec. 1614. Enhanced hospice program safeguards Current Law Medicare statute mandates the establishment of minimum health and safety standards that must be met by providers participating in the Medicare and Medicaid programs (i.e. hospitals, hospices, nursing homes, and home health agencies). In order to receive payment, providers and suppliers must meet these health and safety standards, often referred to as Conditions of Participation (CoPs). Generally, state agencies, under contract with CMS, survey providers to determine compliance with CoPs. Alternatively, a provider can be deemed to meet these requirements if an approved national accreditation body has accredited it. If a provder has been found to be non-compliant with its CoPs, CMS has the authority to impose certain sanctions, including revoking the provider's participation agreement. States also have the authority to impose sanctions on Medicare and Medicaid participating facilities found to be non-compliant with CoPs. Proposed Law This provision would create new tools and penalties for the Secretary to use in improving quality of care in hospices. Under current law, the only options available to the Secretary are program exclusions for hospices. The provision would add a new SSA section 1819A that would require the Secretary to develop and implement intermediate sanctions to apply to hospices that, based on a determination by the Secretary, demonstrate a substandard quality of care and fail to meet such other requirements as the Secretary may find necessary in the interest of the health and safety of the individuals provided care and services by the agency or organization involved. The sanctions may include CMPs of up to $10,000 for each day of non-compliance or in the case of a per instance penalty not more than $25,000, a denial of all or part of future Medicare or Medicaid payments to which the hospice is entitled (which would terminate upon the Secretary's finding that the hospice program no longer demonstrated substandard quality and met other requirements as determined by the Secretary), requiring the appointment of managers to oversee the operation of the hospice program, correction plans, and staff training. The sanctions could be imposed in addition to those imposed under state or federal law and would not be construed as limiting other available remedies. The Secretary would have until January 1, 2012, to develop and implement the sanctions. By July 1, 2011, the Secretary would be required to create the specific procedures and conditions under which the relevant sanctions would apply, including the amount of any fines and severity of the sanctions. The conditions would be required to minimize the |