Protecting the Integrity of Medicare Act (PIMA) of 2014


Synopsis courtesy of Marilyn Singleton, MD, JD @MSingletonMDJD

A Bipartisan Bill to Prevent Medicare Fraud, the Protecting the Integrity of Medicare Act (PIMA) of 2014, has been Introduced by House Ways and Means Health Subcommittee Chairman Kevin Brady (R-TX) and Ranking Member Jim McDermott (D-WA).

Some of the proposed protections include :

  • Prohibition of Inclusion of Social Security Account Numbers on Medicare Cards. This is one of my pet peeves. Having Social Security numbers on Medicare cards is an invitation to defraud our most vulnerable population. Way back in 1996, HIPAA specified a national identifier for patients in lieu of the SSN. However, Congress indefinitely postponed the implementation of this portion of the law. The prohibition on Social Security numbers has been introduced as separate legislation in the past but has gone nowhere, presumably because the bureaucracy has no alternate plan for assigning Medicare numbers.
  • Preventing Wrongful Medicare Payments and for Other Purposes. This provision prevents wrongful Medicare payments for incarcerated, not lawfully present, and deceased individuals.
  • Measures Regarding Medicare Beneficiary Smart Cards. Pending the results of a GAO report on the use of smart card technology in the Medicare program, HHS must examine the cost-effectiveness and technological viability of using such cards.
  • Expansion of the Senior Medicare Patrol (SMP). This must include recommendations for ways to enhance rewards for individuals reporting under the SMP incentive program and how to extend the program to Medicaid. Let us hope this is not an avenue for disgruntled patients to retaliate against their physicians.
  • Requiring Valid Prescriber National Provider Identifiers on Pharmacy Claims. This provision requires that CMS use the NPIs as the only allowed prescriber identifier for the Medicare prescription drug program and requires that all subscriber claims be submitted with a valid prescriber NPI.
  • Programs to Prevent Prescription Drug Abuse Under Medicare Part D. Beneficiaries determined to be at-risk for prescription drug abuse can be limited to one or more physicians and one or more pharmacies for certain opioids and similar drugs. We all know that opioid abuse is a legitimate concern, this has real “big brother” potential.
  • Repealing Duplicative Medicare Secondary Payor Provision. This provision, derived from H.R. 5201, the Medicare Employer Relief Act of 2014, repeals the requirement for employer disclosure of information regarding the health care coverage of employees who are Medicare beneficiaries.
  • Eliminating Certain Civil Money Penalties; Gainsharing Study and Report. The Civil Monetary Penalties statute makes it illegal for a hospital to make payments directly or indirectly to a physician to reduce or limit items or services to Medicaid or Medicare patients. The legislation requires a study to develop permissible gainsharing arrangements that would otherwise be subject to civil monetary penalties by use of exceptions, safe harbors, or other narrowly targeted provisions. The study would suggest recommendations to address accountability, transparency, and quality, including how to limit inducements to stint on care, discharge patients prematurely, or otherwise reduce or limit medically necessary care.

    By way of background, the Office of Inspector General (OIG) defines gainsharing as an arrangement in which a hospital gives physicians a percentage share of any reduction in the hospital’s costs for patient care attributable in part to the physicians’ efforts. Savings that do not affect the quality of patient care may be generated in many ways, including substituting lower cost but equally effective medical supplies, items or devices; re-engineering hospital surgical and medical procedures; reducing utilization of medically unnecessary ancillary services; and reducing unnecessary lengths of stay.

    The OIG has approved several gainsharing arrangements, including opening packaged items only as needed; performing blood cross matching only as needed; substituting less costly items where appropriate; and standardizing product choice for certain devices.

Full text of draft legislation available at:

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