Medicare Transaction Fraud Prevention Act

HR 7147, the Medicare Transaction Fraud Prevention Act, establishes a 2-year pilot program (starting January 1, 2025) to test predictive risk-scoring algorithms for Medicare payments on durable medical equipment and clinical lab tests. It only applies to Medicare beneficiaries who have opted in to receive electronic Medicare Summary Notices, with the option to opt out anytime. The program uses algorithms to score transactions (1-99 risk level) based on factors like new provider relationships or billing patterns, triggering a human review if scores exceed a threshold. Beneficiaries flagged for high-risk transactions receive notification, a chance to correct data, and a 3-month period of electronic notices before potential payment suspension. The pilot requires testing, beneficiary notification, and collaboration with industry before implementation.