H.R. 6863

[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 6863 Introduced in House (IH)]

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119th CONGRESS
1st Session
H. R. 6863

To amend title XVIII of the Social Security Act to improve transparency 
with respect to the suspension of Medicare payments pending an 
investigation into a credible allegation of fraud.

_______________________________________________________________________

IN THE HOUSE OF REPRESENTATIVES

December 18, 2025

Mr. Harder of California (for himself and Mrs. Kim) introduced the 
following bill; which was referred to the Committee on Energy and 
Commerce, and in addition to the Committee on Ways and Means, for a 
period to be subsequently determined by the Speaker, in each case for 
consideration of such provisions as fall within the jurisdiction of the 
committee concerned

_______________________________________________________________________

A BILL

To amend title XVIII of the Social Security Act to improve transparency 
with respect to the suspension of Medicare payments pending an 
investigation into a credible allegation of fraud.

Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

This Act may be cited as the ``Centers for Medicare & Medicaid 
Services Auditor Transparency Act of 2025'' or the ``CAT Act of 2025''.

SEC. 2. FINDINGS.

Congress finds the following:
(1) In 2020, 139,000,000 individuals received health care 
coverage through the Medicare or Medicaid programs, costing the 
Federal Government approximately $1,500,000,000,000. Of these 
funds paid by United States taxpayers, $3,100,000,000 were 
discovered to have been fraudulent claims.
(2) Ensuring the integrity of the Medicare and Medicaid 
programs is crucial to preventing fraud, waste, and abuse and 
safeguarding the financial sustainability of these important 
programs.
(3) Even though the Centers for Medicare & Medicaid 
Services (CMS) utilization of Unified Program Integrity 
Contractors (UPICs) has shown to be effective at identifying 
bad actors defrauding the Federal Government through the 
Medicare and Medicaid programs, current Federal law and 
regulations have shown to be harmful to most providers who are 
submitting Medicare and Medicaid claims in good faith.
(4) Existing law provides CMS and UPICs broad authority and 
discretion to suspend Medicare payments for up to a year 
pending the investigation of ``credible allegations of fraud''.
(5) However, current law does not require adequate 
transparency from CMS or UPICs into the nature of the alleged 
fraud before Medicare payments are suspended. Current law also 
does not require CMS or UPICs to provide adequate due process 
to providers whose payments have been suspended to challenge or 
cure the allegations of fraud prior to the suspension of 
Medicare payments.
(6) In addition, anecdotal reports have shown that some 
UPICs extend the suspension of Medicare payments on a routine 
basis so that they may have additional time to finish their 
audit despite not providing evidence that the continuation of a 
payment suspension is necessary to protect the integrity of the 
Medicare program.
(7) The broad authority to suspend Medicare payments 
pending the investigation of a credible allegation of fraud 
without adequate due process or transparency places the 
financial viability of many Medicare providers acting in good 
faith at risk.
(8) If Medicare providers acting in good faith close their 
doors as a result of the unnecessary suspension of payments by 
CMS or UPICs, Medicare beneficiaries and the American public 
could face additional barriers to access to necessary health 
care services as a direct result of unfair Federal law and 
regulations.

SEC. 3. IMPROVING TRANSPARENCY IN SUSPENSION OF PAYMENTS PENDING 
INVESTIGATION OF CREDIBLE ALLEGATIONS OF FRAUD UNDER 
MEDICARE.

(a) In General.--Section 1862(o) of the Social Security Act (42 
U.S.C. 1395y(o)) is amended--
(1) in paragraph (1)--
(A) by striking ``The Secretary may suspend'' and 
inserting ``Subject to paragraph (5), the Secretary may 
suspend''; and
(B) by inserting ``An investigation of a credible 
allegation of fraud, and the suspension of payment 
pending such investigation under the preceding 
sentence, may only exceed 180 days if the Secretary 
determines there is good cause to extend such 
investigation and suspension.'' at the end;
(2) in paragraph (4)--
(A) by striking ``a fraud hotline tip (as defined 
by the Secretary)'' and inserting ``the following 
items''; and
(B) by striking ``credible allegation of fraud.'' 
and inserting ``credible allegation of fraud:
``(A) A fraud hotline tip (as defined by the 
Secretary).
``(B) Mere error (as defined by the Secretary).
``(C) A billing error found during the course of an 
audit that is attributable to human error.''.
(3) by adding at the end the following new paragraphs:
``(5) Transparency in suspension of payments.--
``(A) In general.--The Secretary may only suspend 
payments to a provider of services or supplier under 
this title pursuant to paragraph (1) if--
``(i) subject to subparagraph (B), not 
later than 30 days before the date on which the 
payment suspension begins, the Secretary 
provides such provider of services or supplier 
with information about each credible allegation 
of fraud that is the basis for the payment 
suspension, including--
``(I) the specific nature of each 
credible allegation of fraud;
``(II) the date of the alleged 
fraud; and
``(III) the basis of the credible 
allegation of fraud, such as whether 
the allegation is based upon--
``(aa) a fraud hotline 
complaint;
``(bb) data mining of data 
with respect to claims for 
payment under this title, title 
XIX, or title XXI; or
``(cc) a pattern identified 
through audits of providers of 
services or suppliers; and
``(ii) not less frequently than once every 
30 days during such payment suspension, the 
Secretary provides such provider of services or 
supplier with--
``(I) a detailed, up-to-date list 
of the findings of the investigation;
``(II) an anticipated timeline for 
the completion of the investigation; 
and
``(III) an opportunity to ask the 
Centers for Medicare & Medicaid 
Services questions regarding the 
payment suspension and the 
investigation.
``(B) Exception.--The Secretary may elect not to 
provide a provider of services or supplier with the 
information described in subparagraph (A)(i) if the 
provision of such information would compromise the 
integrity of the investigation, as determined by the 
Secretary in consultation with the Inspector General of 
the Department of Health and Human Services and State 
auditors (as appropriate).
``(C) Failure to provide information.--If the 
requirements described in subparagraph (A) are not met 
with respect to the suspension of payment to a provider 
of services or a supplier under this title, the 
Secretary shall immediately resume such payment, and 
shall pay to the provider of services or supplier the 
amounts not paid due to such suspension and any 
interest accrued with respect to such amounts.
``(D) Annual report.--Not later than 180 days after 
the end of each fiscal year (beginning with fiscal year 
2025), the Secretary shall submit to Congress a report 
that includes the following information with respect to 
such fiscal year:
``(i) The number of payment suspensions 
issued as the result of a pending investigation 
of a credible allegation of fraud under this 
subsection, section 1860D-12(b)(7) (including 
as applied pursuant to section 1857(f)(3)(D)), 
or section 1903(i)(2)(C).
``(ii) The basis of each such credible 
allegation of fraud.
``(iii) The average duration of a payment 
suspension described in clause (i).
``(iv) The average duration of an 
investigation of a credible allegation of fraud 
described in clause (i).
``(v) If applicable, the average time 
between the completion of an investigation into 
a credible allegation of fraud described in 
clause (i) and the reinstatement of payments to 
the relevant provider of services or supplier.
``(6) Appeals.--Not later than 180 days after the date of 
the enactment of the CAT Act of 2025, the Secretary shall 
provide an independent process by which a provider of services 
or supplier under this title that has received notice of a 
payment suspension due to a pending investigation of a credible 
allegation of fraud pursuant to this subsection may appeal such 
suspension and receive a resolution of such appeal in a timely 
manner.''.
(b) Stakeholder Consultation.--In developing the appeals process 
required under section 1862(o)(6) of the Social Security Act, as added 
by subsection (a), the Secretary of Health and Human Services shall 
consult with relevant stakeholders, including providers of services and 
suppliers under title XVIII of the Social Security Act (42 U.S.C. 1395 
et seq.), title XIX of such Act (42 U.S.C. 1396 et seq.), and title XXI 
of such Act (42 U.S.C. 1397aa et seq.), as determined appropriate by 
the Secretary.
(c) Applicability.--The amendments made by this section shall apply 
with respect to any investigation of a credible allegation of fraud 
under section 1862(o) of the Social Security Act (42 U.S.C. 1395y(o)), 
section 1860D-12(b)(7) of such Act (42 U.S.C. 1395w-112(b)(7)) 
(including as applied pursuant to section 1857(f)(3)(D) of such Act (42 
U.S.C. 1395w-27(f)(3)(D))), or section 1903(i)(2)(C) of such Act (42 
U.S.C. 1396b(i)(2)(C)) that is initiated after the date of enactment of 
this Act.
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