Medicare Payment Integrity Enhancement Act of 2026

Section 1893(h) of the Social Security Act (42 U.S.C. 1395ddd(h)) is amended—

(1) in paragraph (1)—

(A) in matter preceding subparagraph (A)—

(i) by striking and recouping and inserting, recouping; and

(ii) by striking title. and inserting title, and conducting prepayment review of claims for payment under this title.;

(B) in subparagraph (A), by inserting except in the case of prepayment review of claims for payment under this title, before payment shall be made;

(C) in subparagraph (B)—

(i) by inserting except in the case of prepayment review of claims for payment under this title, before from such amounts; and

(ii) in clause (ii), by striking and at the end;

(D) in subparagraph (C), by striking the period at the end and inserting; and; and

(E) by inserting after subparagraph (C) the following new subparagraph:

(D) payment to such a contractor for prepayment review of claims for payment under this title shall be made in amounts determined under a methodology established by the Secretary that—

(i) takes into account the amount of improper payment that such contractor prevented from being paid under this title; and

(ii) incentivizes the timely and accurate prevention of such improper payments, without a disproportionate focus on particular types of claims.;

(2) in paragraph (3), by inserting, and not later than 1 year after the date of the enactment of the Medicare Payment Integrity Enhancement Act of 2026, in the case of contracts relating to the prepayment review of claims for payment under this title after under part C or D;

(3) in paragraph (7)—

(A) by inserting or the prevention of part or all of a payment under this title based on a prepayment review of a claim for payment after individual or entity; and

(B) by inserting or prepayment review after such overpayment;

(4) in paragraph (8), by inserting (and, to the extent that contracts under this subsection require prepayment review of claims for payment under this title, on the performance of such contractors with respect to such prepayment reviews) after recouping overpayments; and

(5) by adding at the end the following new paragraph:

For purposes of making payment to recovery audit contractors for prepayment review of claims for payment under this title, as described in paragraph (1)(D), the Secretary shall provide for the transfer, from the Federal Hospital Insurance Trust Fund under section 1817 and the Federal Supplementary Medical Insurance Trust Fund under section 1841, in such proportion as the Secretary determines appropriate based upon the relative amount of improper payments that such contractors prevented from being paid under parts A and B, of such sums as the Secretary determines necessary, to the Centers for Medicare & Medicaid Services Program Management Account.

Not later than 1 year after the date of the enactment of this section, the Secretary of Health and Human Services shall issue such rules as are necessary to implement the amendments made by subsection (a). Such rules shall include—

(1) a description of the methodology that the Secretary shall use as the basis for making payment to recovery audit contractors for the prepayment review of claims for payment under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.); and

(2) a description of the methodology that the Secretary shall use to calculate savings to the Medicare program under such title XVIII generated by such prepayment reviews.