Summary#
The Medicare Fraud Detection and Deterrence Act of 2025 would amend Titles XI and XVIII of the Social Security Act. Its stated goal is to strengthen rules against health care waste, fraud, and abuse; the bill does not guarantee that these changes would prevent fraud.
- The Secretary of Health and Human Services would have to set rules to deactivate certain health care identifiers when a person or entity is excluded from a federal health care program. Identifier type 1 would be deactivated; type 2 would be deactivated only if the HHS Inspector General requests it and the Secretary finds it appropriate. An identifier would generally be reactivated when the exclusion ends. The rule would not apply if the exclusion is waived for any federal health care program.
- The Secretary would have to compare the HHS Inspector General’s exclusion list with active identifiers at least once a year.
- Medicare Advantage plans would have to include the identifier of the provider who ordered or referred a patient for certain items and services in encounter data. The Secretary would have to reject data that lacks a valid, active identifier.
- Medicare telehealth claims for services furnished by certain physicians and practitioners would need a new claims modifier (a code on a claim identifying the service). After the bill’s 180-day period, no payment could be made for those services without it.
What it means for you#
- Medicare Advantage plans: They would have to submit the ordering or referring provider’s identifier for durable medical equipment, prosthetic or orthotic devices, clinical diagnostic laboratory tests, diagnostic imaging tests, and home health services. The Secretary would specify which imaging tests and home health services are covered by this rule.
- Telehealth clinicians and companies: A physician or practitioner with an employment or contractual relationship with a qualifying telehealth company would need the new modifier on claims for covered telehealth services. The bill defines a qualifying company as one that provides telehealth services through clinicians and provides no in-person services, or only a small amount compared with its telehealth services, as the Secretary specifies.
- People or entities excluded from federal health care programs: Their identifiers could be deactivated under the conditions in the bill. The bill does not say that exclusion itself is new.
- Medicare patients: The bill changes data and claim rules. It does not directly change Medicare eligibility or benefits.
- The public: The bill is at the introduced stage and is not law. Whether it becomes law is uncertain.
Money#
No cost information is available in the supplied material.
- The bill requires the Secretary to set standards, review identifier lists annually, and establish a claims modifier, but gives no estimate of the staff or other resources needed.
- Plans and clinicians would need to meet new data and claims requirements; the bill gives no estimate of their costs.
- The bill creates no tax, fee, or fine.
What is unclear#
- The supplied material does not include the underlying Social Security Act, so the existing rules and how the changes would fit with them could not be verified.
- The bill does not define “entity type 1,” “entity type 2,” or the level of in-person services that counts as “de minimis” (very small). The Secretary would set some of these details.
- The bill does not set out a process for correcting an identifier error or appealing rejected encounter data or an unpaid telehealth claim.
- It does not estimate the cost of setting up and operating the new requirements.
- It does not explain how the changes would interact with other existing fraud-prevention or claims rules.
Case for#
- A possible argument for the bill is that deactivating identifiers during an exclusion could help prevent excluded individuals or entities from using those identifiers in federal health care programs.
- Requiring the identifier of the provider who ordered or referred for certain services could make it easier to trace who was involved in those services.
- A modifier for telehealth services furnished through qualifying companies could help distinguish those claims from other telehealth claims.
Case against#
- The bill makes payment for certain telehealth services depend on using a new modifier. If the modifier is missing or wrong, a claim cannot be paid under this rule, even though the bill does not set out a correction or appeal process.
- Medicare Advantage encounter data would be rejected if it lacks a valid, active identifier. The bill does not explain how plans should handle mistakes or identifier changes.
- Some details depend on decisions by the Secretary, including which imaging tests and home health services are covered and what amount of in-person care counts as “de minimis.”
- The bill requires new federal work and new data and claims steps, but does not provide cost estimates.