Medicare Fraud Detection and Deterrence Act of 2025
Medicare Fraud Detection and Deterrence Act of 2025 would strengthen protections against health care waste, fraud, and abuse by adding three main provisions. First, it would create mandatory deactivation of standard health identifiers (NPIs) for providers or entities excluded from federal health care programs, with automatic inactivation for some cases and a duty to review exclusions annually. Second, it would require Medicare Advantage encounter data to include the ordering provider’s NPI for certain listed items and services, and would reject data that fail to include or properly validate these identifiers. Third, it would require a new telehealth payment rule that creates a claims modifier to identify telehealth services furnished by certain “specified entities” (telehealth companies and their associated physicians/practitioners) and ties payment to the presence of that modifier. Together, these changes aim to improve fraud detection, deter participation by excluded providers, and increase traceability of telehealth and other designated services within Medicare.
Key Points
- 1Mandatory deactivation of NPIs for excluded entities: The Secretary must update standards to deactivate standard unique health identifiers (NPIs) for entities excluded from participation in federal health programs, with separate rules for entity type 1 and entity type 2, and subject to IG requests and Secretary approval for some cases.
- 2Term and review of deactivation: Deactivation begins at the date of exclusion and ends when the exclusion ends; NPIs can be reactivated after exclusion ends; there is an annual (at least) review comparing the exclusion list with active NPIs to ensure compliance.
- 3Nonapplication caveats: In certain waiver situations, the deactivation mandate does not apply if an exclusion has been waived for a federal health care program.
- 4Medicare Advantage encounter data with NPIs: For certain items or services furnished under a Medicare Advantage plan, encounter data must include the standard NPI of the provider who ordered or referred the item/service.
- 5Data rejection for noncompliance: The secretary must reject encounter data that do not include the required NPI or where the NPI is inactive or invalid.
- 6Designated items/services for NPI linkage: The requirement applies to durable medical equipment, prosthetic/orthotic devices, clinical lab tests, diagnostic imaging tests, and home health services.
- 7Telehealth payment modifier: A new claims modifier must be established to identify telehealth services payable under Medicare that are furnished by a “specified entity” (a telehealth company relationship with physicians/practitioners).
- 8Definitions of entities: A “specified entity” is a physician/practitioner employed or contracted with a telehealth company; a “telehealth company” is an entity that employs/contracts with physicians/practitioners to furnish telehealth and does not (or largely does not) employ/contracts to furnish in-person services.