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42 U.S.C. § 1395mmm — Quality and efficiency measurement

Federal law — U.S. Code and appendices · legal_authorities

42 U.S.C. § 1395mmm — Quality and efficiency measurement

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Stable record: federal_law:legal_authorities:record_usc_1040f21829f21a4008013a9c
Source file: Laws/federal/codes/united-states-code/title-42/section-1395mmm-quality-and-efficiency-measurement--ce6caa9aa1.md
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Source location: Title 42, Chapter 7, § 1395mmm; chapter-007-social-security.md

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**(a) Multi-stakeholder group input into selection of quality and efficiency measures** The Secretary shall establish a pre-rulemaking process under which the following steps occur with respect to the selection of quality and efficiency measures described in [section 1395aaa(b)(7)(B) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395aaa/b/7/B&num=0&edition=prelim): (1) **Input** — Pursuant to [section 1395aaa(b)(7) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395aaa/b/7&num=0&edition=prelim), the entity with a contract under [section 1395aaa of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395aaa&num=0&edition=prelim) shall convene multi-stakeholder groups to provide input to the Secretary on the selection of quality and efficiency measures described in subparagraph (B) of such paragraph. (2) **Public availability of measures considered for selection** — Not later than December 1 of each year (beginning with 2011), the Secretary shall make available to the public a list of quality and efficiency measures described in [section 1395aaa(b)(7)(B) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395aaa/b/7/B&num=0&edition=prelim) that the Secretary is considering under this subchapter. (3) **Transmission of multi-stakeholder input** — Pursuant to [section 1395aaa(b)(8) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395aaa/b/8&num=0&edition=prelim), not later than February 1 of each year (beginning with 2012), the entity shall transmit to the Secretary the input of multi-stakeholder groups described in paragraph (1). (4) **Consideration of multi-stakeholder input** — The Secretary shall take into consideration the input from multi-stakeholder groups described in paragraph (1) in selecting quality and efficiency measures described in [section 1395aaa(b)(7)(B) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395aaa/b/7/B&num=0&edition=prelim) that have been endorsed by the entity with a contract under [section 1395aaa of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395aaa&num=0&edition=prelim) and measures that have not been endorsed by such entity. (5) **Rationale for use of quality and efficiency measures** — The Secretary shall publish in the Federal Register the rationale for the use of any quality and efficiency measure described in [section 1395aaa(b)(7)(B) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395aaa/b/7/B&num=0&edition=prelim) that has not been endorsed by the entity with a contract under [section 1395aaa of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395aaa&num=0&edition=prelim). (6) **Assessment of impact** — Not later than March 1, 2012, and at least once every three years thereafter, the Secretary shall— (A) conduct an assessment of the quality and efficiency impact of the use of endorsed measures described in [section 1395aaa(b)(7)(B) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395aaa/b/7/B&num=0&edition=prelim); and (B) make such assessment available to the public. **(b) Process for dissemination of measures used by the Secretary** (1) **In general** — The Secretary shall establish a process for disseminating quality and efficiency measures used by the Secretary. Such process shall include the following: (A) The incorporation of such measures, where applicable, in workforce programs, training curricula, and any other means of dissemination determined appropriate by the Secretary. (B) The dissemination of such quality and efficiency measures through the national strategy developed under [section 280j of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section280j&num=0&edition=prelim). (2) **Existing methods** — To the extent practicable, the Secretary shall utilize and expand existing dissemination methods in disseminating quality and efficiency measures under the process established under paragraph (1). **(c) Review of quality and efficiency measures used by the Secretary** (1) **In general** — The Secretary shall— (A) periodically (but in no case less often than once every 3 years) review quality and efficiency measures described in [section 1395aaa(b)(7)(B) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395aaa/b/7/B&num=0&edition=prelim); and (B) with respect to each such measure, determine whether to— (i) maintain the use of such measure; or (ii) phase out such measure. (2) **Considerations** — In conducting the review under paragraph (1), the Secretary shall take steps to— (A) seek to avoid duplication of measures used; and (B) take into consideration current innovative methodologies and strategies for quality and efficiency improvement practices in the delivery of health care services that represent best practices for such quality and efficiency improvement and measures endorsed by the entity with a contract under [section 1395aaa of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395aaa&num=0&edition=prelim) since the previous review by the Secretary. **(d) Rule of construction** Nothing in this section shall preclude a State from using the quality and efficiency measures identified under sections 1320b–9a and 1320b–9b of this title. **(e) Development of quality and efficiency measures** The Administrator of the Center for Medicare & Medicaid Services shall through contracts develop quality and efficiency measures (as determined appropriate by the Administrator) for use under this chapter. In developing such measures, the Administrator shall consult with the Director of the Agency for Healthcare Research and Quality. **(f) Hospital acquired conditions** The Secretary shall, to the extent practicable, publicly report on measures for hospital-acquired conditions that are currently utilized by the Centers for Medicare & Medicaid Services for the adjustment of the amount of payment to hospitals based on rates of hospital-acquired infections. **(g) Technical expert panel review of opioid and opioid use disorder quality measures** (1) **In general** — Not later than 180 days after October 24, 2018, the Secretary shall establish a technical expert panel for purposes of reviewing quality measures relating to opioids and opioid use disorders, including care, prevention, diagnosis, health outcomes, and treatment furnished to individuals with opioid use disorders. The Secretary may use the entity with a contract under [section 1395aaa(a) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395aaa/a&num=0&edition=prelim) and amend such contract as necessary to provide for the establishment of such technical expert panel. (2) **Review and assessment** — Not later than 1 year after the date the technical expert panel described in paragraph (1) is established (and periodically thereafter as the Secretary determines appropriate), the technical expert panel shall— (A) review quality measures that relate to opioids and opioid use disorders, including existing measures and those under development; (B) identify gaps in areas of quality measurement that relate to opioids and opioid use disorders, and identify measure development priorities for such measure gaps; and (C) make recommendations to the Secretary on quality measures with respect to opioids and opioid use disorders for purposes of improving care, prevention, diagnosis, health outcomes, and treatment, including recommendations for revisions of such measures, need for development of new measures, and recommendations for including such measures in the Merit-Based Incentive Payment System under [section 1395w–4(q) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395w–4/q&num=0&edition=prelim), the alternative payment models under section 1395l(z)(3)(C) of this title, the shared savings program under [section 1395jjj of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395jjj&num=0&edition=prelim), the quality reporting requirements for inpatient hospitals under [section 1395ww(b)(3)(B)(viii) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395ww/b/3/B/viii&num=0&edition=prelim), and the hospital value-based purchasing program under section 1395ww(o) of this title. (3) **Consideration of measures by Secretary** — The Secretary shall consider— (A) using opioid and opioid use disorder measures (including measures used under the Merit-Based Incentive Payment System under [section 1395w–4(q) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395w–4/q&num=0&edition=prelim), measures recommended under paragraph (2)(C), and other such measures identified by the Secretary) in alternative payment models under section 1395l(z)(3)(C) of this title and in the shared savings program under [section 1395jjj of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395jjj&num=0&edition=prelim); and (B) using opioid measures described in subparagraph (A), as applicable, in the quality reporting requirements for inpatient hospitals under [section 1395ww(b)(3)(B)(viii) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395ww/b/3/B/viii&num=0&edition=prelim), and in the hospital value-based purchasing program under section 1395ww(o) of this title. (4) **Prioritization of measure development** — The Secretary shall prioritize for measure development the gaps in quality measures identified under paragraph (2)(B). (5) **Prioritization of measure endorsement** — The Secretary— (A) during the period beginning on October 24, 2018, and ending on December 31, 2023, shall prioritize the endorsement of measures relating to opioids and opioid use disorders by the entity with a contract under subsection (a) of [section 1395aaa of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395aaa&num=0&edition=prelim) in connection with endorsement of measures described in subsection (b)(2) of such section; and (B) on and after January 1, 2024, may prioritize the endorsement of such measures by such entity.

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Federal law — U.S. Code and appendices · legal_authorities

42 U.S.C. § 1395jjj — Payment of provider-based physicians and payment under certain percentage arrangements

**(a) Criteria; amount of payments** (1) The Secretary shall by regulation determine criteria for distinguishing those services (including inpatient and outpatient services) rendered in hospitals or skilled nursing facilities— (A) which constitute professional medical services, which are personally rendered for an individual patient by a physician and which contribute to the diagnosis or treatment of an individual patient, and which may be reimbursed as physicians’ services under part B, and (B) which constitute professional services which are rendered for the general benefit to patients in a hospital or skilled nursing facility and which may be reimbursed only on a reasonable cost basis or on the bases described in [section 1395ww of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395ww&num=0&edition=prelim). (2) (A) For purposes of cost reimbursement, the Secretary shall recognize as a reasonable cost of a hospital or skilled nursing facility only that portion of the costs attributable to services rendered by a physician in such hospital or facility which are services described in paragraph (1)(B), apportioned on the basis of the amount of time actually spent by such physician rendering such services. (B) In determining the amount of the payments which may be made with respect to services described in paragraph (1)(B), after apportioning costs as required by subparagraph (A), the Secretary may not recognize as reasonable (in the efficient delivery of health services) such portion of the provider’s costs for such services to the extent that such costs exceed the reasonable compensation equivalent for such services. The reasonable compensation equivalent for any service shall be established by the Secretary in regul

Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395jjj

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Federal law — U.S. Code and appendices · legal_authorities

42 U.S.C. § 280j — National strategy for quality improvement in health care

**(a) Establishment of national strategy and priorities** (1) **National strategy** — The Secretary, through a transparent collaborative process, shall establish a national strategy to improve the delivery of health care services, patient health outcomes, and population health. (2) **Identification of priorities** (A) *In general* — The Secretary shall identify national priorities for improvement in developing the strategy under paragraph (1). (B) *Requirements* — The Secretary shall ensure that priorities identified under subparagraph (A) will— (i) have the greatest potential for improving the health outcomes, efficiency, and patient-centeredness of health care for all populations, including children and vulnerable populations; (ii) identify areas in the delivery of health care services that have the potential for rapid improvement in the quality and efficiency of patient care; (iii) address gaps in quality, efficiency, comparative effectiveness information (taking into consideration the limitations set forth in subsections (c) and (d) of section 1182 of the Social Security Act [[42 U.S.C. 1320e–1(c)](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1320e–1/c&num=0&edition=prelim), (d)]), and health outcomes measures and data aggregation techniques; (iv) improve Federal payment policy to emphasize quality and efficiency; (v) enhance the use of health care data to improve quality, efficiency, transparency, and outcomes; (vi) address the health care provided to patients with high-cost chronic diseases; (vii) improve research and dissemination of strategies and best practices to improve patient safety and reduce medical errors, preventable admissions and readmissions, and health care-associated infectio

Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 280j

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Federal law — U.S. Code and appendices · legal_authorities

42 U.S.C. § 1395aaa — Limitation on liability where claims are disallowed

**(a) Conditions prerequisite to payment for items and services notwithstanding determination of disallowance** Where— (1) a determination is made that, by reason of section 1395y(a)(1) or (9) of this title or by reason of a coverage denial described in subsection (g), payment may not be made under part A or part B of this subchapter for any expenses incurred for items or services furnished an individual by a provider of services or by another person pursuant to an assignment under [section 1395u(b)(3)(B)(ii) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395u/b/3/B/ii&num=0&edition=prelim), and (2) both such individual and such provider of services or such other person, as the case may be, did not know, and could not reasonably have been expected to know, that payment would not be made for such items or services under such part A or part B, then to the extent permitted by this subchapter, payment shall, notwithstanding such determination, be made for such items or services (and for such period of time as the Secretary finds will carry out the objectives of this subchapter), as though section 1395y(a)(1) and [section 1395y(a)(9) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395y/a/9&num=0&edition=prelim) did not apply and as though the coverage denial described in subsection (g) had not occurred. In each such case the Secretary shall notify both such individual and such provider of services or such other person, as the case may be, of the conditions under which payment for such items or services was made and in the case of comparable situations arising thereafter with respect to such individual or such provider or such other person, each shall, by reason of such notice (or simil

Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1395aaa

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