38 U.S.C. § 1703E — Center for Innovation for Care and Pay-

Page 329 TITLE 38—VETERANS’ BENEFITS § 1703E 1 So in original. obtaining additional information from the en- tity or provider that furnished the care or service, submitted in such format as pre- scribed by the Secretary in regulations for the purpose of paying claims for care or services. (3) The term ‘‘clean paper claim’’ means a paper claim for payment of covered health care expenses that is submitted to the Sec- retary which contains substantially all of the required data elements necessary for accurate adjudication, without obtaining additional in- formation from the entity or provider that furnished the care or service, submitted in such format as prescribed by the Secretary in regulations for the purpose of paying claims for care or services. (4) The term ‘‘fraudulent claims’’ means the knowing misrepresentation of a material fact or facts by a health care entity or provider made to induce the Secretary to pay a claim that was not legally payable to that provider. (5) The term ‘‘health care entity or pro- vider’’ includes any non-Department health care entity or provider, but does not include any Federal health care entity or provider. (Added Pub. L. 115–182, title I, § 111(a), June 6, 2018, 132 Stat. 1418; amended Pub. L. 115–251, title II, §§ 204, 211(a)(5), Sept. 29, 2018, 132 Stat. 3172, 3175.) Editorial Notes REFERENCES IN TEXT The date of the enactment of the Caring for Our Vet- erans Act of 2018, referred to in subsec. (h), is the date of enactment of Pub. L. 115–182, which was approved June 6, 2018. AMENDMENTS 2018—Subsec. (e)(1). Pub. L. 115–251, § 204, substituted ‘‘may deduct’’ for ‘‘shall deduct’’ and inserted before period at end ‘‘and may use any other means author- ized by another provision of law to correct or recover overpayments’’. Subsec. (g)(3). Pub. L. 115–251, § 211(a)(5), substituted ‘‘of this title’’ for ‘‘of this Act, as amended by the Car- ing for Our Veterans Act of 2018,’’. Statutory Notes and Related Subsidiaries PROCESSING OF CLAIMS FOR REIMBURSEMENT THROUGH ELECTRONIC INTERFACE Pub. L. 115–182, title I, § 114, June 6, 2018, 132 Stat. 1423, provided that: ‘‘The Secretary of Veterans Affairs may enter into an agreement with a third-party entity to process, through the use of an electronic interface, claims for reimbursement for health care provided under the laws administered by the Secretary.’’ § 1703E. Center for Innovation for Care and Pay- ment (a) IN GENERAL.—(1) There is established with- in the Department a Center for Innovation for Care and Payment (in this section referred to as the ‘‘Center’’). (2) The Secretary, acting through the Center, may carry out such pilot programs the Sec- retary determines to be appropriate to develop innovative approaches to testing payment and service delivery models in order to reduce ex- penditures while preserving or enhancing the quality of care furnished by the Department. (3) The Secretary, acting through the Center, shall test payment and service delivery models to determine whether such models— (A) improve access to, and quality, timeli- ness, and patient satisfaction of care and serv- ices; and (B) create cost savings for the Department. (4)(A) The Secretary shall test a model in a lo- cation where the Secretary determines that the model will addresses 1 deficits in care (including poor clinical outcomes or potentially avoidable expenditures) for a defined population. (B) The Secretary shall focus on models the Secretary expects to reduce program costs while preserving or enhancing the quality of care re- ceived by individuals receiving benefits under this chapter. (C) The models selected may include those de- scribed in section 1115A(b)(2)(B) of the Social Se- curity Act (42 U.S.C. 1315a(b)(2)(B)). (5) In selecting a model for testing, the Sec- retary may consider, in addition to other factors identified in this subsection, the following fac- tors: (A) Whether the model includes a regular process for monitoring and updating patient care plans in a manner that is consistent with the needs and preferences of individuals re- ceiving benefits under this chapter. (B) Whether the model places the individual receiving benefits under this chapter (includ- ing family members and other caregivers of such individual) at the center of the care team of such individual. (C) Whether the model uses technology or new systems to coordinate care over time and across settings. (D) Whether the model demonstrates effec- tive linkage with other public sector payers, private sector payers, or statewide payment models. (6)(A) Models tested under this section may not be designed in such a way that would allow the United States to recover or collect reason- able charges from a Federal health care program for care or services furnished by the Secretary to a veteran under pilot programs carried out under this section. (B) In this paragraph, the term ‘‘Federal health care program’’ means— (i) an insurance program described in section 1811 of the Social Security Act (42 U.S.C. 1395c) or established by section 1831 of such Act (42 U.S.C. 1395j); (ii) a State plan for medical assistance ap- proved under title XIX of such Act (42 U.S.C. 1396 et seq.); or (iii) a TRICARE program operated under sections 1075, 1075a, 1076, 1076a, 1076c, 1076d, 1076e, or 1076f of title 10. (b) DURATION.—Each pilot program carried out by the Secretary under this section shall termi- nate no later than 5 years after the date of the commencement of the pilot program. (c) LOCATION.—The Secretary shall ensure that each pilot program carried out under this sec- tion occurs in an area or areas appropriate for the intended purposes of the pilot program. To Page 330 TITLE 38—VETERANS’ BENEFITS § 1703E the extent practicable, the Secretary shall en- sure that the pilot programs are located in geo- graphically diverse areas of the United States. (d) BUDGET.—Funding for each pilot program carried out by the Secretary under this section shall come from appropriations— (1) provided in advance in appropriations acts for the Veterans Health Administration; and (2) provided for information technology sys- tems. (e) NOTICE.—The Secretary shall— (1) publish information about each pilot pro- gram under this section in the Federal Reg- ister; and (2) take reasonable actions to provide direct notice to veterans eligible to participate in such pilot programs. (f) WAIVER OF AUTHORITIES.—(1) Subject to re- porting under paragraph (2) and approval under paragraph (3), in implementing a pilot program under this section, the Secretary may waive such requirements in subchapters I, II, and III of this chapter as the Secretary determines nec- essary solely for the purposes of carrying out this section with respect to testing models de- scribed in subsection (a). (2) Before waiving any authority under para- graph (1), the Secretary shall submit to the Speaker of the House of Representatives, the minority leader of the House of Representatives, the majority leader of the Senate, the minority leader of the Senate, and each standing com- mittee with jurisdiction under the rules of the Senate and of the House of Representatives to report a bill to amend the provision or provi- sions of law that would be waived by the Depart- ment, a report on a request for waiver that de- scribes in detail the following: (A) The specific authorities to be waived under the pilot program. (B) The standard or standards to be used in the pilot program in lieu of the waived au- thorities. (C) The reasons for such waiver or waivers. (D) A description of the metric or metrics the Secretary will use to determine the effect of the waiver or waivers upon the access to and quality, timeliness, or patient satisfaction of care and services furnished through the pilot program. (E) The anticipated cost savings, if any, of the pilot program. (F) The schedule for interim reports on the pilot program describing the results of the pilot program so far and the feasibility and ad- visability of continuing the pilot program. (G) The schedule for the termination of the pilot program and the submission of a final re- port on the pilot program describing the result of the pilot program and the feasibility and advisability of making the pilot program per- manent. (H) The estimated budget of the pilot pro- gram. (3)(A) Upon receipt of a report submitted under paragraph (2), each House of Congress shall provide copies of the report to the chair- man and ranking member of each standing com- mittee with jurisdiction under the rules of the House of Representatives or the Senate to report a bill to amend the provision or provisions of law that would be waived by the Department under this subsection. (B) The waiver requested by the Secretary under paragraph (2) shall be considered approved under this paragraph if there is enacted into law a joint resolution approving such request in its entirety. (C) For purposes of this paragraph, the term ‘‘joint resolution’’ means only a joint resolution which is introduced within the period of five leg- islative days beginning on the date on which the Secretary transmits the report to the Congress under such paragraph (2), and— (i) which does not have a preamble; and (ii) the matter after the resolving clause of which is as follows: ‘‘that Congress approves the request for a waiver under section 1703E(f) of title 38, United States Code, as submitted by the Secretary on llllllllll’’, the blank space being filled with the appropriate date. (D)(i) Any committee of the House of Rep- resentatives to which a joint resolution is re- ferred shall report it to the House without amendment not later than 15 legislative days after the date of introduction thereof. If a com- mittee fails to report the joint resolution within that period, the committee shall be discharged from further consideration of the joint resolu- tion. (ii) It shall be in order at any time after the third legislative day after each committee au- thorized to consider a joint resolution has re- ported or has been discharged from consider- ation of a joint resolution, to move to proceed to consider the joint resolution in the House. All points of order against the motion are waived. Such a motion shall not be in order after the House has disposed of a motion to proceed on a joint resolution addressing a particular submis- sion. The previous question shall be considered as ordered on the motion to its adoption without intervening motion. The motion shall not be de- batable. A motion to reconsider the vote by which the motion is disposed of shall not be in order. (iii) The joint resolution shall be considered as read. All points of order against the joint resolu- tion and against its consideration are waived. The previous question shall be considered as or- dered on the joint resolution to its passage with- out intervening motion except two hours of de- bate equally divided and controlled by the pro- ponent and an opponent. A motion to reconsider the vote on passage of the joint resolution shall not be in order. (E)(i) A joint resolution introduced in the Sen- ate shall be referred to the Committee on Vet- erans’ Affairs. (ii) Any committee of the Senate to which a joint resolution is referred shall report it to the Senate without amendment not later than 15 session days after the date of introduction of a joint resolution described in paragraph (C). If a committee fails to report the joint resolution within that period, the committee shall be dis- charged from further consideration of the joint resolution and the joint resolution shall be placed on the calendar. Page 331 TITLE 38—VETERANS’ BENEFITS § 1703E (iii)(I) Notwithstanding Rule XXII of the Standing Rules of the Senate, it is in order at any time after the third session day on which the Committee on Veterans’ Affairs has reported or has been discharged from consideration of a joint resolution described in paragraph (C) (even though a previous motion to the same effect has been disagreed to) to move to proceed to the consideration of the joint resolution, and all points of order against the joint resolution (and against consideration of the joint resolution) are waived. The motion to proceed is not debat- able. The motion is not subject to a motion to postpone. A motion to reconsider the vote by which the motion is agreed to or disagreed to shall not be in order. If a motion to proceed to the consideration of the resolution is agreed to, the joint resolution shall remain the unfinished business until disposed of. (II) Consideration of the joint resolution, and on all debatable motions and appeals in connec- tion therewith, shall be limited to not more than two hours, which shall be divided equally between the majority and minority leaders or their designees. A motion further to limit de- bate is in order and not debatable. An amend- ment to, or a motion to postpone, or a motion to proceed to the consideration of other business, or a motion to recommit the joint resolution is not in order. (III) If the Senate has voted to proceed to a joint resolution, the vote on passage of the joint resolution shall occur immediately following the conclusion of consideration of the joint reso- lution, and a single quorum call at the conclu- sion of the debate if requested in accordance with the rules of the Senate. (IV) Appeals from the decisions of the Chair relating to the application of the rules of the Senate, as the case may be, to the procedure re- lating to a joint resolution shall be decided without debate. (F) A joint resolution considered pursuant to this paragraph shall not be subject to amend- ment in either the House of Representatives or the Senate. (G)(i) If, before the passage by one House of the joint resolution of that House, that House receives the joint resolution from the other House, then the following procedures shall apply: (I) The joint resolution of the other House shall not be referred to a committee. (II) With respect to the joint resolution of the House receiving the joint resolution— (aa) the procedure in that House shall be the same as if no joint resolution had been received from the other House; but (bb) the vote on passage shall be on the joint resolution of the other House. (ii) If the Senate fails to introduce or consider a joint resolution under this paragraph, the joint resolution of the House shall be entitled to expedited floor procedures under this subpara- graph. (iii) If, following passage of the joint resolu- tion in the Senate, the Senate then receives the companion measure from the House of Rep- resentatives, the companion measure shall not be debatable. (H) This subparagraph is enacted by Con- gress— (i) as an exercise of the rulemaking power of the Senate and House of Representatives, re- spectively, and as such it is deemed a part of the rules of each House, respectively, but ap- plicable only with respect to the procedure to be followed in that House in the case of a joint resolution, and it supersedes other rules only to the extent that it is inconsistent with such rules; and (ii) with full recognition of the constitu- tional right of either House to change the rules (so far as relating to the procedure of that House) at any time, in the same manner, and to the same extent as in the case of any other rule of that House. (g) LIMITATIONS.—(1) The Secretary may not carry out more than 10 pilot programs concur- rently. (2)(A) Subject to subparagraph (B), the Sec- retary may not expend more than $50,000,000 in any fiscal year from amounts under subsection (d). (B) The Secretary may expend more than the amount in subparagraph (A) if— (i) the Secretary determines that the addi- tional expenditure is necessary to carry out pilot programs under this section; (ii) the Secretary submits to the Commit- tees on Veterans’ Affairs of the Senate and the House of Representatives a report setting forth the amount of the additional expendi- ture and a justification for the additional ex- penditure; and (iii) the Chairmen of the Committees on Vet- erans’ Affairs of the Senate and the House of Representatives transmit to the Secretary a letter approving of the additional expenditure. (3) The waiver provisions in subsection (f) shall not apply unless the Secretary, in accord- ance with the requirements in subsection (f), submits the first proposal for a pilot program not later than 18 months after the date of the enactment of the Caring for Our Veterans Act of 2018. (4) Notwithstanding section 502 of this title, decisions by the Secretary under this section shall, consistent with section 511 of this title, be final and conclusive and may not be reviewed by any other official or by any court, whether by an action in the nature of mandamus or other- wise. (5)(A) If the Secretary determines that a pilot program is not improving the quality of care or producing cost savings, the Secretary shall— (i) propose a modification to the pilot pro- gram in the interim report that shall also be considered a report under subsection (f)(2) and shall be subject to the terms and conditions of subsection (f)(2); or (ii) terminate such pilot program not later than 30 days after submitting the interim re- port to Congress. (B) If the Secretary terminates a pilot pro- gram under subparagraph (A)(ii), for purposes of subparagraphs (F) and (G) of subsection (f)(2), such interim report will also serve as the final report for that pilot program. (h) EVALUATION AND REPORTING REQUIRE- MENTS.—(1) The Secretary shall conduct an eval- uation of each model tested, which shall include, at a minimum, an analysis of— Page 332 TITLE 38—VETERANS’ BENEFITS § 1703F (A) the quality of care furnished under the model, including the measurement of patient- level outcomes and patient-centeredness cri- teria determined appropriate by the Sec- retary; and (B) the changes in spending by reason of that model. (2) The Secretary shall make the results of each evaluation under this subsection available to the public in a timely fashion and may estab- lish requirements for other entities partici- pating in the testing of models under this sec- tion to collect and report information that the Secretary determines is necessary to monitor and evaluate such models. (i) COORDINATION AND ADVICE.—(1) The Sec- retary shall obtain advice from the Under Sec- retary for Health and the Special Medical Advi- sory Group established pursuant to section 7312 of this title in the development and implementa- tion of any pilot program operated under this section. (2) In carrying out the duties under this sec- tion, the Secretary shall consult representatives of relevant Federal agencies, and clinical and analytical experts with expertise in medicine and health care management. The Secretary shall use appropriate mechanisms to seek input from interested parties. (j) EXPANSION OF SUCCESSFUL PILOT PRO- GRAMS.—Taking into account the evaluation under subsection (f), the Secretary may, through rulemaking, expand (including imple- mentation on a nationwide basis) the duration and the scope of a model that is being tested under subsection (a) to the extent determined appropriate by the Secretary, if— (1) the Secretary determines that such ex- pansion is expected to— (A) reduce spending without reducing the quality of care; or (B) improve the quality of patient care without increasing spending; and (2) the Secretary determines that such ex- pansion would not deny or limit the coverage or provision of benefits for individuals receiv- ing benefits under this chapter. (Added Pub. L. 115–182, title I, § 152(a), June 6, 2018, 132 Stat. 1432.) Editorial Notes REFERENCES IN TEXT The Social Security Act, referred to in subsec. (a)(6)(B)(ii), is act Aug. 14, 1935, ch. 531, 49 Stat. 620. Title XIX of the Act is classified generally to sub- chapter XIX (§ 1396 et seq.) of chapter 7 of Title 42, The Public Health and Welfare. For complete classification of this Act to the Code, see section 1305 of Title 42 and Tables. The date of the enactment of the Caring for Our Vet- erans Act of 2018, referred to in subsec. (g)(3), is the date of enactment of Pub. L. 115–182, which was ap- proved June 6, 2018. § 1703F. Credentialing verification requirements for providers of non-Department health care services (a) IN GENERAL.—The Secretary shall ensure that Third Party Administrators and credentials verification organizations comply with the re- quirements specified in subsection (b) to help ensure certain health care providers are ex- cluded from providing non-Department health care services. (b) REQUIREMENTS SPECIFIED.—The Secretary shall require Third Party Administrators and credentials verification organizations to carry out the following: (1) Hold and maintain an active credential verification accreditation from a national health care accreditation body. (2) Conduct initial verification of provider history and license sanctions for all States and United States territories for a period of time— (A) that includes the period before the pro- vider began providing non-Department health care services; and (B) dating back not less than 10 years. (3) Not less frequently than every three years, perform recredentialing, including verifying provider history and license sanc- tions for all States and United States terri- tories. (4) Implement continuous monitoring of each provider through the National Practi- tioner Data Bank established pursuant to the Health Care Quality Improvement Act of 1986 (42 U.S.C. 11101 et seq.). (5) Perform other forms of credentialing verification as the Secretary considers appro- priate. (c) DEFINITIONS.—In this section: (1) The term ‘‘credentials verification orga- nization’’ means an entity that manages the provider credentialing process and performs credentialing verification for non-Department providers that participate in the Veterans Community Care Program under section 1703 of this title through a Veterans Care Agree- ment. (2) The term ‘‘Third Party Administrator’’ means an entity that manages a provider net- work and performs administrative services re- lated to such network within the Veterans Community Care Program under section 1703 of this title. (3) The term ‘‘Veterans Care Agreement’’ means an agreement for non-Department health care services entered into under section 1703A of this title. (4) The term ‘‘non-Department health care services’’ means services— (A) provided under this subchapter at non- Department facilities (as defined in section 1701 of this title); (B) provided under section 101 of the Vet- erans Access, Choice, and Accountability Act of 2014 (Public Law 113–146; 38 U.S.C. 1701 note); (C) purchased through the Medical Com- munity Care account of the Department; or (D) purchased with amounts deposited in the Veterans Choice Fund under section 802 of the Veterans Access, Choice, and Ac- countability Act of 2014 (Public Law 113–146; 38 U.S.C. 1701 note). (Added Pub. L. 117–328, div. U, title I, § 141(a)(1), Dec. 29, 2022, 136 Stat. 5422.)