HR 10625

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IN THE HOUSE OF REPRESENTATIVES

September 28, 2026

Mr. Joyce of Pennsylvania (for himself, Mr. Bilirakis, Mr. Pfluger, Mr. Kennedy of Utah, Mr. Carter of Georgia, and Mr. Balderson) introduced the following bill; which was referred to the Committee on Energy and Commerce

A BILL

To amend title XIX of the Social Security Act to require State Medicaid fraud control units to conduct annual audits.

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

This Act may be cited as the “Medicaid Integrity Improvement Act”.

SEC. 2. REQUIRING STATE MEDICAID FRAUD CONTROL UNITS TO CONDUCT ANNUAL AUDITS.

Section 1903(q) of the Social Security Act (42 U.S.C. 1396b(q)) is amended—

(1) in the matter preceding paragraph (1), by inserting “, subject to paragraph (8)(C),” before “annually recertifies”; and

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

“(8)(A) Beginning not later than the date that is 1 year after the date of the enactment of this paragraph, and not less frequently than annually thereafter, for purposes of conducting the statewide program under paragraph (3), the entity, in coordination with the Inspector General of the Department of Health and Human Services and the State agency responsible for administering the State plan under this title (as appropriate), audits a statistically valid sample of high-risk providers and suppliers for purposes of identifying potential fraud, waste, and abuse.

“(B) Beginning with respect to the first annual report submitted to the Secretary under paragraph (7) after the date that is 1 year after the date of the enactment of this paragraph, the entity shall include in such report a summary of the audits conducted under this paragraph, including a description of the extent to which overpayments were identified and collected (or referred for collection) on the basis of such audits.

“(C) In the case that the Secretary determines that an entity has not met the requirement under subparagraph (A), the Secretary may nonetheless certify (or recertify) the entity as having met such requirement if the entity submits to the Secretary and implements a corrective action plan meeting such standards as the Secretary may specify.

“(D) For purposes of subparagraph (A), the term ‘high-risk provider or supplier’ means a provider or supplier participating under the State plan (or a waiver of such plan) that—

“(i) is designated as a high categorical risk under the process for screening providers and suppliers under this title, as established by the Secretary under section 1866(j)(2); or

“(ii) is otherwise identified by the entity as high-risk, based upon risk factors such as abnormal billing patterns, prior audits, payment anomalies, ownership-related risk factors (including ownership changes, undisclosed ownership interests, or affiliations with entities that have been sanctioned or are subject to investigation), or credible allegations of fraud.”. <all>