Health Care Claims Guidance Act

Summary: Health Care Claims Guidance Act - Amends Federal law relating to claims against the U. S. Government to prohibit any action under such provisions based on a claim submitted:  (1) under a federally funded health care program unless the amount of damages alleged is a material amount; (2) in reliance on erroneous information supplied by a Federal agency or in reliance on written statements of Federal policy which affects such claim provided by a Federal agency; or (3) by a person that is in substantial compliance with a model compliance plan issued by the Secretary of Health and Human Services (in consultation with the Secretary of Defense).  Requires that the Government prove an allegation of a false health care claim by clear and convincing evidence.  Defines, for the amendments made by this Act, "federally funded health care program" to mean a program that provides health benefits, directly or otherwise, established under Social Security Act titles XVIII (Medicare), XIX (Medicaid), or XXI (Children's Health Insurance) or provisions of Federal law relating to the armed forces.

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Health Care Claims Guidance Act''.

SEC. 2. RULES FOR ACTIONS UNDER FALSE CLAIMS PROVISIONS BASED ON CLAIMS 
              SUBMITTED UNDER CERTAIN HEALTH CARE PROGRAMS.

    (a) In General.--Subchapter III of chapter 37 of title 31, United 
States Code, is amended by adding at the end the following:
``Sec. 3734. Rules for certain actions based on health care claims
    ``(a) In General.--In the case of any action that is brought under 
this subchapter based on a claim submitted with respect to a federally 
funded health care program, the preceding provisions of this subchapter 
shall apply only to the extent that such provisions are consistent with 
the provisions of this section.
    ``(b) Actions if Amount of Damages Are Material Amount.--
Notwithstanding the preceding sections of this subchapter, no action 
may be brought under this subchapter based on a claim that is submitted 
under a federally funded health care program unless the amount of 
damages alleged to have been sustained by the United States Government 
with respect to such claim is a material amount.
    ``(c) Actions for Claims Submitted in Reliance on Official 
Guidance.--Notwithstanding the preceding sections of this subchapter, 
no action may be brought under this subchapter based on a claim 
submitted--
            ``(1) in reliance on (and correctly using) erroneous 
        information supplied by a Federal agency (or an agent thereof) 
        about matters of fact at issue; or
            ``(2) in reliance on (and correctly applying) written 
        statements of Federal policy which affects such claim provided 
        by a Federal agency (or an agent thereof).
    ``(d) Action for Claims Submitted by Persons in Substantial 
Compliance With Model Compliance Plan.--Notwithstanding the preceding 
sections of this subchapter, no action may be brought under this 
subchapter based on a claim submitted by a person that is in 
substantial compliance with a model compliance plan issued by the 
Secretary of Health and Human Services (in consultation with the 
Secretary of Defense).
    ``(e) Standard of Proof.--In any action brought under this 
subchapter with respect to a claim submitted to a federally funded 
health care program, section 3731(c) shall be applied by substituting 
`clear and convincing evidence' for `a preponderance of the evidence'.
    ``(f) Rule of Construction.--Nothing in this section shall be 
construed as limiting the authority of the Government of the United 
States to recoup or otherwise recover damages with respect to a claim 
submitted to a federally funded health care program under provisions of 
law other than this subchapter.
    ``(g) Definitions; Related Rules.--For purposes of this section--
            ``(1) the term `claim' means a claim (as defined in section 
        3729(c)) made with respect to a federally funded health care 
        program;
            ``(2) the term `damages' means the amount of any 
        overpayment made by the United States Government with respect 
        to a claim;
            ``(3) the term `federally funded health care program' means 
        a program that provides health benefits, whether directly, 
        through the purchase of insurance, or otherwise, that is 
        established under--
                    ``(A) title XVIII, XIX, or XXI of the Social 
                Security Act, or
                    ``(B) title 10, United States Code;
            ``(4) the amount of damages alleged to have been sustained 
        by the United States Government with respect to a claim 
        submitted by (or on behalf of) a person shall be treated as a 
        `material amount' only if such amount exceeds a proportion 
        (specified in regulations promulgated by the Secretary of 
        Health and Human Services in consultation with the Secretary of 
        Defense) of the total of the amounts for which claims were 
        submitted by (or on behalf of) such person--
                    ``(A) to the same federally funded health care 
                program, and
                    ``(B) for the same calendar year,
        as the claim upon which an action under this subchapter is 
        based;
            ``(5) the regulations specifying the proportion referred to 
        in paragraph (4) shall be based on the definition of the term 
        `material' used by the American Institute of Certified Public 
        Accountants as of the date of the enactment of this section; 
        and
            ``(6) in determining whether an amount of damages is a 
        `material amount' under paragraph (4), with respect to a 
        person--
                    ``(A) the amount of damages for more than 1 claim 
                may be aggregated only if the acts or omissions 
                resulting in such damages were part of a pattern of 
                related acts or omissions by such person, and
                    ``(B) if damages for more than 1 claim are 
                aggregated in accordance with subparagraph (A), the 
                proportion referred to in such paragraph shall be 
                determined by comparing the amount of such aggregate 
                damages to the total of the amounts for which claims 
                were submitted by (or on behalf of) such person to the 
                same federally funded health care program for each of 
                the calendar years for which any claim upon which such 
                aggregate damages were based was submitted.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to actions brought under subchapter III of chapter 37 of title 
31, United States Code, with respect to claims submitted before, on, 
and after the date of the enactment of this Act.