Federal Employees Health Benefits Provider Integrity Amendments of 1997

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Federal Employees Health Benefits 
Provider Integrity Amendments of 1997''.

SEC. 2. DEBARMENT AND OTHER SANCTIONS.

    (a) Amendments.--Section 8902a of title 5, United States Code, is 
amended--
            (1) in subsection (a)--
                    (A) in paragraph (1)--
                            (i) by striking ``and'' at the end of 
                        subparagraph (B);
                            (ii) by striking the period at the end and 
                        inserting ``; and''; and
                            (iii) by adding at the end the following:
            ``(D) the term `should know' means that a person, with 
        respect to information, acts in deliberate ignorance of, or in 
        reckless disregard of, the truth or falsity of the information, 
        and no proof of specific intent to defraud is required.''; and
                    (B) in paragraph (2)(A), by striking ``subsection 
                (b) or (c)'' and inserting ``subsection (b), (c), or 
                (d)'';
            (2) in subsection (b)--
                    (A) by striking ``The Office of Personnel 
                Management may bar'' and inserting ``The Office of 
                Personnel Management shall bar''; and
                    (B) by amending paragraph (5) to read as follows:
            ``(5) Any provider that is currently suspended or excluded 
        from participation under any program of the Federal Government 
        involving procurement or nonprocurement activities.'';
            (3) by redesignating subsections (c) through (i) as 
        subsections (d) through (j), respectively, and by inserting 
        after subsection (b) the following:
    ``(c) The Office may bar the following providers of health care 
services from participating in the program under this chapter:
            ``(1) Any provider--
                    ``(A) whose license to provide health care services 
                or supplies has been revoked, suspended, restricted, or 
                not renewed, by a State licensing authority for reasons 
                relating to the provider's professional competence, 
                professional performance, or financial integrity; or
                    ``(B) that surrendered such a license while a 
                formal disciplinary proceeding was pending before such 
                an authority, if the proceeding concerned the 
                provider's professional competence, professional 
                performance, or financial integrity.
            ``(2) Any provider that is an entity directly or indirectly 
        owned, or with a 5 percent or more controlling interest, by an 
        individual who is convicted of any offense described in 
        subsection (b), against whom a civil monetary penalty has been 
        assessed under subsection (d), or who has been debarred from 
        participation under this chapter.
            ``(3) Any individual who directly or indirectly owns or has 
        a controlling interest in an entity and who knows or should 
        know of the action constituting the basis for the entity's 
        conviction of any offense described in subsection (b), 
        assessment with a civil monetary penalty under subsection (d), 
        or debarment from participation under this chapter.
            ``(4) Any provider that the Office determines, in 
        connection with claims presented under this chapter, has 
        charged for health care services or supplies in an amount 
        substantially in excess of such provider's customary charge for 
        such services or supplies (unless the Office finds there is 
        good cause for such charge), or charged for health care 
        services or supplies which are substantially in excess of the 
        needs of the covered individual or which are of a quality that 
        fails to meet professionally recognized standards for such 
        services or supplies.
            ``(5) Any provider that the Office determines has committed 
        acts described in subsection (d).'';
            (4) in subsection (d) (as so redesignated by paragraph (3)) 
        by amending paragraph (1) to read as follows:
            ``(1) in connection with claims presented under this 
        chapter, that a provider has charged for a health care service 
        or supply which the provider knows or should have known 
        involves--
                    ``(A) an item or service not provided as claimed,
                    ``(B) charges in violation of applicable charge 
                limitations under section 8904(b), or
                    ``(C) an item or service furnished during a period 
                in which the provider was debarred from participation 
                under this chapter pursuant to a determination by the 
                Office under this section, other than as permitted 
                under subsection (g)(2)(B);'';
            (5) in subsection (f) (as so redesignated by paragraph (3)) 
        by inserting after ``under this section'' the first place it 
        appears the following: ``(where such debarment is not 
        mandatory)'';
            (6) in subsection (g) (as so redesignated by paragraph 
        (3))--
                    (A) by striking ``(g)(1)'' and all that follows 
                through the end of paragraph (1) and inserting the 
                following:
    ``(g)(1)(A) Except as provided in subparagraph (B), debarment of a 
provider under subsection (b) or (c) shall be effective at such time 
and upon such reasonable notice to such provider, and to carriers and 
covered individuals, as shall be specified in regulations prescribed by 
the Office. Any such provider that is debarred from participation may 
request a hearing in accordance with subsection (h)(1).
    ``(B) Unless the Office determines that the health or safety of 
individuals receiving health care services warrants an earlier 
effective date, the Office shall not make a determination adverse to a 
provider under subsection (c)(5) or (d) until such provider has been 
given reasonable notice and an opportunity for the determination to be 
made after a hearing as provided in accordance with subsection 
(h)(1).'';
                    (B) in paragraph (3)--
                            (i) by inserting ``of debarment'' after 
                        ``notice''; and
                            (ii) by adding at the end the following: 
                        ``In the case of a debarment under paragraph 
                        (1), (2), (3), or (4) of subsection (b), the 
                        minimum period of debarment shall not be less 
                        than 3 years, except as provided in paragraph 
                        (4)(B)(ii).'';
                    (C) in paragraph (4)(B)(i)(I) by striking 
                ``subsection (b) or (c)'' and inserting ``subsection 
                (b), (c), or (d)''; and
                    (D) by striking paragraph (6);
            (7) in subsection (h) (as so redesignated by paragraph (3)) 
        by striking ``(h)(1)'' and all that follows through the end of 
        paragraph (2) and inserting the following:
    ``(h)(1) Any provider of health care services or supplies that is 
the subject of an adverse determination by the Office under this 
section shall be entitled to reasonable notice and an opportunity to 
request a hearing of record, and to judicial review as provided in this 
subsection after the Office renders a final decision. The Office shall 
grant a request for a hearing upon a showing that due process rights 
have not previously been afforded with respect to any finding of fact 
which is relied upon as a cause for an adverse determination under this 
section. Such hearing shall be conducted without regard to subchapter 
II of chapter 5 and chapter 7 of this title by a hearing officer who 
shall be designated by the Director of the Office and who shall not 
otherwise have been involved in the adverse determination being 
appealed. A request for a hearing under this subsection shall be filed 
within such period and in accordance with such procedures as the Office 
shall prescribe by regulation.
    ``(2) Any provider adversely affected by a final decision under 
paragraph (1) made after a hearing to which such provider was a party 
may seek review of such decision in the United States District Court 
for the District of Columbia or for the district in which the plaintiff 
resides or has his or her principal place of business by filing a 
notice of appeal in such court within 60 days after the date the 
decision is issued, and by simultaneously sending copies of such notice 
by certified mail to the Director of the Office and to the Attorney 
General. In answer to the appeal, the Director of the Office shall 
promptly file in such court a certified copy of the transcript of the 
record, if the Office conducted a hearing, and other evidence upon 
which the findings and decision complained of are based. The court 
shall have power to enter, upon the pleadings and evidence of record, a 
judgment affirming, modifying, or setting aside, in whole or in part, 
the decision of the Office, with or without remanding the case for a 
rehearing. The district court shall not set aside or remand the 
decision of the Office unless there is not substantial evidence on the 
record, taken as whole, to support the findings by the Office of a 
cause for action under this section or unless action taken by the 
Office constitutes an abuse of discretion.''; and
            (8) in subsection (i) (as so redesignated by paragraph 
        (3))--
                    (A) by striking ``subsection (c)'' and inserting 
                ``subsection (d)''; and
                    (B) by adding at the end the following: ``The 
                amount of a penalty or assessment as finally determined 
                by the Office, or other amount the Office may agree to 
                in compromise, may be deducted from any sum then or 
                later owing by the United States to the party against 
                whom the penalty or assessment has been levied.''.
    (b) Effective Date.--
            (1) In general.--Except as provided in paragraph (2), the 
        amendments made by this section shall take effect on the date 
        of the enactment of this Act.
            (2) Exceptions.--(A) Paragraphs (2), (3), and (5) of 
        section 8902a(c) of title 5, United States Code, as amended by 
        subsection (a)(3), shall apply only to the extent that the 
        misconduct which is the basis for debarment under such 
        paragraph (2), (3), or (5), as applicable, occurs after the 
        date of the enactment of this Act.
    (B) Paragraph (1)(B) of section 8902a(d) of title 5, United States 
Code, as amended by subsection (a)(4), shall apply only with respect to 
charges which violate section 8904(b) of such title for items or 
services furnished after the date of the enactment of this Act.
    (C) Paragraph (3) of section 8902a(g) of title 5, United States 
Code, as amended by subsection (a)(6)(B), shall apply only with respect 
to debarments based on convictions occurring after the date of the 
enactment of this Act.

SEC. 3. AMENDMENT TO THE SOCIAL SECURITY ACT.

    Section 1128B(f)(1) of the Social Security Act (42 U.S.C. 1320a-
7b(f)(1)), as amended by section 204(a)(7) of the Health Insurance 
Portability and Accountability Act of 1996 (Public Law 104-191; 110 
Stat. 2000), is amended by striking ``(other than the health insurance 
program under chapter 89 of title 5, United States Code)''.

Summary: Federal Employees Health Benefits Provider Integrity Amendments of 1997 - Amends Federal law, with respect to Federal employees' health insurance coverage under the Federal Employees Health Benefits Program (FEHB), to revise provisions regarding the debarment of any health care provider found to have engaged in fraudulent practices, including requiring debarment for certain fraudulent practices. Amends the Social Security Act, as amended by the Health Insurance Portability and Accountability Act of 1996, to apply certain criminal health antifraud and abuse sanctions to fraud and abuse involving the FEHB Program.