I 

108TH CONGRESS 

1ST SESSION H. R. 18

To amend title XVIII of the Social Security Act to establish additional 

provisions to combat waste, fraud, and abuse within the Medicare Program, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

JANUARY 7, 2003

Mrs. BIGGERT introduced the following bill; which was referred to the Committee on Ways and Means, and in addition to the Committees on Energy 

and Commerce, and the Judiciary, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions 

as fall within the jurisdiction of the committee concerned 

A BILL

To amend title XVIII of the Social Security Act to establish 

additional provisions to combat waste, fraud, and abuse 

within the Medicare Program, and for other purposes.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

4 (a) SHORT TITLE.—This Act may be cited as the 

5 ‘‘Medicare Fraud Prevention and Enforcement Act of 

6 2003’’. 

7 (b) TABLE OF CONTENTS.—The table of contents for 

8 this Act is as follows:
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Sec. 1. Short title; table of contents. 

Sec. 2. Site inspections and background checks. 

Sec. 3. Registration of billing agencies. 

Sec. 4. Expanded access to the health integrity protection database (HIPDB). 

Sec. 5. Liability of medicare carriers and fiscal intermediaries for claims submitted by excluded providers. 

Sec. 6. Community mental health centers. 

Sec. 7. Limiting the use of discharge in bankruptcy proceedings for provider liability for health care fraud. 

Sec. 8. Illegal distribution of a medicare or medicaid beneficiary identification 

or provider number. 

Sec. 9. Treatment of certain Social Security Act crimes as Federal health care 

offenses. 

Sec. 10. Authority of Office of Inspector General of the Department of Health 

and Human Services. 

Sec. 11. Universal product numbers on claims forms for reimbursement under 

the medicare program.

1 SEC. 2. SITE INSPECTIONS AND BACKGROUND CHECKS. 

2 (a) SITE INSPECTIONS FOR DME SUPPLIERS, COM3 MUNITY MENTAL HEALTH CENTERS, AND OTHER PRO4 VIDER GROUPS.—Title XVIII of the Social Security Act 

5 (42 U.S.C. 1395 et seq.) is amended by adding at the end 

6 the following: 

7 ‘‘SITE INSPECTIONS FOR DME SUPPLIERS, COMMUNITY

8 MENTAL HEALTH CENTERS, AND OTHER PROVIDER

9 GROUPS

10 ‘‘SEC. 1897. (a) SITE INSPECTIONS.—

11 ‘‘(1) IN GENERAL.—The Secretary shall con12 duct a site inspection for each applicable provider 

13 (as defined in paragraph (2)) that applies for a pro14 vider number in order to provide items or services 

15 under this title. Such site inspection shall be in addi16 tion to any other site inspection that the Secretary 
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1 would otherwise conduct with regard to an applica2 ble provider. 

3 ‘‘(2) APPLICABLE PROVIDER DEFINED.—

4 ‘‘(A) IN GENERAL.—Except as provided in 

5 subparagraph (B), in this section the term ‘ap6 plicable provider’ means—

7 ‘‘(i) a supplier of durable medical 

8 equipment (including items described in 

9 section 1834(a)(13)); 

10 ‘‘(ii) a supplier of prosthetics, 

11 orthotics, or supplies (including items de12 scribed in paragraphs (8) and (9) of sec13 tion 1861(s)); 

14 ‘‘(iii) a community mental health cen15 ter; or 

16 ‘‘(iv) any other provider group, as de17 termined by the Secretary. 

18 ‘‘(B) EXCEPTION.—In this section, the 

19 term ‘applicable provider’ does not include—

20 ‘‘(i) a physician that provides durable 

21 medical equipment (as described in sub22 paragraph (A)(i)) or prosthetics, orthotics, 

23 or supplies (as described in subparagraph 

24 (A)(ii)) to an individual as incident to an 

25 office visit by such individual; or 
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1 ‘‘(ii) a hospital that provides durable 

2 medical equipment (as described in sub3 paragraph (A)(i)) or prosthetics, orthotics, 

4 or supplies (as described in subparagraph 

5 (A)(ii)) to an individual as incident to an 

6 emergency room visit by such individual. 

7 ‘‘(b) STANDARDS AND REQUIREMENTS.—In con8 ducting the site inspection pursuant to subsection (a), the 

9 Secretary shall ensure that the site being inspected is in 

10 full compliance with all the conditions and standards of 

11 participation and requirements for obtaining medicare bill12 ing privileges under this title. 

13 ‘‘(c) TIME.—The Secretary shall conduct the site in14 spection for an applicable provider prior to the issuance 

15 of a provider number to such provider. 

16 ‘‘(d) TIMELY REVIEW.—The Secretary shall provide 

17 for procedures to ensure that the site inspection required 

18 under this section does not unreasonably delay the 

19 issuance of a provider number to an applicable provider.’’. 

20 (b) BACKGROUND CHECKS.—Title XVIII of the So21 cial Security Act (42 U.S.C. 1395 et seq.) (as amended 

22 by subsection (a)) is amended by adding at the end the 

23 following:

24 ‘‘BACKGROUND CHECKS

25 ‘‘SEC. 1898. (a) BACKGROUND CHECK REQUIRED.—

26 Except as provided in subsection (b), the Secretary shall 
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1 conduct a background check on any individual or entity 

2 that applies to the Secretary for a provider number for 

3 the purpose of furnishing any item or service under this

4 title. In performing the background check, the Secretary 

5 shall—

6 ‘‘(1) conduct the background check before 

7 issuing a provider number to an individual or entity; 

8 ‘‘(2) include a search of criminal records in the 

9 background check; and 

10 ‘‘(3) provide for procedures that ensure the 

11 background check does not unreasonably delay the 

12 issuance of a provider number to an eligible indi13 vidual or entity. 

14 ‘‘(b) USE OF STATE LICENSING PROCEDURE.—The 

15 Secretary may use the results of a State licensing proce16 dure as a background check under subsection (a) if the 

17 State licensing procedure meets the requirements of sub18 section (a). 

19 ‘‘(c) ATTORNEY GENERAL REQUIRED TO PROVIDE

20 INFORMATION.—

21 ‘‘(1) IN GENERAL.—Upon request of the Sec22 retary, the Attorney General shall provide the crimi23 nal background check information referred to in sub24 section (a)(2) to the Secretary. 
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1 ‘‘(2) RESTRICTION ON USE OF DISCLOSED IN2 FORMATION.—The Secretary may only use the infor3 mation disclosed under subsection (a) for the pur4 pose of carrying out the Secretary’s responsibilities 

5 under this title. 

6 ‘‘(d) REFUSAL TO ISSUE PROVIDER NUMBER.—

7 ‘‘(1) AUTHORITY.—In addition to any other 

8 remedy available to the Secretary, the Secretary may 

9 refuse to issue a provider number to an individual 

10 or entity if the Secretary determines, after a back11 ground check conducted under this section, that 

12 such individual or entity has a history of acts that 

13 indicate issuance of a provider number to such indi14 vidual or entity would be detrimental to the best in15 terests of the program or program beneficiaries. 

16 Such acts may include, but are not limited to—

17 ‘‘(A) any bankruptcy; 

18 ‘‘(B) any act resulting in a civil judgment 

19 against such individual or entity; or 

20 ‘‘(C) any felony conviction under Federal 

21 or State law. 

22 ‘‘(2) REPORTING OF REFUSAL TO ISSUE PRO23 VIDER NUMBER TO THE HEALTH INTEGRITY PRO24 TECTION DATABASE (HIPDB).—A determination to 

25 refuse to issue a provider number to an individual 
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1 or entity as a result of a background check con2 ducted under this section shall be reported to the 

3 health integrity protection database established 

4 under section 1128E in accordance with the proce5 dures for reporting final adverse actions taken 

6 against a health care provider, supplier, or practi7 tioner under that section.’’. 

8 (c) REGULATIONS; EFFECTIVE DATE.—

9 (1) REGULATIONS.—Not later than 1 year after 

10 the date of enactment of this Act, the Secretary of 

11 Health and Human Services shall promulgate such 

12 regulations as are necessary to implement the 

13 amendments made by subsections (a) and (b). 

14 (2) EFFECTIVE DATE.—The amendments made 

15 by subsections (a) and (b) shall apply to applications 

16 received by the Secretary of Health and Human 

17 Services on or after January 1, 2004. 

18 (d) USE OF MEDICARE INTEGRITY PROGRAM

19 FUNDS.—The Secretary of Health and Human Services 

20 may use funds appropriated or transferred for purposes 

21 of carrying out the medicare integrity program established 

22 under section 1893 of the Social Security Act (42 U.S.C. 

23 1395ddd) to carry out the provisions of sections 1897 and 

24 1898 of that Act (as added by subsections (a) and (b)). 
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1 SEC. 3. REGISTRATION OF BILLING AGENCIES. 

2 (a) REGISTRATION OF BILLING AGENCIES AND INDI3 VIDUALS.—Title XVIII of the Social Security Act (42 

4 U.S.C. 1395 et seq.) (as amended by section 2(b)) is 

5 amended by adding at the end the following: 

6 ‘‘REGISTRATION OF BILLING AGENCIES AND INDIVIDUALS

7 ‘‘SEC. 1899. (a) REGISTRATION.—The Secretary 

8 shall establish procedures for the registration of all appli9 cable persons. 

10 ‘‘(b) REQUIRED APPLICATION.—Each applicable per11 son shall submit a registration application to the Secretary 

12 at such time, in such manner, and accompanied by such 

13 information as the Secretary may require. 

14 ‘‘(c) IDENTIFICATION NUMBER.—If the Secretary ap15 proves an application submitted under subsection (b), the 

16 Secretary shall assign a unique identification number to 

17 the applicable person. 

18 ‘‘(d) REQUIREMENT.—Every claim for reimburse19 ment under this title that is compiled and submitted by 

20 an applicable person shall contain the identification num21 ber that is assigned to the applicable person pursuant to 

22 subsection (c). 

23 ‘‘(e) TIMELY REVIEW.—The Secretary shall provide 

24 for procedures that ensure the timely consideration and 

25 determination regarding approval of applications under 

26 this section. 
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1 ‘‘(f) DEFINITION OF APPLICABLE PERSON.—In this 

2 section, the term ‘applicable person’ means an individual 

3 or an entity that compiles and submits claims for reim4 bursement under this title to the Secretary on behalf of 

5 any individual or entity.’’. 

6 (b) PERMISSIVE EXCLUSION.—Section 1128(b) of 

7 the Social Security Act (42 U.S.C. 1320a–7(b)) is amend8 ed by adding at the end the following: 

9 ‘‘(16) FRAUD BY APPLICABLE PERSON.—An ap10 plicable person (as defined in section 1899(f)) that 

11 the Secretary determines knowingly submitted or 

12 caused to be submitted a claim for reimbursement 

13 under title XVIII that the applicable person knows 

14 or should know is false or fraudulent.’’. 

15 (c) REGULATIONS; EFFECTIVE DATE.—

16 (1) REGULATIONS.—Not later than 1 year after 

17 the date of enactment of this Act, the Secretary of 

18 Health and Human Services shall promulgate such 

19 regulations as are necessary to implement the 

20 amendment made by subsections (a) and (b). 

21 (2) EFFECTIVE DATE.—The amendment made 

22 by subsections (a) and (b) shall take effect on Janu23 ary 1, 2004.
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1 SEC. 4. EXPANDED ACCESS TO THE HEALTH INTEGRITY 

2 PROTECTION DATABASE (HIPDB). 

3 (a) IN GENERAL.—Section 1128E(d)(1) of the Social 

4 Security Act (42 U.S.C. 1320a–7e(d)(1)) is amended to 

5 read as follows:

6 ‘‘(1) AVAILABILITY.—The information in the 

7 database maintained under this section shall be 

8 available to—

9 ‘‘(A) Federal and State government agen10 cies and health plans, and any health care pro11 vider, supplier, or practitioner entering an em12 ployment or contractual relationship with an in13 dividual or entity who could potentially be the 

14 subject of a final adverse action, where the con15 tract involves the furnishing of items or services 

16 reimbursed by 1 or more Federal health care 

17 programs (regardless of whether the individual 

18 or entity is paid by the programs directly, or 

19 whether the items or services are reimbursed di20 rectly or indirectly through the claims of a di21 rect provider); and 

22 ‘‘(B) utilization and quality control peer 

23 review organizations and accreditation entities 

24 as defined by the Secretary, including but not 

25 limited to organizations described in part B of 

26 this title and in section 1154(a)(4)(C).’’. 
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1 (b) CRIMINAL PENALTY FOR MISUSE OF INFORMA2 TION.—Section 1128B(b) of the Social Security Act (42 

3 U.S.C. 1320a–7b(b)) is amended by adding at the end the 

4 following: 

5 ‘‘(4) Whoever knowingly uses information maintained 

6 in the health integrity protection database maintained in 

7 accordance with section 1128E for a purpose other than 

8 a purpose authorized under that section shall be impris9 oned for not more than 3 years or fined under title 18, 

10 United States Code, or both.’’. 

11 (c) EFFECTIVE DATE.—The amendments made by 

12 this section shall take effect on the date of enactment of 

13 this Act. 

14 SEC. 5. LIABILITY OF MEDICARE CARRIERS AND FISCAL 

15 INTERMEDIARIES FOR CLAIMS SUBMITTED 

16 BY EXCLUDED PROVIDERS. 

17 (a) REIMBURSEMENT TO THE SECRETARY FOR

18 AMOUNTS PAID TO EXCLUDED PROVIDERS.—

19 (1) REQUIREMENTS FOR FISCAL INTER20 MEDIARIES.—

21 (A) IN GENERAL.—Section 1816 of the So22 cial Security Act (42 U.S.C. 1395h) is amended 

23 by adding at the end the following: 

24 ‘‘(m) An agreement with an agency or organization 

25 under this section shall require that such agency or orga-
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1 nization reimburse the Secretary for any amounts paid by 

2 the agency or organization for a service under this title 

3 which is furnished by an individual or entity during any 

4 period for which the individual or entity is excluded, pur5 suant to section 1128, 1128A, or 1156, from participation 

6 in the health care program under this title if the amounts 

7 are paid after the 60-day period beginning on the date 

8 the Secretary provides notice of the exclusion to the agen9 cy or organization, unless the payment was made as a re10 sult of incorrect information provided by the Secretary or 

11 the individual or entity excluded from participation has 

12 concealed or altered their identity.’’. 

13 (B) CONFORMING AMENDMENT.—Section 

14 1816(i) of the Social Security Act (42 U.S.C. 

15 1395h(i)) is amended by adding at the end the 

16 following: 

17 ‘‘(4) Nothing in this subsection shall be construed to 

18 prohibit reimbursement by an agency or organization pur19 suant to subsection (m).’’. 

20 (2) REQUIREMENTS FOR CARRIERS.—Section 

21 1842(b)(3) of the Social Security Act (42 U.S.C. 

22 1395u(b)(3)) is amended—

23 (A) by striking ‘‘and’’ at the end of sub24 paragraph (I); and 
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1 (B) by inserting after subparagraph (I) the 

2 following: 

3 ‘‘(J) will reimburse the Secretary for any 

4 amounts paid by the carrier for an item or service 

5 under this part which is furnished by an individual 

6 or entity during any period for which the individual 

7 or entity is excluded, pursuant to section 1128, 

8 1128A, or 1156, from participation in the health 

9 care program under this title if the amounts are 

10 paid after the 60-day period beginning on the date 

11 the Secretary provides notice of the exclusion to the 

12 carrier, unless the payment was made as a result of 

13 incorrect information provided by the Secretary or 

14 the individual or entity excluded from participation 

15 has concealed or altered their identity; and’’. 

16 (b) CONFORMING REPEAL OF MANDATORY PAYMENT

17 RULE.—Section 1862(e) of the Social Security Act (42 

18 U.S.C. 1395y(e)) is amended—

19 (1) in paragraph (1)(B), by striking ‘‘and when 

20 the person’’ and all that follows through ‘‘person)’’; 

21 and 

22 (2) by amending paragraph (2) to read as fol23 lows: 

24 ‘‘(2) No individual or entity may bill (or collect any 

25 amount from) any individual for any item or service for 
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1 which payment is denied under paragraph (1). No indi2 vidual is liable for payment of any amounts billed for such 

3 an item or service in violation of the preceding sentence.’’. 

4 (c) EFFECTIVE DATE.—

5 (1) IN GENERAL.—The amendments made by 

6 this section shall apply to claims for payment sub7 mitted on or after the date of enactment of this Act. 

8 (2) CONTRACT MODIFICATION.—The Secretary 

9 of Health and Human Services shall take such steps 

10 as may be necessary to modify contracts and agree11 ments entered into, renewed, or extended prior to 

12 the date of enactment of this Act to conform such 

13 contracts or agreements to the provisions of this sec14 tion. 

15 SEC. 6. COMMUNITY MENTAL HEALTH CENTERS. 

16 (a) IN GENERAL.—Section 1861(ff)(3)(B) of the So17 cial Security Act (42 U.S.C. 1395x(ff)(3)(B)) is amended 

18 by striking ‘‘entity that—’’ and all that follows and insert19 ing the following: ‘‘entity that—

20 ‘‘(i) provides the community mental health serv21 ices specified in paragraph (1) of section 1913(c) of 

22 the Public Health Service Act; 

23 ‘‘(ii) meets applicable certification or licensing 

24 requirements for community mental health centers 

25 in the State in which it is located;
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1 ‘‘(iii) provides a significant share of its services 

2 to individuals who are not eligible for benefits under 

3 this title; and

4 ‘‘(iv) meets such additional standards or re5 quirements for obtaining medicare billing privileges 

6 as the Secretary may specify to ensure—

7 ‘‘(I) the health and safety of beneficiaries 

8 receiving such services; or 

9 ‘‘(II) the furnishing of such services in an 

10 effective and efficient manner.’’. 

11 (b) RESTRICTION.—Section 1861(ff)(3)(A) of such 

12 Act (42 U.S.C. 1395x(ff)(3)(A)) is amended by inserting 

13 ‘‘other than in an individual’s home or in an inpatient or 

14 residential setting’’ before the period. 

15 (c) EFFECTIVE DATE.—The amendments made by 

16 this section shall apply to items and services furnished 

17 after the sixth month that begins after the date of enact18 ment of this Act. 

19 SEC. 7. LIMITING THE DISCHARGE OF DEBTS IN BANK20 RUPTCY PROCEEDINGS IN CASES WHERE A 

21 HEALTH CARE PROVIDER OR A SUPPLIER EN22 GAGES IN FRAUDULENT ACTIVITY. 

23 (a) IN GENERAL.—

24 (1) CIVIL MONETARY PENALTIES.—Section 

25 1128A(a) of the Social Security Act (42 U.S.C. 
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1 1320a–7a(a)) is amended by adding at the end the 

2 following: ‘‘Notwithstanding any other provision of 

3 law, amounts made payable under this section are 

4 not dischargeable under section 727, 944, 1141, 

5 1228, or 1328 of title 11, United States Code, or 

6 any other provision of such title.’’. 

7 (2) RECOVERY OF OVERPAYMENT TO PRO8 VIDERS OF SERVICES UNDER PART A OF MEDI9 CARE.—Section 1815(d) of the Social Security Act 

10 (42 U.S.C. 1395g(d)) is amended—

11 (A) by inserting ‘‘(1)’’ after ‘‘(d)’’; and 

12 (B) by adding at the end the following: 

13 ‘‘(2) Notwithstanding any other provision of law, 

14 amounts due to the Secretary under this section are not 

15 dischargeable under section 727, 944, 1141, 1228, or 

16 1328 of title 11, United States Code, or any other provi17 sion of such title if the overpayment was the result of 

18 fraudulent activity, as may be defined by the Secretary.’’. 

19 (3) RECOVERY OF OVERPAYMENT OF BENEFITS

20 UNDER PART B OF MEDICARE.—Section 1833(j) of 

21 the Social Security Act (42 U.S.C. 1395l(j)) is 

22 amended—

23 (A) by inserting ‘‘(1)’’ after ‘‘(j)’’; and 

24 (B) by adding at the end the following: 
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1 ‘‘(2) Notwithstanding any other provision of law, 

2 amounts due to the Secretary under this section are not 

3 dischargeable under section 727, 944, 1141, 1228, or 

4 1328 of title 11, United States Code, or any other provi5 sion of such title if the overpayment was the result of 

6 fraudulent activity, as may be defined by the Secretary.’’. 

7 (4) COLLECTION OF PAST-DUE OBLIGATIONS

8 ARISING FROM BREACH OF SCHOLARSHIP AND LOAN

9 CONTRACT.—Section 1892(a) of the Social Security 

10 Act (42 U.S.C. 1395ccc(a)) is amended by adding at 

11 the end the following: 

12 ‘‘(5) Notwithstanding any other provision of 

13 law, amounts due to the Secretary under this section 

14 are not dischargeable under section 727, 944, 1141, 

15 1228, or 1328 of title 11, United States Code, or 

16 any other provision of such title.’’. 

17 (b) EFFECTIVE DATE.—The amendments made by 

18 subsection (a) shall apply to bankruptcy petitions filed 

19 after the date of enactment of this Act. 

20 SEC. 8. ILLEGAL DISTRIBUTION OF A MEDICARE OR MED21 ICAID BENEFICIARY IDENTIFICATION OR 

22 PROVIDER NUMBER. 

23 Section 1128B(b) of the Social Security Act (42 

24 U.S.C. 1320a–7b(b)), as amended by section 4(b), is 

25 amended by adding at the end the following: 
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1 ‘‘(5) Whoever knowingly, intentionally, and with the 

2 intent to defraud purchases, sells or distributes, or ar3 ranges for the purchase, sale, or distribution of 2 or more 

4 medicare or medicaid beneficiary identification numbers or 

5 provider numbers shall be imprisoned for not more than 

6 3 years or fined under title 18, United States Code (or, 

7 if greater, an amount equal to the monetary loss to the 

8 Federal and any State government as a result of such 

9 acts), or both.’’. 

10 SEC. 9. TREATMENT OF CERTAIN SOCIAL SECURITY ACT 

11 CRIMES AS FEDERAL HEALTH CARE OF12 FENSES. 

13 (a) IN GENERAL.—Section 24(a) of title 18, United 

14 States Code, is amended—

15 (1) by striking the period at the end of para16 graph (2) and inserting ‘‘; or’’; and

17 (2) by adding at the end the following: 

18 ‘‘(3) section 1128B of the Social Security Act 

19 (42 U.S.C. 1320a–7b).’’. 

20 (b) EFFECTIVE DATE.—The amendment made by 

21 subsection (a) shall take effect on the date of enactment 

22 of this Act and apply to acts committed on or after the 

23 date of enactment of this Act. 
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1 SEC. 10. AUTHORITY OF OFFICE OF INSPECTOR GENERAL 

2 OF THE DEPARTMENT OF HEALTH AND 

3 HUMAN SERVICES. 

4 (a) AUTHORITY.—Notwithstanding any other provi5 sion of law, upon designation by the Inspector General of 

6 the Department of Health and Human Services, any 

7 criminal investigator of the Office of Inspector General of 

8 such department may, in accordance with guidelines 

9 issued by the Secretary of Health and Human Services 

10 and approved by the Attorney General, while engaged in 

11 activities within the lawful jurisdiction of such Inspector 

12 General—

13 (1) obtain and execute any warrant or other 

14 process issued under the authority of the United 

15 States; 

16 (2) make an arrest without a warrant for—

17 (A) any offense against the United States 

18 committed in the presence of such investigator; 

19 or 

20 (B) any felony offense against the United 

21 States, if such investigator has reasonable cause 

22 to believe that the person to be arrested has 

23 committed or is committing that felony offense; 

24 and
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1 (3) exercise any other authority necessary to 

2 carry out the authority described in paragraphs (1) 

3 and (2). 

4 (b) FUNDS.—The Office of Inspector General of the 

5 Department of Health and Human Services may receive 

6 and expend funds that represent the equitable share from 

7 the forfeiture of property in investigations in which the 

8 Office of Inspector General participated, and that are 

9 transferred to the Office of Inspector General by the De10 partment of Justice, the Department of the Treasury, or 

11 the United States Postal Service. Such equitable sharing 

12 funds shall be deposited in a separate account and shall 

13 remain available until expended. 

14 SEC. 11. UNIVERSAL PRODUCT NUMBERS ON CLAIMS 

15 FORMS FOR REIMBURSEMENT UNDER THE 

16 MEDICARE PROGRAM. 

17 (a) UPNS ON CLAIMS FORMS FOR REIMBURSEMENT

18 UNDER THE MEDICARE PROGRAM.—

19 (1) ACCOMMODATION OF UPNS ON MEDICARE

20 CLAIMS FORMS.—Not later than February 1, 2005, 

21 all claims forms developed or used by the Secretary 

22 of Health and Human Services for reimbursement 

23 under the medicare program under title XVIII of the 

24 Social Security Act (42 U.S.C. 1395 et seq.) shall 
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1 accommodate the use of universal product numbers 

2 for a UPN covered item. 

3 (2) REQUIREMENT FOR PAYMENT OF CLAIMS.—

4 Title XVIII of the Social Security Act (42 U.S.C. 

5 1395 et seq.) is amended by adding at the end the 

6 following: 

7 ‘‘USE OF UNIVERSAL PRODUCT NUMBERS

8 ‘‘SEC. 1899A. (a) IN GENERAL.—No payment shall 

9 be made under this title for any claim for reimbursement 

10 for any UPN covered item unless the claim contains the 

11 universal product number of the UPN covered item. 

12 ‘‘(b) DEFINITIONS.—In this section: 

13 ‘‘(1) UPN COVERED ITEM.—

14 ‘‘(A) IN GENERAL.—Except as provided in 

15 subparagraph (B), the term ‘UPN covered 

16 item’ means—

17 ‘‘(i) a covered item as that term is de18 fined in section 1834(a)(13); 

19 ‘‘(ii) an item described in paragraph 

20 (8) or (9) of section 1861(s); 

21 ‘‘(iii) an item described in paragraph 

22 (5) of section 1861(s); and 

23 ‘‘(iv) any other item for which pay24 ment is made under this title that the Sec25 retary determines to be appropriate. 
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1 ‘‘(B) EXCLUSION.—The term ‘UPN cov2 ered item’ does not include a customized item 

3 for which payment is made under this title. 

4 ‘‘(2) UNIVERSAL PRODUCT NUMBER.—The 

5 term ‘universal product number’ means a number 

6 that is—

7 ‘‘(A) affixed by the manufacturer to each 

8 individual UPN covered item that uniquely 

9 identifies the item at each packaging level; and 

10 ‘‘(B) based on commercially acceptable 

11 identification standards such as, but not limited 

12 to, standards established by the Uniform Code 

13 Council-International Article Numbering Sys14 tem or the Health Industry Business Commu15 nication Council.’’. 

16 (3) DEVELOPMENT AND IMPLEMENTATION OF

17 PROCEDURES.—

18 (A) INFORMATION INCLUDED IN UPN.—

19 The Secretary of Health and Human Services, 

20 in consultation with manufacturers and entities 

21 with appropriate expertise, shall determine the 

22 relevant descriptive information appropriate for 

23 inclusion in a universal product number for a 

24 UPN covered item. 
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1 (B) REVIEW OF PROCEDURE.—From the 

2 information obtained by the use of universal 

3 product numbers on claims for reimbursement 

4 under the medicare program, the Secretary of 

5 Health and Human Services, in consultation 

6 with interested parties, shall periodically review 

7 the UPN covered items billed under the Health 

8 Care Financing Administration Common Proce9 dure Coding System and adjust such coding 

10 system to ensure that functionally equivalent 

11 UPN covered items are billed and reimbursed 

12 under the same codes. 

13 (4) EFFECTIVE DATE.—The amendment made 

14 by paragraph (2) shall apply to claims for reim15 bursement submitted on and after February 1, 

16 2005. 

17 (b) STUDY AND REPORTS TO CONGRESS.—

18 (1) STUDY.—The Secretary of Health and 

19 Human Services shall conduct a study on the results 

20 of the implementation of the provisions in paragraph 

21 (1) and (3) of subsection (a) and the amendment to 

22 the Social Security Act in paragraph (2) of that sub23 section. 

24 (2) REPORTS.—
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1 (A) PROGRESS REPORT.—Not later than 6 

2 months after the date of enactment of this Act, 

3 the Secretary of Health and Human Services 

4 shall submit a report to Congress that contains 

5 a detailed description of the progress of the 

6 matters studied pursuant to paragraph (1). 

7 (B) IMPLEMENTATION.—Not later than 18 

8 months after the date of enactment of this Act, 

9 and annually thereafter for 3 years, the Sec10 retary of Health and Human Services shall sub11 mit a report to Congress that contains a de12 tailed description of the results of the study 

13 conducted pursuant to paragraph (1), together 

14 with the Secretary’s recommendations regard15 ing the use of universal product numbers and 

16 the use of data obtained from the use of such 

17 numbers. 

18 (c) DEFINITIONS.—In this section: 

19 (1) UPN COVERED ITEM.—The term ‘‘UPN 

20 covered item’’ has the meaning given such term in 

21 section 1899A(b)(1) of the Social Security Act (as 

22 added by subsection (a)(2)). 

23 (2) UNIVERSAL PRODUCT NUMBER.—The term 

24 ‘‘universal product number’’ has the meaning given 
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1 such term in section 1899A(b)(2) of the Social Secu2 rity Act (as added by subsection (a)(2)). 

3 (d) AUTHORIZATION OF APPROPRIATIONS.—There 

4 are authorized to be appropriated such sums as may be 

5 necessary for the purpose of carrying out the provisions 

6 in paragraphs (1) and (3) of subsection (a), subsection 

7 (b), and section 1899A of the Social Security Act (as 

8 added by subsection (a)(2)).

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