I

106TH CONGRESS

2D SESSION H. R. 5094

To reduce the amount of paperwork and improve payment policies for health

care services, to prevent fraud and abuse through health care provider

education, and for other purposes.

IN THE HOUSE OF REPRESENTATIVES

JULY 27, 2000

Mr. THORNBERRY introduced the following bill; which was referred to the

Committee on Commerce, and in addition to the Committee on Ways and

Means, 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 reduce the amount of paperwork and improve payment

policies for health care services, to prevent fraud and

abuse through health care provider education, 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.

4 This Act may be cited as the ‘‘Health Care Fraud

5 Prevention and Paperwork Reduction Act of 2000’’.
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1 SEC. 2. FEDERAL COMMISSION ON BILLING CODES AND

2 FORMS SIMPLIFICATION.

3 (a) ESTABLISHMENT.—There is hereby established

4 the Commission on Billing Codes and Forms Simplifica5 tion (in this section referred to as the ‘‘Commission’’).

6 (b) DUTIES.—The Commission shall make rec7 ommendations regarding the following:

8 (1) STANDARDIZED FORMS.—Standardizing

9 credentialing and billing forms respecting health

10 care claims, that all Federal Government agencies

11 would use and that the private sector is able (and

12 is encouraged, but not required) to use.

13 (2) REDUCTION IN BILLING CODES.—A signifi14 cant reduction and simplification in the number of

15 billing codes.

16 (c) MEMBERSHIP.—

17 (1) NUMBER AND APPOINTMENT.—The Com18 mission shall be composed of such members as the

19 Comptroller General of the United States shall ap20 point.

21 (2) QUALIFICATIONS.—The membership of the

22 Commission shall include individuals who are mem23 bers of the medical community.

24 (d) INCORPORATION OF MEDPAC PROVISIONS.—The

25 provisions of paragraphs (3) through (6) of subsection (c)

26 and subsections (d) through (f) of section 1805 of the So-
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1 cial Security Act (42 U.S.C. 1395b–6) shall apply to the

2 Commission in the same manner as they apply to the

3 Medicare Payment Advisory Commission.

4 (e) REPORTS.—The Commission shall submit to Con5 gress and the President such periodic reports on its rec6 ommendations as it deems appropriate.

7 SEC. 3. EDUCATION OF PHYSICIANS AND PROVIDERS CON8 CERNING MEDICARE PROGRAM PAYMENTS.

9 (a) WRITTEN REQUESTS.—

10 (1) IN GENERAL.—The Secretary of Health and

11 Human Services shall establish a process under

12 which a physician may request, in writing from a

13 carrier, assistance in addressing questionable codes

14 and procedures under the medicare program under

15 title XVIII of the Social Security Act and then the

16 carrier shall respond in writing within 30 business

17 days respond with the correct billing or procedural

18 answer.

19 (2) USE OF WRITTEN STATEMENT.—

20 (A) IN GENERAL.—Subject to subpara21 graph (B), a written statement under para22 graph (1) may be used as proof against a fu23 ture audit or overpayment under the medicare

24 program.
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1 (B) LIMIT ON APPLICATION.—Subpara2 graph (A) shall not apply retroactively and shall

3 not apply to cases of fraudulent billing.

4 (b) RESTORATION OF TOLL-FREE HOTLINE.—

5 (1) IN GENERAL.—The Administrator of the

6 Health Care Financing Administration shall restore

7 the toll-free telephone hotline so that physicians may

8 call for information and questions about the medi9 care program.

10 (2) AUTHORIZATION OF APPROPRIATIONS.—

11 There are authorized to be appropriated such sums

12 as may be necessary to carry out paragraph (1).

13 (c) DEFINITIONS.—For purposes of this section:

14 (1) PHYSICIAN.—The term ‘‘physician’’ has the

15 meaning given such term in section 1861(r) of the

16 Social Security Act (42 U.S.C. 1395x(r)).

17 (2) CARRIER.—The term ‘‘carrier’’ means a

18 carrier (as defined in section 1842(f) of the Social

19 Security Act (42 U.S.C. 1395u(f))) with a contract

20 under title XVIII of such Act to administer benefits

21 under part B of such title.

22 SEC. 4. POLICY DEVELOPMENT REGARDING E&M GUIDE23 LINES UNDER THE MEDICARE PROGRAM.

24 (a) IN GENERAL.—HCFA may not implement any

25 new evaluation and management guidelines (in this section
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1 referred to as ‘‘E&M guidelines’’) under the medicare pro2 gram, unless HCFA—

3 (1) has provided for an assessment of the pro4 posed guidelines by physicians;

5 (2) has established a plan that contains specific

6 goals, including a schedule, for improving participa7 tion of physicians;

8 (3) has carried out a minimum of 4 pilot

9 projects consistent with subsection (b) in at least 4

10 different HCFA regions (to be specified by the Sec11 retary) to test such guidelines; and

12 (4) finds that the objectives described in sub13 section (c) will be met in the implementation of such

14 guidelines.

15 (b) PILOT PROJECTS.—

16 (1) LENGTH AND CONSULTATION.—Each pilot

17 project under this subsection shall—

18 (A) be of sufficient length to allow for pre19 paratory physician and carrier education, anal20 ysis, and use and assessment of potential E&M

21 guidelines; and

22 (B) be conducted, throughout the planning

23 and operational stages of the project, in con24 sultation with national and State medical soci25 eties.
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1 (2) PEER REVIEW AND RURAL PILOT

2 PROJECTS.—Of the pilot projects conducted under

3 this subsection—

4 (A) at least one shall focus on a peer re5 view method by physicians which evaluates

6 medical record information for statistical outlier

7 services relative to definitions and guidelines

8 published in the CPT book, instead of an ap9 proach using the review of randomly selected

10 medical records using non-clinical personnel;

11 and

12 (B) at least one shall be conducted for

13 services furnished in a rural area.

14 (3) STUDY OF IMPACT.—Each pilot project

15 shall examine the effect of the E&M guidelines on—

16 (A) different types of physician practices,

17 such as large and small groups; and

18 (B) the costs of compliance, and patient

19 and physician satisfaction.

20 (4) REPORT ON HOW MET OBJECTIVES.—

21 HCFA shall submit a report to the Committees on

22 Commerce and Ways and Means of the House of

23 Representatives, the Committee on Finance of the

24 Senate, and the Practicing Physicians Advisory

25 Council, six months after the conclusion of the pilot
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1 projects. Such report shall include the extent to

2 which the pilot projects met the objectives specified

3 in subsection (c).

4 (c) OBJECTIVES FOR E&M GUIDELINES.—The objec5 tives for E&M guidelines specified in this subsection are

6 as follows (relative to the E&M guidelines and review poli7 cies in effect as of the date of the enactment of this Act):

8 (1) Enhancing clinically relevant documentation

9 needed to accurately code and assess coding levels

10 accurately.

11 (2) Reducing administrative burdens.

12 (3) Decreasing the level of non-clinically perti13 nent and burdensome documentation time and con14 tent in the record.

15 (4) Increased accuracy by carrier reviewers.

16 (5) Education of both physicians and reviewers.

17 (6) Appropriate use of E&M codes by physi18 cians and their staffs.

19 (7) The extent to which the tested E&M docu20 mentation guidelines substantially adhere to the

21 CPT coding rules.

22 (d) DEFINITIONS.—For purposes of this section and

23 sections 5 and 6:
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1 (1) PHYSICIAN.—The term ‘‘physician’’ has the

2 meaning given such term in section 1861(r) of the

3 Social Security Act (42 U.S.C. 1395x(r)).

4 (2) CARRIER.—The term ‘‘carrier’’ means a

5 carrier (as defined in section 1842(f) of the Social

6 Security Act (42 U.S.C. 1395u(f))) with a contract

7 under title XVIII of such Act to administer benefits

8 under part B of such title.

9 (3) SECRETARY.—The term ‘‘Secretary’’ means

10 the Secretary of Health and Human Services.

11 (4) HCFA.—The term ‘‘HCFA’’ means the

12 Health Care Financing Administration.

13 (5) MEDICARE PROGRAM.—The term ‘‘medicare

14 program’’ means the program under title XVIII of

15 the Social Security Act.

16 SEC. 5. OVERPAYMENTS UNDER THE MEDICARE PROGRAM.

17 (a) INDIVIDUALIZED NOTICE.—If a carrier proceeds

18 with a post-payment audit of a physician under the medi19 care program, the carrier shall provide the physician with

20 an individualized notice of billing problems, such as a per21 sonal visit or carrier-to-physician telephone conversation

22 during normal working hours, within 3 months of initi23 ating such audit. The notice should include suggestions

24 to the physician on how the billing problem may be rem25 edied.
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1 (b) REPAYMENT OF OVERPAYMENTS WITHOUT PEN2 ALTY.—The Secretary shall permit physicians to repay

3 medicare overpayments within 3 months without penalty

4 or interest and without threat of denial of other claims

5 based upon extrapolation. If a physician should discover

6 an overpayment before a carrier notifies the physician of

7 the error, the physician may reimburse the medicare pro8 gram without penalty and the Secretary may not audit or

9 target the physician on the basis of such repayment, un10 less other evidence of fraudulent billing exists.

11 (c) TREATMENT OF FIRST-TIME BILLING ERRORS.—

12 If a physician’s medicare billing error was a first-time

13 error and the physician has not previously been the subject

14 of a post-payment audit, the carrier may not assess a fine

15 through extrapolation of such an error to other claims,

16 unless the physician has submitted a fraudulent claim.

17 (d) TIMELY NOTICE OF PROBLEM CLAIMS BEFORE

18 USING EXTRAPOLATION.—A carrier may seek reimburse19 ment or penalties against a physician based on extrapo20 lation of a medicare claim only if the carrier has informed

21 the physician of potential problems with the claim within

22 one year after the date the claim was submitted for reim23 bursement.

24 (e) SUBMISSION OF ADDITIONAL INFORMATION.—A

25 physician may submit additional information and docu-
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1 mentation to dispute a carrier’s charges of overpayment

2 without waiving the physician’s right to a hearing by an

3 administrative law judge.

4 (f) LIMITATION ON DELAY IN PAYMENT.—Following

5 a post-payment audit, a carrier that is conducting a pre6 payment screen on a physician service under the medicare

7 program may not delay reimbursements for more than one

8 month and as soon as the physician submits a corrected

9 claim, the carrier shall eliminate application of such a pre10 payment screen.

11 SEC. 6. ENFORCEMENT PROVISIONS UNDER THE MEDI12 CARE PROGRAM.

13 If a physician is suspected of fraud or wrongdoing

14 in the medicare program, inspectors associated with the

15 Office of Inspector General of the Department of Health

16 and Human Services—

17 (1) may not enter the physician’s private office

18 with a gun or deadly weapon to make an arrest; and

19 (2) may not make such an arrest without a

20 valid warrant of arrest, unless the physician is flee21 ing or deemed dangerous.

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