I

104TH CONGRESS

1ST SESSION H. R. 1912

To deter and penalize health care fraud and abuse and to simplify the

administration of health benefit plans.

IN THE HOUSE OF REPRESENTATIVES

JUNE 22, 1995

Mr. STARK introduced the following bill; which was referred to the Committee

on Commerce, and in addition to the Committees on Ways and Means,

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 deter and penalize health care fraud and abuse and

to simplify the administration of health benefit plans.

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 ‘‘Health Care Fraud Prevention and Paperwork Reduction

6 Act of 1995’’.

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

8 this Act is as follows:

Sec. 1. Short title; table of contents.

Sec. 2. Findings.
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Sec. 3. Inapplicability of McCarran-Ferguson Act.

Sec. 4. Definitions.

TITLE I—FRAUD AND ABUSE

Subtitle A—Amendments to Anti-Fraud and Abuse Provisions Applicable to

Medicare, Medicaid, and State Health Care Programs

Sec. 101. Anti-kickback statutory provisions.

Sec. 102. Civil money penalties.

Sec. 103. Private right of action.

Sec. 104. Amendments to exclusionary provisions in fraud and abuse program.

Sec. 105. Sanctions against practitioners and persons for failure to comply with

statutory obligations relating to quality of care.

Sec. 106. Revisions to criminal penalties.

Sec. 107. Effective date.

Subtitle B—Establishment of All-Payer Health Care Fraud and Abuse

Control Program

Sec. 111. All-payer health care fraud and abuse control program.

Sec. 112. Establishment of all-payer health care fraud and abuse control account.

Subtitle C—Application of Fraud and Abuse Authorities Under the Social

Security Act to Other Payers

Sec. 121. Application of civil money penalties to all payers.

Sec. 122. Application of certain criminal penalties to all payers.

Sec. 123. Construction of social security act references.

Subtitle D—Advisory Opinions on Kickbacks and Self-Referral

Sec. 131. Establishment of process for issuance of advisory opinions.

Sec. 132. Imposition of fees.

Subtitle E—Preemption of State Corporate Practice Laws

Sec. 141. Preemption of State laws prohibiting corporate practice of medicine.

TITLE II—INFORMATION SYSTEMS AND ADMINISTRATIVE

SIMPLIFICATION

Sec. 201. Requirement for health benefit cards.

Sec. 202. National enrollment verification system.

Sec. 203. Requirements for uniform claims and electronic claims data set.

Sec. 204. Reporting of uniform clinical data sets.

Sec. 205. Uniform hospital cost reporting.

Sec. 206. Use of task forces.

1 SEC. 2. FINDINGS.

2 The Congress finds as follows:

3 (1) The costs of health care consume more than

4 14 percent of the gross domestic product of the
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1 United States, significantly affecting interstate com2 merce and the budget of the Federal Government.

3 (2) Federal outlays for the medicare program

4 alone totaled $162,500,000,000 in fiscal year 1994

5 and are expected to exceed $177,000,000,000 in fis6 cal year 1995 and $198,000,000,000 in fiscal year

7 1996.

8 (3) According to the General Accounting Office,

9 as much as 10 percent of all health care expendi10 tures in the United States, or $100,000,000,000, is

11 lost each year to health care fraud and abuse.

12 (4) As a direct provider of health care and as

13 a source of payment for health care, the Federal

14 Government has a significant interest in assessing

15 the quality and costs of health care through the eval16 uative activities of several Federal agencies.

17 (5) The health care system existing throughout

18 the United States has a significant effect on the

19 amount, distribution, and use of Federal funds be20 cause of the large numbers of—

21 (A) individuals who receive health care

22 benefits under programs operated or financed

23 in whole or in part by the Federal Government;

24 (B) individuals who benefit because of the

25 exclusion from Federal taxes of the amounts
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1 spent by their employers to provide them with

2 health insurance benefits;

3 (C) health care providers and professionals

4 who provide items and services for which the

5 Federal Government makes payments; and

6 (D) health care providers and professionals

7 who have received direct or indirect financial

8 assistance from the Federal Government be9 cause of their status as such a provider or pro10 fessional.

11 (6) It is in the interest of the United States

12 that there be a national ‘‘all-payer’’ anti-fraud pro13 gram, and a national administrative simplification

14 program, for our health care industry.

15 SEC. 3. INAPPLICABILITY OF MCCARRAN-FERGUSON ACT.

16 For purposes of section 2(b) of the Act of March 9,

17 1945 (15 U.S.C. 1012(b); commonly known as the

18 McCarran-Ferguson Act), this Act shall be considered to

19 specifically relate to the business of insurance.

20 SEC. 4. DEFINITIONS.

21 For purposes of this Act:

22 (1) CARRIER.—The term ‘‘carrier’’ means a li23 censed insurance company, a hospital or medical

24 service corporation (including an existing Blue Cross

25 or Blue Shield organization, within the meaning of
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1 section 833(c)(2) of the Internal Revenue Code of

2 1986), a health maintenance organization, or other

3 entity licensed or certified by a State to provide

4 health insurance or health benefits. The Secretary

5 may issue regulations that provide for affiliated car6 riers to be treated as a single carrier where appro7 priate under this title.

8 (2) HEALTH BENEFIT PLAN.—

9 (A) IN GENERAL.—The term ‘‘health bene10 fit plan’’ means—

11 (i) a health plan, other than a plan

12 described in subparagraph (B);

13 (ii) the medicare program;

14 (ii) medicare supplemental health in15 surance;

16 (iii) the medicaid program; and

17 (iv) except as the Secretary may pro18 vide, other Federal or State programs that

19 provide for payments for health care serv20 ices (other than coverage or insurance de21 scribed in subparagraph (B)).

22 (B) EXCEPTION.—The term ‘‘health bene23 fit plan’’ does not include any of the following

24 (or any combination thereof):
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1 (i) Coverage only for accident, dental,

2 vision, disability income, or long-term care

3 insurance, or any combination thereof.

4 (ii) Coverage issued as a supplement

5 to liability insurance.

6 (iii) Liability insurance, including gen7 eral liability insurance and automobile li8 ability insurance.

9 (iv) Worker’s compensation or similar

10 insurance.

11 (v) Automobile medical-payment in12 surance.

13 (vi) Coverage for a specified disease

14 or illness.

15 (vii) A hospital or fixed indemnity pol16 icy.

17 (3) HEALTH BENEFIT PLAN SPONSOR.—The

18 term ‘‘health benefit plan sponsor’’ means, in rela19 tion to a health benefit plan that—

20 (A) is an insured plan, the carrier provid21 ing the plan; or

22 (B) is a self-insured plan, the entity that

23 sponsors the plan (as defined by the Secretary).

24 (4) HEALTH CARE PROVIDER.—The term

25 ‘‘health care provider’’ includes a provider of services
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1 (as defined in section 1861(u) of the Social Security

2 Act), a physician, a laboratory (as defined in section

3 353(a) of the Public Health Service Act), a supplier,

4 and any other person furnishing health care in a

5 State. Such term includes a Federal or State pro6 gram that provides directly for the provision of

7 health care to beneficiaries.

8 (5) HEALTH PLAN.—The term ‘‘health plan’’

9 means—

10 (A) any contract of health insurance, in11 cluding any hospital or medical service policy or

12 certificate, hospital or medical service plan con13 tract, or health maintenance organization group

14 contract, that is provided by a carrier in a

15 State; or

16 (B) an employee welfare benefit plan or

17 other arrangement insofar as the plan or ar18 rangement provides health benefits in a State

19 and is funded in a manner other than through

20 the purchase of one or more policies or con21 tracts described in subparagraph (A).

22 (6) MANAGED CARE PLAN.—The term ‘‘man23 aged care plan’’ means a health plan that provides

24 for items and services covered under the plan pri-
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1 marily through providers in the provider network of

2 the plan.

3 (7) POINT-OF-SERVICE PLAN.—The term

4 ‘‘point-of-service plan’’ means a health plan other

5 than a managed care plan that permits an enrollee

6 to receive benefits through a provider network.

7 (8) PROVIDER NETWORK.—The term ‘‘provider

8 network’’ means, with respect to a health plan, pro9 viders who have entered into an agreement with the

10 plan under which such providers are obligated to

11 provide items and services covered under the plan to

12 individuals enrolled in the plan.

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

14 the Secretary of Health and Human Services.

15 (10) SELF-INSURED.—The term ‘‘self-insured’’

16 means, with respect to a health plan, a plan that is

17 described in paragraph (5)(B).

18 (11) STATE.—The term ‘‘State’’ means the 50

19 States, the District of Columbia, Puerto Rico, the

20 Virgin Islands, Guam, the Northern Mariana Is21 lands, and American Samoa.
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1 TITLE I—FRAUD AND ABUSE

2 Subtitle A—Amendments to Anti3 Fraud and Abuse Provisions Ap4 plicable to Medicare, Medicaid,

5 and State Health Care Programs

6 SEC. 101. ANTI-KICKBACK STATUTORY PROVISIONS.

7 (a) REVISION TO PENALTIES.—

8 (1) PERMITTING SECRETARY TO IMPOSE CIVIL

9 MONETARY PENALTY.—Section 1128A(a) of the So10 cial Security Act (42 U.S.C. 1320a–7a(a)) is amend11 ed—

12 (A) by striking ‘‘or’’ at the end of para13 graphs (1) and (2);

14 (B) by striking the semicolon at the end of

15 paragraph (3) and inserting ‘‘; or’’; and

16 (C) by inserting after paragraph (3) the

17 following new paragraph:

18 ‘‘(4) carries out any activity in violation of

19 paragraph (1) or (2) of section 1128B(b);’’.

20 (2) DESCRIPTION OF CIVIL MONETARY PEN21 ALTY APPLICABLE.—Section 1128A(a) of such Act

22 (42 U.S.C. 1320a–7a(a)) is amended—

23 (A) by striking ‘‘given).’’ at the end of the

24 first sentence and inserting the following:
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1 ‘‘given or, in cases under paragraph (4),

2 $50,000 for each such violation).’’; and

3 (B) by striking ‘‘claim.’’ at the end of the

4 second sentence and inserting the following:

5 ‘‘claim (or, in cases under paragraph (4), dam6 ages of not more than three times the total

7 amount of remuneration offered, paid, solicited,

8 or received.’’.

9 (3) INCREASE IN CRIMINAL PENALTY.—Para10 graphs (1) and (2) of section 1128B(b) of such Act

11 (42 U.S.C. 1320a–7b(b)) are each amended—

12 (A) by striking ‘‘$25,000’’ and inserting

13 ‘‘$50,000’’; and

14 (B) by striking the period at the end and

15 inserting the following: ‘‘, and shall be subject

16 to damages of not more than three times the

17 total remuneration offered, paid, solicited, or

18 received.’’.

19 (b) REVISIONS TO EXCEPTIONS.—

20 (1) EXCEPTION FOR DISCOUNTS.—Section

21 1128B(b)(3)(A) of such Act (42 U.S.C. 1320a–

22 7b(b)(3)(A)) is amended by striking ‘‘program;’’ and

23 inserting ‘‘program and is not in the form of a cash

24 payment;’’.
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1 (2) EXCEPTION FOR PAYMENTS TO EMPLOY2 EES.—Section 1128B(b)(3)(B) of such Act (42

3 U.S.C. 1320a–7b(b)(3)(B)) is amended by inserting

4 at the end ‘‘if the amount of remuneration under the

5 arrangement is consistent with the fair market value

6 of the services and is not determined in a manner

7 that takes into account (directly or indirectly) the

8 volume or value of any referrals, except that such

9 employee can be paid remuneration in the form of

10 a productivity bonus based on services personally

11 performed by the employee.’’.

12 (3) EXCEPTION FOR WAIVER OF COINSURANCE

13 BY CERTAIN PROVIDERS.—Section 1128B(b)(3)(D)

14 of such Act (42 U.S.C. 1320a–7b(b)(3)(D)) is

15 amended to read as follows:

16 ‘‘(D) a waiver or reduction of any coinsurance

17 or other copayment if—

18 ‘‘(i) the waiver or reduction is made pursu19 ant to a public schedule of discounts which the

20 person is obligated as a matter of law to apply

21 to certain individuals,

22 ‘‘(ii) the waiver or reduction is made pur23 suant to an established program and applies to

24 a defined group of individuals whose incomes do

25 not exceed 150 percent (or such higher percent-
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1 age as the Secretary may permit) of the official

2 poverty line (as defined by the Office of Man3 agement and Budget, and revised annually in

4 accordance with section 673(2) of the Omnibus

5 Budget Reconciliation Act of 1981) applicable

6 to a family of the size involved,

7 ‘‘(iii) the waiver or reduction of coinsur8 ance is not offered as part of any advertisement

9 or solicitation and the person offering the waiv10 er or reduction determines in good faith that

11 the individual is in financial need,

12 ‘‘(iv) the person offering the waiver or re13 duction fails to collect the coinsurance or other

14 payment after making reasonable collection ef15 forts, or

16 ‘‘(v) the waiver or reduction of coinsurance

17 is in accordance with a cost sharing schedule or

18 a supplemental benefit package which may be

19 offered by a managed care plan (as defined in

20 section 4 of the Health Care Fraud Prevention

21 and Paperwork Reduction Act of 1995); and’’.

22 (4) NEW EXCEPTION FOR CAPITATED PAY23 MENTS.—Section 1128B(b)(3) of such Act (42

24 U.S.C. 1320a–7b(b)(3)) is amended—
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1 (A) by striking ‘‘and’’ at the end of sub2 paragraph (D);

3 (B) by striking the period at the end of

4 subparagraph (E) and inserting ‘‘; and’’; and

5 (C) by adding at the end the following new

6 subparagraphs:

7 ‘‘(F) any reduction in cost sharing or increased

8 benefits given to an individual, any amounts paid to

9 a provider for an item or service furnished to an in10 dividual, or any discount or reduction in price given

11 by the provider for such an item or service, if the

12 individual is enrolled with and such item or service

13 is covered under any of the following:

14 ‘‘(i) A health plan which is furnishing

15 items or services under a risk-sharing contract

16 under section 1876 or section 1903(m).

17 ‘‘(ii) A health plan receiving payments on

18 a prepaid basis, under a demonstration project

19 under section 402(a) of the Social Security

20 Amendments of 1967 or under section 222(a)

21 of the Social Security Amendments of 1972;

22 and

23 ‘‘(G) any amounts paid to a provider for an

24 item or service furnished to an individual or any dis25 count or reduction in price given by the provider for
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1 such an item or service, if the individual is enrolled

2 with and such item or service is covered under a

3 health plan under which the provider furnishing the

4 item or service is paid by the health plan for fur5 nishing the item or service only on a capitated basis

6 pursuant to a written arrangement between the plan

7 and the provider in which the provider assumes fi8 nancial risk for furnishing the item or service.’’.

9 (c) AUTHORIZATION FOR THE SECRETARY TO ISSUE

10 REGULATIONS.—Section 1128B(b) of such Act (42 U.S.C.

11 1320a–7b(b)) is amended by adding at the end the follow12 ing new paragraph:

13 ‘‘(4) The Secretary is authorized to impose by regula14 tion such other requirements as needed to protect against

15 program or patient abuse with respect to any of the excep16 tions described in paragraph (3).’’.

17 (d) CLARIFICATION OF OTHER ELEMENTS OF OF18 FENSE.—Section 1128B(b) of such Act (42 U.S.C.

19 1320a–7b(b)) is amended—

20 (1) in paragraph (1)(A), by striking ‘‘in return

21 for referring’’ and inserting ‘‘to refer’’;

22 (2) in paragraph (1)(B), by striking ‘‘in return

23 for purchasing, leasing, ordering, or arranging for or

24 recommending’’ and inserting ‘‘to purchase, lease,

25 order, or arrange for or recommend’’; and
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1 (3) by adding at the end of paragraphs (1) and

2 (2) the following sentence: ‘‘A violation exists under

3 this paragraph if one or more purposes of the remu4 neration is unlawful under this paragraph.’’.

5 SEC. 102. CIVIL MONEY PENALTIES.

6 (a) PROHIBITION AGAINST OFFERING INDUCEMENTS

7 TO INDIVIDUALS ENROLLED UNDER PLANS.—

8 (1) OFFER OF REMUNERATION.—Section

9 1128A(a) of the Social Security Act (42 U.S.C.

10 1320a–7a(a)), as amended by section 101(a)(1), is

11 amended—

12 (A) by striking ‘‘; or’’ at the end of para13 graph (3) and inserting a semicolon;

14 (B) by striking the semicolon at the end of

15 paragraph (4) and inserting ‘‘; or’’; and

16 (C) by inserting after paragraph (4) the

17 following new paragraph:

18 ‘‘(5) offers, pays, or transfers remuneration to

19 any individual eligible for benefits under title XVIII

20 of this Act, or under a State health care program

21 (as defined in section 1128(h)) that such person

22 knows or should know is likely to influence such in23 dividual to order or receive from a particular pro24 vider, practitioner, or supplier any item or service

25 for which payment may be made, in whole or in
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1 part, under title XVIII, or a State health care pro2 gram, other than to influence an individual enrolled

3 in a managed care plan or a point-of-service plan (as

4 defined in section 4 of the Health Care Fraud Pre5 vention and Paperwork Reduction Act of 1995 to re6 ceive benefits under the plan in accordance with es7 tablished practice patterns for the delivery of medi8 cally necessary services;’’.

9 (2) REMUNERATION DEFINED.—Section

10 1128A(i) of such Act (42 U.S.C. 1320a–7a(i)) is

11 amended by adding at the end the following new

12 paragraph:

13 ‘‘(6) The term ‘remuneration’ includes the waiv14 er or reduction of coinsurance amounts, and trans15 fers of items or services for free or for other than

16 fair market value, except that such term does not in17 clude the waiver or reduction of coinsurance

18 amounts by a person or entity, if—

19 ‘‘(A) the waiver or reduction is made pur20 suant to a public schedule of discounts which

21 the person is obligated as a matter of law to

22 apply to certain individuals,

23 ‘‘(B) the waiver or reduction is made pur24 suant to an established program and applies to

25 a defined group of individuals whose incomes do
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1 not exceed 150 percent (or such higher percent2 age as the Secretary may permit) of the official

3 poverty line (as defined by the Office of Man4 agement and Budget, and revised annually in

5 accordance with section 673(2) of the Omnibus

6 Budget Reconciliation Act of 1981) applicable

7 to a family of the size involved,

8 ‘‘(C) the waiver or reduction of coinsur9 ance is not offered as part of any advertisement

10 or solicitation and the person offering the waiv11 er or reduction determines in good faith that

12 the individual is in financial need,

13 ‘‘(D) the person offering the waiver or re14 duction fails to collect the coinsurance or other

15 payment after making reasonable collection ef16 forts, or

17 ‘‘(E) the waiver or reduction of coinsur18 ance is in accordance with a cost sharing sched19 ule or a supplemental benefit package which

20 may be offered by a managed care plan under

21 section 4 of the Health Care Fraud Prevention

22 and Paperwork Reduction Act of 1995.’’.

23 (b) ADDITIONAL OFFENSES.—Section 1128A(a) of

24 such Act, as amended by section 101(a)(1) and subsection

25 (a)(1), is further amended—
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1 (1) by striking ‘‘or’’ at the end of paragraph

2 (4);

3 (2) by striking the semicolon at the end of

4 paragraph (5) and inserting ‘‘; or’’; and

5 (3) by inserting after paragraph (5) the follow6 ing new paragraphs:

7 ‘‘(6) engages in a practice which has the effect

8 of limiting or discouraging (as compared to other

9 plan enrollees) the utilization of medically necessary

10 health care services covered by law or under the

11 service contract by title XIX or other publicly sub12 sidized patients, including but not limited to dif13 ferential standards for the location and hours of

14 service offered by providers participating in the plan;

15 ‘‘(7) substantially fails to cooperate with a qual16 ity assurance program or a utilization review activ17 ity;

18 ‘‘(8) engaging in a pattern of failing substan19 tially to provide or authorize medically necessary

20 items and services that are required to be provided

21 to an individual covered under a health plan (as de22 fined in section 4 of the Health Care Fraud Preven23 tion and Paperwork Reduction Act of 1995) or pub24 lic program for the delivery of or payment for health

25 care items or services, if the failure has adversely af-
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1 fected (or had a substantial likelihood of adversely

2 affecting) the individual; or

3 ‘‘(9) submits false or fraudulent statements,

4 data or information on claims to the Secretary, a

5 State health care agency, or any other Federal,

6 State or local agency charged with implementation

7 or oversight of a health plan or a public program

8 that the person knows or should know is fraudu9 lent;’’.

10 (c) MODIFICATIONS OF AMOUNTS OF PENALTIES

11 AND ASSESSMENTS.—Section 1128A(a) of such Act (42

12 U.S.C. 1320a–7a(a)), as amended by section 101(a), sub13 section (a)(1), and subsection (b), is amended in the mat14 ter following paragraph (9)—

15 (1) by striking ‘‘$2,000’’ and inserting

16 ‘‘$10,000’’;

17 (2) by inserting after ‘‘under paragraph (4),

18 $50,000 for each such violation’’ the following: ‘‘; in

19 cases under paragraph (5), $10,000 for each such

20 offer, payment, or transfer; in cases under para21 graphs (6) through (9), an amount not to exceed

22 $10,000 for each such determination by the Sec23 retary’’; and

24 (3) by striking ‘‘twice the amount’’ and insert25 ing ‘‘three times the amount’’.
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1 (d) INTEREST ON PENALTIES.—Section 1128A(f) of

2 such Act (42 U.S.C. 1320a–7a(f)) is amended by adding

3 after the first sentence the following: ‘‘Interest shall ac4 crue on the penalties and assessments imposed by a final

5 determination of the Secretary in accordance with an an6 nual rate established by the Secretary under the Federal

7 Claims Collection Act. The rate of interest charged shall

8 be the rate in effect on the date the determination becomes

9 final and shall remain fixed at that rate until the entire

10 amount due is paid. In addition, the Secretary is author11 ized to recover the costs of collection in any case where

12 the penalties and assessments are not paid within 30 days

13 after the determination becomes final, or in the case of

14 a compromised amount, where payments are more than

15 90 days past due. In lieu of actual costs, the Secretary

16 is authorized to impose a charge of up to 10 percent of

17 the amount of penalties and assessments owed to cover

18 the costs of collection.’’.

19 (e) AUTHORIZATION TO ACT.—

20 (1) IN GENERAL.—The first sentence of section

21 1128A(c)(1) of such Act (42 U.S.C. 1320a–

22 7a(c)(1)) is amended by striking all that follows

23 ‘‘(b)’’ and inserting the following: ‘‘unless, within

24 one year after the date the Secretary presents a case

25 to the Attorney General for consideration, the Attor-
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1 ney General brings an action in a district court of

2 the United States.’’.

3 (2) EFFECTIVE DATE.—The amendment made

4 by this paragraph (1) shall apply to cases presented

5 by the Secretary of Health and Human Services for

6 consideration on or after the date of the enactment

7 of this Act.

8 (f) DEPOSIT OF PENALTIES COLLECTED INTO ALL9 PAYER ACCOUNT.—Section 1128A(f)(3) of such Act (42

10 U.S.C. 1320a–7a(f)(3)) is amended by striking ‘‘as mis11 cellaneous receipts of the Treasury of the United States’’

12 and inserting ‘‘in the All-Payer Health Care Fraud and

13 Abuse Control Account established under section 112 of

14 the Health Care Fraud Prevention and Paperwork Reduc15 tion Act of 1995’’.

16 (g) CLARIFICATION OF PENALTY IMPOSED ON EX17 CLUDED PROVIDER FURNISHING SERVICES.—Section

18 1128A(a)(1)(D) of such Act (42 U.S.C. 1320a–

19 7a(a)(1)(D)) is amended by inserting ‘‘who furnished the

20 service’’ after ‘‘in which the person’’.

21 SEC. 103. PRIVATE RIGHT OF ACTION.

22 Section 1128A of the Social Security Act (42 U.S.C.

23 1320a–7a) is amended by adding at the end the following

24 new subsection:
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1 ‘‘(m)(1) Subject to paragraphs (2) and (3), a carrier

2 offering an insured health plan and the sponsor of a self3 insured health plan that suffers financial harm as a direct

4 result of the submission of claims by an individual or en5 tity for payment for items and services furnished under

6 the plan which makes the individual or entity subject to

7 a civil monetary penalty under this section may, in a civil

8 action against the individual or entity in the United States

9 District Court, obtain damages against the individual or

10 entity and such equitable relief as is appropriate.

11 ‘‘(2) A carrier or sponsor may bring a civil action

12 under this subsection only if the carrier or sponsor pro13 vides the Secretary and the Attorney General with written

14 notice of the intent to bring an action under this sub15 section, the identities of the individuals or entities the car16 rier or sponsor intends to name as defendants to the ac17 tion, and all information the carrier or sponsor possesses

18 regarding the activity that is the subject of the action that

19 may materially affect the Secretary’s decision to initiate

20 a proceeding to impose a civil monetary penalty under this

21 section against the defendants.

22 ‘‘(3) A carrier or sponsor may bring a civil action

23 under this subsection only if any of the following condi24 tions are met:
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1 ‘‘(A) During the 60-day period that begins on

2 the date the Secretary receives the written notice de3 scribed in paragraph (2), the Secretary does not no4 tify the carrier or sponsor that the Secretary intends

5 to initiate a proceeding to impose a civil monetary

6 penalty under this section against the defendants.

7 ‘‘(B) If the Secretary notifies the carrier or

8 sponsor during the 60-day period described in sub9 paragraph (A) that the Secretary intends to initiate

10 a proceeding to impose a civil monetary penalty

11 under this section against the defendants, the Sec12 retary subsequently notifies the carrier or sponsor

13 that the Secretary no longer intends to initiate such

14 a proceeding against the defendants.

15 ‘‘(C) After the expiration of the 2-year period

16 that begins on the date the Secretary notifies the

17 carrier or sponsor that the Secretary intends to initi18 ate a proceeding to impose a civil monetary penalty

19 under this section against the defendants, the Sec20 retary has not made a good faith effort to initiate

21 such a proceeding against the defendants.

22 ‘‘(4) If a carrier or sponsor is awarded any amounts

23 in an action brought under this subsection that are in ex24 cess of the damages suffered by the carrier or sponsor as

25 a result of the defendant’s activities, 10 percent of such
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1 amounts shall be withheld from the carrier or sponsor for

2 payment into the All-Payer Health Care Fraud and Abuse

3 Control Account established under section 112 of the

4 Health Care Fraud Prevention and Paperwork Reduction

5 Act of 1995.

6 ‘‘(5) No action may be brought under this subsection

7 more than 6 years after the date of the activity with re8 spect to which the action is brought.’’.

9 SEC. 104. AMENDMENTS TO EXCLUSIONARY PROVISIONS IN

10 FRAUD AND ABUSE PROGRAM.

11 (a) MANDATORY EXCLUSION OF INDIVIDUAL CON12 VICTED OF CRIMINAL OFFENSE RELATED TO HEALTH

13 CARE FRAUD.—

14 (1) IN GENERAL.—Section 1128(a) of the So15 cial Security Act (42 U.S.C. 1320a–7(a)) is amend16 ed by adding at the end the following new para17 graph:

18 ‘‘(3) FELONY CONVICTION RELATING TO

19 FRAUD.—Any individual or entity that has been con20 victed under Federal or State law, in connection

21 with the delivery of a health care item or service on

22 or after January 1, 1997, or with respect to any act

23 or omission on or after such date in a program oper24 ated by or financed in whole or in part by any Fed25 eral, State, or local government agency, of a criminal
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1 offense consisting of a felony relating to fraud, theft,

2 embezzlement, breach of fiduciary responsibility, or

3 other financial misconduct.’’.

4 (2) CONFORMING AMENDMENT.—Section

5 1128(b)(1) of such Act (42 U.S.C. 1320a–7(b)(1))

6 is amended—

7 (A) in the heading, by striking ‘‘CONVIC8 TION’’ and inserting ‘‘MISDEMEANOR CONVIC9 TION’’; and

10 (B) by striking ‘‘criminal offense’’ and in11 serting ‘‘criminal offense consisting of a mis12 demeanor’’.

13 (b) ESTABLISHMENT OF MINIMUM PERIOD OF EX14 CLUSION FOR CERTAIN INDIVIDUALS AND ENTITIES SUB15 JECT TO PERMISSIVE EXCLUSION FROM MEDICARE AND

16 STATE HEALTH CARE PROGRAMS.—

17 (1) IN GENERAL.—Section 1128(c)(3) of such

18 Act (42 U.S.C. 1320a–7(c)(3)) is amended by add19 ing at the end the following new subparagraphs:

20 ‘‘(D) In the case of an exclusion of an individual or

21 entity under paragraphs (1), (2), or (3) of subsection (b),

22 the period of exclusion shall be a minimum of 3 years,

23 unless the Secretary determines that an alternative period

24 is appropriate because of aggravating or mitigating cir25 cumstances.
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1 ‘‘(E) In the case of an exclusion of an individual or

2 entity under paragraph (4) or (5) of subsection (b), the

3 period of the exclusion shall not be less than the period

4 during which the individual’s or entity’s license to provide

5 health care is revoked, suspended, or surrendered, or the

6 individual or the entity is excluded or suspended from a

7 Federal or State health care program.

8 ‘‘(F) In the case of an exclusion of an individual or

9 entity under subsection (b)(6)(B), the period of the exclu10 sion shall be not less than 1 year.’’.

11 (2) CONFORMING AMENDMENT.—Section

12 1128(c)(3)(A) of such Act (42 U.S.C. 1320a–

13 7(c)(3)(A)) is amended by striking ‘‘subsection

14 (b)(12)’’ and inserting ‘‘paragraph (1), (2), (3), (4),

15 (6)(B), or (12) of subsection (b)’’.

16 SEC. 105. SANCTIONS AGAINST PRACTITIONERS AND PER17 SONS FOR FAILURE TO COMPLY WITH STATU18 TORY OBLIGATIONS RELATING TO QUALITY

19 OF CARE.

20 (a) MINIMUM PERIOD OF EXCLUSION FOR PRACTI21 TIONERS AND PERSONS FAILING TO MEET STATUTORY

22 OBLIGATIONS.—

23 (1) IN GENERAL.—The second sentence of sec24 tion 1156(b)(1) of the Social Security Act (42

25 U.S.C. 1320c–5(b)(1)) is amended by striking ‘‘may
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1 prescribe)’’ and inserting ‘‘may prescribe, except

2 that such period may not be less than one year)’’.

3 (2) CONFORMING AMENDMENT.—Section

4 1156(b)(2) of such Act (42 U.S.C. 1320c–5(b)(2)) is

5 amended by striking ‘‘shall remain’’ and inserting

6 ‘‘shall (subject to the minimum period specified in

7 the second sentence of paragraph (1)) remain’’.

8 (b) AMOUNT OF CIVIL MONEY PENALTY.—Section

9 1156(b)(3) of such Act (42 U.S.C. 1320c–5(b)(3)) is

10 amended by striking ‘‘the actual or estimated cost’’ and

11 inserting the following: ‘‘$10,000 for each instance’’.

12 (c) REPEAL OF ‘‘UNWILLING OR UNABLE’’ CONDI13 TION FOR IMPOSITION OF SANCTION.—Section 1156(b)(1)

14 of such Act (42 U.S.C. 1320c–5(b)(1)) is amended—

15 (1) in the second sentence, by striking ‘‘and de16 termines’’ and all that follows through ‘‘such obliga17 tions,’’ and

18 (2) by striking the third sentence.

19 SEC. 106. REVISIONS TO CRIMINAL PENALTIES.

20 (a) TREBLE DAMAGES FOR CRIMINAL SANCTIONS.—

21 Section 1128B of the Social Security Act (42 U.S.C.

22 1320a–7b) is amended by adding at the end the following

23 new subsection:

24 ‘‘(f) In addition to the fines that may be imposed

25 under subsection (a) or (c) any individual found to have
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1 violated the provisions of any of such subsections may be

2 subject to treble damages.’’.

3 (b) IDENTIFICATION OF COMMUNITY SERVICE OP4 PORTUNITIES.—Section 1128B of such Act (42 U.S.C.

5 1320a–7b), as amended by subsection (a), is further

6 amended by adding at the end the following new sub7 section:

8 ‘‘(g) The Secretary shall—

9 ‘‘(1) in consultation with State and local health

10 care officials, identify opportunities for the satisfac11 tion of community service obligations that a court

12 may impose upon the conviction of an offense under

13 this section, and

14 ‘‘(2) make information concerning such oppor15 tunities available to Federal and State law enforce16 ment officers and State and local health care offi17 cials.’’.

18 SEC. 107. EFFECTIVE DATE.

19 The amendments made by this subtitle shall take ef20 fect January 1, 1997.
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1 Subtitle B—Establishment of All2 Payer Health Care Fraud and

3 Abuse Control Program

4 SEC. 111. ALL-PAYER HEALTH CARE FRAUD AND ABUSE

5 CONTROL PROGRAM.

6 (a) IN GENERAL.—Not later than January 1, 1997,

7 the Secretary (acting through the Inspector General of the

8 Department of Health and Human Services) and the At9 torney General shall establish a program—

10 (1) to coordinate the functions of the Attorney

11 General, the Secretary, and other organizations with

12 respect to the prevention, detection, and control of

13 health care fraud and abuse,

14 (2)(A) to conduct investigations, audits, evalua15 tions, and inspections relating to the delivery of and

16 payment for health care services in the United

17 States which are not subject to investigation, audit,

18 evaluation, and inspection by the Inspector General

19 of another executive department, and (B) to facili20 tate the conducting of such investigations, audits,

21 evaluations, and inspections relating to the delivery

22 of and payment for other health care services in the

23 United States, and
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1 (3) to facilitate the enforcement of this subtitle

2 and other statutes applicable to health care fraud

3 and abuse.

4 (b) COORDINATION WITH LAW ENFORCEMENT

5 AGENCIES.—In carrying out the program under sub6 section (a), the Secretary and Attorney General shall con7 sult with, and arrange for the sharing of data and re8 sources with Federal, State and local law enforcement

9 agencies, State Medicaid Fraud Control Units, and State

10 agencies responsible for the licensing and certification of

11 health care providers.

12 (c) COORDINATION WITH HEALTH PLANS.—In car13 rying out the program under subsection (a), the Secretary

14 and Attorney General shall consult with, and arrange for

15 the sharing of data with representatives of qualified health

16 plans.

17 (d) AUTHORITIES OF ATTORNEY GENERAL AND IN18 SPECTOR GENERAL.—In carrying out duties under sub19 section (a), the Attorney General and the Inspector Gen20 eral are authorized—

21 (1) to conduct, supervise, and coordinate audits,

22 civil and criminal investigations, inspections, and

23 evaluations relating to the program established

24 under such subsection; and
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1 (2) to have access (including on-line access as

2 requested and available) to all records available to

3 qualified health plans relating to the activities de4 scribed in paragraph (1) (subject to restrictions

5 based on the confidentiality of certain information

6 under section 204(a)).

7 (e) FAILURE TO PROVIDE INFORMATION AS

8 GROUNDS FOR PERMISSIVE EXCLUSION UNDER MEDI9 CARE AND MEDICAID.—Section 1128(b)(9) of the Social

10 Security Act (42 U.S.C. 1320a–7(b)(9)) is amended by

11 striking the period at the end and inserting ‘‘, or provide

12 any information requested by the Attorney General or the

13 Inspector General of the Department of Health and

14 Human Services to carry out the All-Payer Health Care

15 Fraud and Abuse Control Program established under sec16 tion 111 of the Health Care Fraud Prevention and Paper17 work Reduction Act of 1995.’’;

18 (f) QUALIFIED IMMUNITY FOR PROVIDING INFORMA19 TION.—The provisions of section 1157(a) of the Social Se20 curity Act (relating to limitation on liability) shall apply

21 to a person providing information or communications to

22 the Secretary or Attorney General in conjunction with

23 their performance of duties under this section, in the same

24 manner as such section applies to information provided
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1 to organizations with a contract under part B of title XI

2 of such Act.

3 (g) AUTHORIZATIONS OF APPROPRIATIONS FOR IN4 VESTIGATORS AND OTHER PERSONNEL.—In addition to

5 any other amounts authorized to be appropriated to the

6 Secretary and the Attorney General for health care anti7 fraud and abuse activities for a fiscal year, there are au8 thorized to be appropriated such additional amounts as

9 may be necessary to enable the Secretary and the Attorney

10 General to conduct investigations, audits, evaluations, and

11 inspections of allegations of health care fraud and abuse

12 and otherwise carry out the program established under

13 subsection (a) in a fiscal year.

14 (h) USE OF POWERS UNDER INSPECTOR GENERAL

15 ACT OF 1978.—In carrying out duties and responsibilities

16 under the program established under subsection (a), the

17 Inspector General is authorized to exercise all powers

18 granted under the Inspector General Act of 1978 to the

19 same manner and extent as provided in that Act.

20 (i) DEFINITION.—In this subtitle, the term ‘‘Inspec21 tor General’’ means the Inspector General of the Depart22 ment of Health and Human Services.

23 SEC. 112. ESTABLISHMENT OF ALL-PAYER HEALTH CARE

24 FRAUD AND ABUSE CONTROL ACCOUNT.

25 (a) ESTABLISHMENT.—
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1 (1) IN GENERAL.—There is hereby created on

2 the books of the Treasury of the United States an

3 account to be known as the ‘‘All-Payer Health Care

4 Fraud and Abuse Control Account’’ (in this section

5 referred to as the ‘‘Anti-Fraud Account’’). The Anti6 Fraud Account shall consist of such gifts and be7 quests as may be made as provided in paragraph (2)

8 and such amounts as may be deposited in such Anti9 Fraud Account as provided in section 122(d)(2) and

10 title XI of the Social Security Act. It shall also in11 clude the following:

12 (A) All criminal fines imposed in cases in13 volving a Federal health care offense (as de14 fined in subsection (d)).

15 (B) Penalties and damages imposed under

16 the False Claims Act (31 U.S.C. 3729 et seq.),

17 in cases involving claims related to the provision

18 of health care items and services (other than

19 funds awarded to a relator or for restitution).

20 (C) Administrative penalties and assess21 ments imposed under titles XI, XVIII, and XIX

22 of the Social Security Act and section 122 (ex23 cept as otherwise provided by law).
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1 (D) Amounts resulting from the forfeiture

2 of property by reason of a Federal health care

3 offense.

4 (E) Amounts received from the payment of

5 fees to the Secretary of Health and Human

6 Services and the Attorney General under sec7 tion 132 by individuals and entities requesting

8 advisory opinions under section 131.

9 Any such funds received on or after the date of the

10 enactment of this Act shall be deposited in the Anti11 Fraud Account.

12 (2) AUTHORIZATION TO ACCEPT GIFTS.—The

13 Anti-Fraud Account is authorized to accept on be14 half of the United States money gifts and bequests

15 made unconditionally to the Anti-Fraud Account, for

16 the benefit of the Anti-Fraud Account or any activ17 ity financed through the Anti-Fraud Account.

18 (3) ADMINISTRATION THROUGH BOARD OF

19 TRUSTEES.—The Anti-Fraud Account shall have a

20 Board of Trustees consisting of the Secretary of

21 Treasury, the Attorney General, the Secretary of

22 Health and Human Services, the Inspector General,

23 and a State Attorney General selected by the Inspec24 tor General. The Board of Trustees shall allocate
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1 and dispense funds in the Account and generally ad2 minister the operations of the Account.

3 (b) USE OF FUNDS.—

4 (1) IN GENERAL.—Amounts in the Anti-Fraud

5 Account shall be available without appropriation and

6 until expended as determined jointly by the Sec7 retary and Attorney General in carrying out the All8 Payer Health Care Fraud and Abuse Control Pro9 gram established under section 111 (including the

10 administration of the Program), and may be used to

11 cover costs incurred in operating the Program, in12 cluding—

13 (A) costs of prosecuting health care mat14 ters (through criminal, civil and administrative

15 proceedings);

16 (B) costs of investigations (including

17 equipment, salaries, administratively uncontrol18 lable work, travel, and training of law enforce19 ment personnel);

20 (C) costs of financial and performance au21 dits of health care programs and operations;

22 and

23 (D) costs of inspections and other evalua24 tions.
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1 (2) FUNDS USED TO SUPPLEMENT AGENCY AP2 PROPRIATIONS.—It is intended that disbursements

3 made from the Anti-Fraud Account to any Federal

4 agency be used to increase and not supplant the re5 cipient agency’s appropriated operating budget.

6 (3) USE OF FUNDS FOR EDUCATIONAL ACTIVI7 TIES.—Amounts in the Anti-Fraud Account may be

8 used to carry out activities designed to educate pro9 viders of health care services about the provisions of

10 this subtitle (and the provisions of law amended by

11 this subtitle).

12 (4) START-UP COSTS OF PROCESS FOR ISSU13 ANCE OF ADVISORY OPINIONS.—Amounts in the

14 Anti-Fraud Account may be used to establish the

15 process described in section 131 for the issuance of

16 advisory opinions by the Secretary of Health and

17 Human Services and the Attorney General, but only

18 during the first year for which the process is in op19 eration.

20 (c) ANNUAL REPORT.—The Board of Trustees shall

21 submit an annual report to Congress on the amount of

22 revenue which is generated and disbursed by the Anti23 Fraud Account in each fiscal year.
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1 (d) FEDERAL HEALTH CARE OFFENSE DEFINED.—

2 The term ‘‘Federal health care offense’’ means a violation

3 of, or a criminal conspiracy to violate—

4 (1) sections 226, 668, 1033, or 1347 of title

5 18, United States Code;

6 (2) section 1128B of the Social Security Act;

7 (3) sections 287, 371, 664, 666, 1001, 1027,

8 1341, 1343, or 1954 of title 18, United States Code,

9 if the violation or conspiracy relates to health care

10 fraud;

11 (4) sections 501 or 511 of the Employee Retire12 ment Income Security Act of 1974, if the violation

13 or conspiracy relates to health care fraud; or

14 (5) sections 301, 303(a)(2), or 303(b) or (e) of

15 the Federal Food, Drug and Cosmetic Act, if the

16 violation or conspiracy relates to health care fraud.

17 Subtitle C—Application of Fraud

18 and Abuse Authorities Under

19 the Social Security Act to Other

20 Payers

21 SEC. 121. APPLICATION OF CIVIL MONEY PENALTIES TO

22 ALL PAYERS.

23 (a) ACTIONS SUBJECT TO PENALTY.—Any person

24 who is determined by the Secretary to have committed any

25 of the following actions with respect to a qualified health
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1 plan shall be subject to a penalty in accordance with sub2 section (b):

3 (1) ACTIONS SUBJECT TO PENALTY UNDER

4 MEDICARE, MEDICAID, AND OTHER SOCIAL SECURITY

5 HEALTH PROGRAMS.—Any action that would subject

6 the person to a penalty under paragraphs (1)

7 through (9) of section 1128A(a) of the Social Secu8 rity Act if the action was taken with respect to title

9 V, XVIII, XIX, or XX of such Act.

10 (2) DISCRIMINATING ON BASIS OF MEDICAL

11 CONDITION.—The engagement in any practice that

12 would reasonably be expected to have the effect of

13 denying or discouraging the initial or continued en14 rollment in a health plan by individuals whose medi15 cal condition or history indicates a need for substan16 tial future medical services.

17 (3) INDUCING ENROLLMENT ON FALSE PRE18 TENSES.—The engagement in any practice to induce

19 enrollment in a health plan through representations

20 to individuals which the person knows or should

21 know are false or fraudulent.

22 (b) PENALTIES DESCRIBED.—

23 (1) GENERAL RULE.—Any person who the Sec24 retary determines has committed an action described

25 in paragraphs (2) through (4) of subsection (a) shall
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1 be subject to a civil monetary penalty in an amount

2 not to exceed $10,000 for each such determination.

3 (2) ACTIONS SUBJECT TO PENALTIES UNDER

4 SOCIAL SECURITY ACT.—In the case of a person who

5 the Secretary determines has committed an action

6 described in paragraph (1) of subsection (a), the

7 person shall be subject to the civil monetary penalty

8 (together with any additional assessment) to which

9 the person would be subject under section 1128A of

10 the Social Security Act if the action on which the

11 determination is based had been committed with re12 spect to title V, XVIII, XIX, or XX of such Act.

13 (c) APPLICABILITY OF PROCEDURES UNDER SOCIAL

14 SECURITY ACT.—The provisions of section 1128A of the

15 Social Security Act (other than subsections (a) and (b)

16 and the second sentence of subsection (f)) shall apply to

17 the imposition of a civil monetary penalty or assessment

18 under this section in the same manner as such provisions

19 apply with respect to the imposition of a penalty or assess20 ment under section 1128A of such Act.

21 (d) TREATMENT OF AMOUNTS RECOVERED.—Any

22 amounts recovered under this section shall be paid to the

23 Secretary and disposed of as follows:

24 (1) Such portions of the amounts recovered as

25 is determined to have been improperly paid from a
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1 qualified health plan for the delivery of or payment

2 for health care items or services shall be repaid to

3 such plan.

4 (2) The remainder of the amounts recovered

5 shall be deposited in the All-Payer Health Care

6 Fraud and Abuse Control Account established under

7 section 112.

8 (e) NOTIFICATION OF LICENSING AUTHORITIES.—

9 Whenever the Secretary’s determination to impose a pen10 alty or assessment under this section becomes final, the

11 Secretary shall notify the appropriate State or local licens12 ing agency or organization (including the agency specified

13 in section 1864(a) and 1902(a)(33) of the Social Security

14 Act) that such a penalty or assessment has become final

15 and the reasons therefore.

16 SEC. 122. APPLICATION OF CERTAIN CRIMINAL PENALTIES

17 TO ALL PAYERS.

18 Any person who is determined by the Attorney Gen19 eral (in consultation with the Secretary) to have commit20 ted any action with respect to a qualified health plan that

21 would subject the person to a penalty under subsection

22 (a) or (b) of section 1128B of the Social Security Act if

23 the action was taken with respect to title V, XVIII, XIX,

24 or XX of such Act shall be subject to the penalty (together
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1 with any assessment) that would apply if the action was

2 taken with respect to any such title.

3 SEC. 123. CONSTRUCTION OF SOCIAL SECURITY ACT REF4 ERENCES.

5 (a) INCORPORATION OF OTHER AMENDMENTS.—Any

6 reference in this subtitle to a provision of the Social Secu7 rity Act shall be considered a reference to the provision

8 as amended under subtitle A.

9 (b) EFFECT OF SUBSEQUENT AMENDMENTS.—Ex10 cept as provided in subsection (a), any reference to a pro11 vision of the Social Security Act in this subtitle shall be

12 deemed to be a reference to such provision as in effect

13 on the date of the enactment of this Act, and (except as

14 Congress may otherwise provide) any amendments made

15 to such provisions after such date shall not be taken into

16 account in determining the applicability of such provisions

17 to individuals and entities under this Act.

18 Subtitle D—Advisory Opinions on

19 Kickbacks and Self-Referral

20 SEC. 131. ESTABLISHMENT OF PROCESS FOR ISSUANCE OF

21 ADVISORY OPINIONS.

22 (a) ESTABLISHMENT.—Not later than 1 year after

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

24 Health and Human Services (in consultation with the At25 torney General) shall establish a process under which indi-
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1 viduals and entities may submit a request to the Secretary

2 for an advisory opinion regarding whether any conduct of

3 the individual or entity—

4 (1) constitutes grounds for the imposition of a

5 sanction under section 1128B(b) (relating to kick6 backs, bribes, and rebates) of the Social Security

7 Act or under subtitle C through the application of

8 such section; or

9 (2) would result in the denial of payment for a

10 service furnished by the individual or entity, or the

11 imposition of a civil money penalty, on the basis de12 scribed in section 1877 of the Social Security Act.

13 (b) DEADLINE FOR RESPONSE.—The Secretary of

14 Health and Human Services shall respond to a request

15 for an advisory opinion submitted under subsection (a) not

16 later than 90 days after receiving the request.

17 (c) OPINIONS LIMITED TO QUESTIONS OF FACT.—

18 An advisory opinion issued under subsection (a) may only

19 respond to the facts presented by the individual or entity

20 requesting the advisory opinion.

21 (d) ISSUANCE OF REGULATIONS.—The Secretary

22 may issue such regulations as the Secretary considers ap23 propriate to carry out this subtitle, including regulations

24 concerning the process under which individuals and enti-
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1 ties submit and the Secretary responds to requests for ad2 visory opinions.

3 SEC. 132. IMPOSITION OF FEES.

4 (a) IN GENERAL.—The Secretary of Health and

5 Human Services and the Attorney General shall require

6 an individual or entity requesting an advisory opinion

7 under section 131 to submit a fee.

8 (b) AMOUNT.—The amount of the fee required under

9 subsection (a) shall be equal to the costs incurred by the

10 Secretary and the Attorney General in responding to the

11 request.

12 Subtitle E—Preemption of State

13 Corporate Practice Laws

14 SEC. 141. PREEMPTION OF STATE LAWS PROHIBITING COR15 PORATE PRACTICE OF MEDICINE.

16 No provision of State or local law shall apply that

17 prohibits a corporation from practicing medicine.

18 TITLE II—INFORMATION SYS19 TEMS AND ADMINISTRATIVE

20 SIMPLIFICATION

21 SEC. 201. REQUIREMENT FOR HEALTH BENEFIT CARDS.

22 (a) HEALTH BENEFIT CARDS.—

23 (1) REQUIREMENT.—Each health benefit plan

24 sponsor shall issue a health benefit card that meets

25 the requirements of subsection (c) for each individ-
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1 ual who is entitled to benefits under a health benefit

2 plan provided or sponsored by the sponsor.

3 (2) DEADLINE FOR APPLICATION OF REQUIRE4 MENT.—The deadline specified under this paragraph

5 for the requirement under paragraph (1) is 12

6 months after the date the standards are established

7 under subsection (c).

8 (b) ENFORCEMENT THROUGH CIVIL MONEY PEN9 ALTIES.—

10 (1) IN GENERAL.—In the case of a health bene11 fit plan sponsor that fails to issue a health benefit

12 card in accordance with subsection (a)(1), the spon13 sor is subject to a civil money penalty not to exceed

14 $100 for each such violation. The provisions of sec15 tion 1128A of the Social Security Act (other than

16 subsections (a) and (b)) shall apply to a civil money

17 penalty under this subsection in the same manner as

18 such provisions apply to a penalty or proceeding

19 under section 1128A(a) of such Act.

20 (2) EFFECTIVE DATE.—No penalty may be im21 posed under paragraph (1) for any failure occurring

22 before the deadline specified in subsection (a)(2).

23 (c) HEALTH BENEFIT CARDS.—

24 (1) IN GENERAL.—The Secretary shall establish

25 standards consistent with this subsection respecting
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1 the form and information to be contained on health

2 benefit cards (for purposes of subsection (a)).

3 (2) ELECTRONIC.—

4 (A) IN GENERAL.—Subject to subpara5 graph (B), the card shall be in a form similar

6 to that of a credit card and shall have, encoded

7 in electronic form—

8 (i) the identity of the individual enti9 tled to health benefits;

10 (ii) the health benefit plan in which

11 the individual is enrolled;

12 (iii) the identity of each principal in13 sured (as defined by the Secretary) for the

14 family that includes the individual, in the

15 case of an individual who is enrolled under

16 a family class of enrollment;

17 (iv) the telephone number or numbers

18 to be used for the submission electronically

19 of claims under the plan under section

20 203; and

21 (v) information relating to organ do22 nation.

23 (B) USE OF ELECTRONIC READ-AND24 WRITE CARDS.—The Secretary may provide for

25 cards in an electronic form that permits infor-
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•HR 1912 IH

1 mation on the card to be readily changed. Such

2 information may include information relating to

3 the health coverage status of the individual and

4 the medical history of the individual.

5 (C) PERSONAL IDENTIFIER.—For pur6 poses of subparagraph (A) and for purposes of

7 claims processing and related purposes under

8 section 203, the Social Security account number

9 of the individual or, in the case of an infant or

10 other individual to whom such a number has

11 not been issued, such a Social Security account

12 number of a parent or guardian or other num13 ber as the Secretary shall specify, shall be used

14 as the personal identifier for the individual.

15 (3) ADDITIONAL INFORMATION.—The card

16 shall include such additional information, in elec17 tronic or other form, as the Secretary may require

18 to carry out the purposes of this Act. In addition,

19 the health benefit plan sponsor issuing the card may

20 include such additional information on the card as

21 the sponsor desires, subject to such limitations as

22 the Secretary may provide.

23 (4) PERMISSIBLE USES OF CARD.—A health

24 benefit card that is issued to an individual who is

25 entitled to benefits under a health benefit plan may
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1 be used by an individual or entity only for the pur2 pose of providing or assisting the individual entitled

3 to benefits in obtaining an item or service that is

4 covered under such plan.

5 (5) DEADLINE.—The Secretary shall first es6 tablish the standards for health benefit cards under

7 this subsection by not later than 18 months after

8 the date of the enactment of this Act.

9 (d) APPLICATION TO MEDICARE AND MEDICAID PRO10 GRAM.—

11 (1) MEDICARE PROGRAM.—The Secretary shall

12 provide, in regulations promulgated to carry out the

13 medicare program, that identification cards issued

14 under that program are modified to the extent re15 quired to conform to the standards established under

16 subsection (c), by not later than the deadline speci17 fied in subsection (a)(2).

18 (2) STATE MEDICAID PLANS.—As a condition

19 for the approval of a State plan under the medicaid

20 program, effective for calendar quarters beginning

21 on or after the deadline specified in subsection

22 (a)(2), each such plan shall provide, in accordance

23 with regulations of the Secretary, that identification

24 cards issued under the plan are modified to the ex25 tent required to conform to subsection (c).
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1 SEC. 202. NATIONAL ENROLLMENT VERIFICATION SYSTEM.

2 (a) ESTABLISHMENT.—The Secretary shall establish

3 a national enrollment verification system for the verifica4 tion of an individual’s enrollment in a health benefit plan

5 and entitlement to benefits under such plan. The system

6 shall assist in the identification of, and collection from,

7 parties responsible for the payment for health care items

8 and services furnished to individuals enrolled under a

9 health benefit plan.

10 (b) INFORMATION IN SYSTEM.—The enrollment ver11 ification system shall contain such information submitted

12 by health benefit plan sponsors, employers, and other indi13 viduals and entities specified by the Secretary as the Sec14 retary shall determine in standards established under this

15 section. The information shall include the following with

16 respect to each individual enrolled in a health benefit plan

17 (regardless of whether the individual is enrolled under an

18 individual or a family class of enrollment):

19 (1) The name, address, and personal identifier

20 of the individual and the identity of each principal

21 insured (as defined by the Secretary under section

22 201(c)(2)(A)(iii)) for the family that includes the in23 dividual, in the case of an individual who is enrolled

24 under a family class of enrollment.
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1 (2) The name, address, and telephone number

2 of each health benefit plan in which the individual

3 is enrolled.

4 (3) The type of coverage elected.

5 (4) Race and ethnicity data.

6 (5) The period for which such coverage is elect7 ed.

8 (6) The status of individuals with respect to

9 deductibles, copayments, coinsurance, or out-of-pock10 et limits on cost sharing.

11 (7) Coordination of benefit information appro12 priate in determining liability in cases in which bene13 fits may be payable under 2 or more health benefit

14 plans.

15 (c) PERIODICITY OF SUBMISSIONS.—The standards

16 established by the Secretary under this subsection shall

17 require the submission of information to the national en18 rollment verification system on a periodic basis (as deter19 mined by the Secretary) in order to report applicable

20 changes with respect to enrollment status or eligibility.

21 (d) FORM OF INQUIRY.—The verification system

22 shall be capable of accepting inquiries from health care

23 providers, health benefit plan sponsors (and any other in24 dividual or entity determined appropriate by the Sec-
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1 retary) in a variety of electronic and other forms, includ2 ing—

3 (1) through electronic transmission of informa4 tion on the health benefit card (in a manner similar

5 to that for verification of credit card purchases);

6 (2) through the use of a touch-tone telephone

7 line; and

8 (3) through the use of a computer modem.

9 (e) FORM OF RESPONSE.—The system shall be capa10 ble of responding to inquiries under subsection (d) in a

11 variety of electronic and other forms, including—

12 (1) through modem transmission of informa13 tion;

14 (2) through computer synthesized voice commu15 nication; and

16 (3) through transmission of information to a

17 facsimile (fax) machine.

18 (f) LIMITS ON DISCLOSURE OF INFORMATION RE19 PORTED.—The disclosure of information reported to the

20 national enrollment verification system shall be restricted

21 by the Secretary under standards established by the Sec22 retary.

23 (g) FEES.—The Secretary may impose a fee for the

24 acceptance of, or response to, an inquiry to the verification

25 system.
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1 (h) PUBLIC DOMAIN SOFTWARE TO PROVIDERS.—

2 The Secretary shall provide for the development, and shall

3 make available without charge to health care providers,

4 such computer software as will enable such providers to

5 make inquiries to, and receive responses from, the national

6 enrollment verification system in electronic form.

7 (i) DEADLINE.—The Secretary shall establish the

8 system and standards under this section (and shall develop

9 and make available the software under subsection (h)) by

10 not later than 12 months after the date of the enactment

11 of this Act.

12 (j) CIVIL MONEY PENALTY.—In the case of a failure

13 of an individual or entity to report information to the en14 rollment verification system under a standard established

15 by the Secretary under this section, the individual or en16 tity shall be subject, in addition to any other penalties that

17 may be prescribed by law, to a civil money penalty of not

18 more than $100 for each day in which such failure per19 sists. The provisions of section 1128A of the Social Secu20 rity Act (other than subsections (a) and (b)) shall apply

21 to a civil money penalty under this subsection in the same

22 manner as such provisions apply to a penalty or proceed23 ing under section 1128A(a) of such Act.

24 (k) ELIMINATION OF EMPLOYER REQUIREMENT TO

25 REPORT CERTAIN INFORMATION TO MEDICARE AND
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1 MEDICAID COVERAGE DATA BANK.—Effective upon full

2 implementation of the national enrollment verification sys3 tem under this section—

4 (1) no employer is required to make any reports

5 under section 1144(c) of the Social Security Act;

6 and

7 (2) information and functions previously in or

8 performed by the Medicare and Medicaid Coverage

9 Data Bank under section 1144 of such Act shall be

10 subsumed by the enrollment verification system.

11 SEC. 203. REQUIREMENTS FOR UNIFORM CLAIMS AND

12 ELECTRONIC CLAIMS DATA SET.

13 (a) REQUIREMENTS.—

14 (1) SUBMISSION OF CLAIMS.—Each health care

15 provider that furnishes services in the United States

16 for which payment may be made under a health ben17 efit plan shall submit any claim for payment for

18 such services only in a form and manner consistent

19 with the standards established under subsection (c).

20 (2) ACCEPTANCE OF CLAIMS.—A health benefit

21 plan sponsor may not reject a claim for payment

22 under the health benefit plan provided on the basis

23 of the form or manner in which the claim is submit24 ted if the claim is submitted in accordance with the

25 standards established under subsection (c).
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1 (3) EFFECTIVE DATE.—This subsection shall

2 apply to claims for services furnished on or after the

3 date that is 6 months after the date standards are

4 established under subsection (c).

5 (b) ENFORCEMENT THROUGH CIVIL MONEY PEN6 ALTIES.—

7 (1) IN GENERAL.—

8 (A) PROVIDERS.—In the case of a health

9 care provider that submits a claim in violation

10 of subsection (a)(1), the provider is subject to

11 a civil money penalty of not to exceed $100 (or,

12 if greater, the amount of the claim) for each

13 such violation.

14 (B) HEALTH BENEFIT PLAN SPONSORS.—

15 In the case of a health benefit plan sponsor

16 that rejects a claim in violation of subsection

17 (a)(2), the sponsor is subject to a civil money

18 penalty of not to exceed $100 (or, if greater,

19 the amount of the claim) for each such viola20 tion.

21 (2) PROCESS.—The provisions of section 1128A

22 of the Social Security Act (other than subsections

23 (a) and (b)) shall apply to a civil money penalty

24 under paragraph (1) in the same manner as such
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1 provisions apply to a penalty or proceeding under

2 section 1128A(a) of such Act.

3 (c) STANDARDS RELATING TO UNIFORM CLAIMS AND

4 ELECTRONIC CLAIMS DATA SET.—

5 (1) ESTABLISHMENT OF STANDARDS.—The

6 Secretary shall establish standards that relate to the

7 form and manner of submission of claims for bene8 fits under a health benefit plan. The standards—

9 (A) shall require that such claims be sub10 mitted electronically;

11 (B) shall define the data elements to be

12 contained in a uniform electronic claims data

13 set to be used with respect to such claims;

14 (C) establish a uniform electronic format

15 for the electronic transmission of such elements;

16 (D) shall include instructions on record

17 keeping in support of claims submitted; and

18 (E) shall ensure the suitability of elec19 tronic data as evidence in a court of law.

20 (2) SCOPE OF INFORMATION.—

21 (A) IN GENERAL.—The standards under

22 this subsection are intended to cover substan23 tially most claims that are filed under health

24 benefit plans. Such information need not in25 clude all elements that may potentially be re-
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1 quired to be reported under utilization review

2 provisions of plans.

3 (B) ENSURING ACCOUNTABILITY FOR

4 CLAIMS SUBMITTED ELECTRONICALLY.—In es5 tablishing such standards, the Secretary, in

6 consultation with appropriate agencies, shall in7 clude such methods of ensuring provider re8 sponsibility and accountability for claims sub9 mitted electronically that are designed to con10 trol fraud and abuse in the submission of such

11 claims.

12 (C) COMPONENTS.—In establishing such

13 standards the Secretary shall—

14 (i) with respect to data elements, de15 fine data fields, formats, and medical no16 menclature, and plan benefit and insurance

17 information; and

18 (ii) develop a single, uniform, up-to19 date coding system for procedures, serv20 ices, and diagnoses based, to the maximum

21 extent possible, on the American Medical

22 Association’s Common Procedural Termi23 nology, Fourth Edition or a revised version

24 of such text (with respect to procedures

25 and services) and the International Classi-
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1 fication of Diseases, 9th Revision, Clinical

2 Modification, Third Edition or a revised

3 version of such text (with respect to diag4 noses), with additional coding developed as

5 necessary by the Secretary.

6 (3) COORDINATION WITH STANDARDS FOR

7 ELECTRONIC MEDICAL RECORDS.—In establishing

8 standards under this subsection, the Secretary shall

9 assure that—

10 (A) the development of such standards is

11 coordinated with the development of the stand12 ards for reporting uniform clinical data sets

13 under section 204; and

14 (B) the coding of data elements under the

15 uniform electronic claims data set and the cod16 ing of the same elements in the uniform hos17 pital clinical data set and the uniform patient

18 information data set developed under section

19 204 are consistent.

20 (4) UNIFORM, UNIQUE PROVIDER IDENTIFICA21 TION CODES.—In establishing standards under this

22 subsection—

23 (A) the Secretary shall provide for a

24 unique identifier code for each health care pro25 vider and group practice that furnishes services
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1 for which a claim may be submitted under a

2 health benefit plan; and

3 (B) in the case of a provider that has a

4 unique identifier issued for purposes of the

5 medicare program, the code provided under

6 subparagraph (A) shall be the same as such

7 unique identifier.

8 (5) PUBLIC DOMAIN SOFTWARE TO PROVID9 ERS.—The Secretary shall provide for the develop10 ment, and shall make available without charge to

11 health care providers, such computer software as will

12 enable the providers to submit claims and to receive

13 verification of claims status electronically.

14 (6) STANDARDS FOR CLAIMS FOR CLINICAL

15 LABORATORY TESTS.—The standards shall provide

16 that claims for clinical laboratory tests for which

17 benefits are provided under a health benefit plan

18 shall be submitted directly by the person or entity

19 that performed (or supervised the performance of)

20 the tests to the plan in a manner consistent with

21 (and subject to such exceptions as are provided

22 under) the requirement for direct submission of such

23 claims under the medicare program.

24 (7) DEADLINE.—The Secretary shall first pro25 vide for the standards for the uniform claims under
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1 this subsection (and shall develop and make avail2 able the software under paragraph (6)) by not later

3 than 1 year after the date of the enactment of this

4 Act.

5 (d) USE UNDER MEDICARE AND MEDICAID PRO6 GRAMS.—

7 (1) REQUIREMENT FOR PROVIDERS.—In the

8 case of a health care provider that submits a claim

9 for services furnished under the medicare program

10 or medicaid program in violation of subsection

11 (a)(1), no payment shall be made under such pro12 gram for such services.

13 (2) REQUIREMENTS OF INTERMEDIARIES AND

14 CARRIERS UNDER MEDICARE PROGRAM.—The Sec15 retary shall provide, in regulations promulgated to

16 carry out title XVIII of the Social Security Act, that

17 the claims process provided under that title is modi18 fied to the extent required to conform to the stand19 ards established under subsection (c).

20 (3) REQUIREMENTS OF STATE MEDICAID

21 PLANS.—As a condition for the approval of State

22 plans under the medicaid program, effective as of

23 the effective date specified in subsection (a)(3), each

24 such plan shall provide, in accordance with regula25 tions of the Secretary, that the claims process pro-
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1 vided under the plan is modified to the extent re2 quired to conform to the standards established under

3 subsection (c).

4 SEC. 204. REPORTING OF UNIFORM CLINICAL DATA SETS.

5 (a) STANDARDS FOR ELECTRONIC REPORTING OF

6 UNIFORM CLINICAL DATA SETS.—

7 (1) PROMULGATION OF STANDARDS.—

8 (A) IN GENERAL.—Not later than the

9 deadlines provided in paragraph (5), the Sec10 retary shall promulgate standards described in

11 paragraph (2) concerning the uniform clinical

12 data sets described in such paragraph.

13 (B) REVISION.—The Secretary may from

14 time to time revise the standards promulgated

15 under this paragraph.

16 (2) CONTENTS OF STANDARDS.—The standards

17 promulgated under paragraph (1) shall include at

18 least the following:

19 (A) A definition of a uniform hospital clini20 cal data set, including a definition of the set of

21 comprehensive data elements, for use by utiliza22 tion and quality control peer review organiza23 tions.

24 (B) A definition of a uniform patient infor25 mation data set including data obtained at the
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1 point of care, for use by utilization and quality

2 control peer review organizations with respect

3 to physician care.

4 (C) A specification of, and manner of pres5 entation of, the individual data elements of the

6 sets under this paragraph.

7 (D) Standards concerning the electronic

8 transmission of such data sets.

9 (E) Standards relating to confidentiality of

10 health information reported under this section,

11 which include the physical security of electronic

12 data and the use of keys, passwords,

13 encryption, and other means to ensure the pro14 tection of the confidentiality and privacy of

15 electronic data.

16 (F) Standards to ensure the suitability of

17 electronic data as evidence in a court of law.

18 (3) COORDINATION WITH STANDARDS FOR UNI19 FORM ELECTRONIC CLAIMS DATA SET.—In establish20 ing standards under this subsection, the Secretary

21 shall ensure that—

22 (A) the development of the standards is co23 ordinated with the development of the stand24 ards for the uniform electronic claims data set

25 under section 203;
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1 (B) the coding of the same data elements

2 under the uniform hospital clinical data set, the

3 uniform patient information data set, and the

4 uniform electronic claims data set is consistent;

5 and

6 (C) the standards under this subsection

7 are consistent, to the maximum extent prac8 ticable, with other standards existing at the

9 time the standards under this subsection are es10 tablished, including any standard set by the

11 American National Standards Institute.

12 (4) CONSULTATION.—in establishing standards

13 under this subsection, the Secretary shall—

14 (A) consult with the American National

15 Standards Institute, health care providers,

16 health benefit plan sponsors, and other inter17 ested parties; and

18 (B) take into consideration the data set

19 used by the utilization and quality control peer

20 review program under part B of title XI of the

21 Social Security Act.

22 (5) DEADLINES.—The Secretary shall promul23 gate standards described in paragraph (2) concern24 ing the uniform hospital clinical data set prior to the

25 expiration of the 1-year period beginning on the date
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1 of the enactment of this Act. The Secretary shall

2 promulgate standards described in paragraph (2)

3 concerning the uniform patient information clinical

4 data set prior to January 1, 2001.

5 (b) REQUIREMENT FOR APPLICATION OF ELEC6 TRONIC RECORDS STANDARDS TO HOSPITALS.—

7 (1) AS CONDITION OF MEDICARE PARTICIPA8 TION.—As of January 1, 2001, each hospital, as a

9 requirement of each participation agreement under

10 section 1866 of the Social Security Act, shall, in ac11 cordance with the standards promulgated under sub12 section (a)(1)—

13 (A) maintain clinical data included in the

14 uniform hospital clinical data set under sub15 section (a)(2)(A) in electronic form on all inpa16 tients;

17 (B) upon request of the Secretary or of a

18 utilization and quality control peer review orga19 nization (with which the Secretary has entered

20 into a contract under part B of title XI of such

21 Act), transmit electronically data requested

22 from such data set; and

23 (C) upon request of the Secretary, or of a

24 fiscal intermediary or carrier, transmit elec-
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1 tronically any data (with respect to a claim)

2 from such data set.

3 (2) APPLICATION OF PRESENTATION AND

4 TRANSMISSION STANDARDS TO ELECTRONIC TRANS5 MISSION TO FEDERAL AGENCIES.—Effective Janu6 ary 1, 2001, if a hospital is required under a Fed7 eral program to transmit a data element included in

8 the uniform hospital clinical data set that is subject

9 to a standard, promulgated under subsection (a)(1),

10 described in subparagraph (C) or (D) of subsection

11 (a)(2), the head of the Federal agency responsible

12 for such program (if not otherwise authorized) is au13 thorized to require the provider to present and

14 transmit the data element electronically in accord15 ance with such a standard.

16 (c) LIMITATION ON DATA REQUIREMENTS WHERE

17 STANDARDS IN EFFECT.—

18 (1) IN GENERAL.—On or after January 1,

19 2001, a health benefit plan sponsor may not require,

20 for the purpose of utilization review or as a condi21 tion of providing benefits or making payments under

22 the plan provided, that a hospital—

23 (A) provide any data element not in the

24 uniform hospital clinical data set specified
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1 under the standards promulgated under sub2 section (a); or

3 (B) transmit or present any such data ele4 ment in a manner inconsistent with such stand5 ards applicable to such transmission or presen6 tation.

7 (2) COMPLIANCE.—The Secretary may impose

8 a civil money penalty on any health benefit plan

9 sponsor that fails to comply with paragraph (1) in

10 an amount not to exceed $100 for each such failure.

11 The provisions of section 1128A of the Social Secu12 rity Act (other than the first sentence of subsection

13 (a) and other than subsection (b)) shall apply to a

14 civil money penalty under this paragraph in the

15 same manner as such provisions apply to a penalty

16 or proceeding under section 1128A(a) of such Act.

17 (3) APPLICATION TO MEDICARE PROGRAM.—Ef18 fective as of January 1, 2001, neither the Secretary,

19 nor any carrier or fiscal intermediary, nor any utili20 zation and quality control peer review organization

21 may require, for the purpose of utilization review or

22 as a condition of providing benefits or making pay23 ments under the medicare program, that a hos24 pital—
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1 (A) provide any data element not in the

2 uniform hospital clinical data set specified

3 under the standards promulgated under sub4 section (a); or

5 (B) transmit or present any such data ele6 ment in a manner inconsistent with such stand7 ards applicable to such transmission or presen8 tation.

9 (4) APPLICATION TO MEDICAID PROGRAM.—As

10 a condition for the approval of State plans under the

11 medicaid program and in accordance with regula12 tions of the Secretary, effective as of January 1,

13 2001, each such plan may not require that a hos14 pital, for the purpose of utilization review or as a

15 condition of providing benefits or making payments

16 under the plan—

17 (A) provide any data element not in the

18 uniform hospital clinical data set specified

19 under the standards promulgated under sub20 section (a), or

21 (B) transmit or present any such data ele22 ment in a manner inconsistent with such stand23 ards applicable to such transmission or presen24 tation.

25 (d) PREEMPTION OF STATE QUILL PEN LAWS.—
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1 (1) IN GENERAL.—Any provision of State law

2 that requires medical or health insurance records

3 (including billing information) to be maintained in

4 written, rather than electronic, form is deemed to be

5 satisfied if the records are maintained in an elec6 tronic form that meets standards established by the

7 Secretary under paragraph (2).

8 (2) SECRETARIAL AUTHORITY.—Not later than

9 1 year after the date of the enactment of this Act,

10 the Secretary shall issue regulations to carry out

11 paragraph (1). The regulations shall provide for an

12 electronic substitute that is in the form of a unique

13 identifier (assigned to each authorized individual)

14 that serves the functional equivalent of a signature.

15 The regulations may provide for such exceptions to

16 paragraph (1) as the Secretary determines to be nec17 essary to prevent fraud and abuse, to prevent the il18 legal distribution of controlled substances, and in

19 such other cases as the Secretary deems appropriate.

20 (3) EFFECTIVE DATE.—Paragraph (1) shall

21 take effect on the first day of the first month that

22 begins more than 30 days after the date the Sec23 retary issues the regulations referred to in para24 graph (2).
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1 SEC. 205. UNIFORM HOSPITAL COST REPORTING.

2 Each hospital, as a requirement under a participation

3 agreement under section 1866(a) of the Social Security

4 Act for each cost reporting period beginning during or

5 after fiscal year 1996, shall provide for the reporting of

6 information to the Secretary with respect to any hospital

7 care provided in a uniform manner consistent with stand8 ards established by the Secretary to carry out section

9 4007(c) of the Omnibus Budget Reconciliation Act of

10 1987 and in an electronic form consistent with standards

11 established by the Secretary.

12 SEC. 206. USE OF TASK FORCES.

13 In adopting standards under this title, the Sec14 retary—

15 (1) shall take into account the recommenda16 tions of—

17 (A) current task forces, including at least

18 the Workgroup on Electronic Data Interchange,

19 National Uniform Billing Committee, the Uni20 form Claim Task Force, and the Computer21 based Patient Record Institute; and

22 (B) national organizations representing

23 health care financial managers; and

24 (2) shall provide that electronic transmission

25 standards are consistent, to the extent practicable,

26 with the applicable standards established by the Ac-
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1 credited Standards Committee X–12 of the Amer2 ican National Standards Institute.

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