I 

113TH CONGRESS 

1ST SESSION H. R. 2931 

To amend the false claims provisions of title 31, United States Code, with 

respect to health care programs, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

AUGUST 1, 2013 

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

on the Judiciary 

A BILL 

To amend the false claims provisions of title 31, United 

States Code, with respect to health care programs, 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 ‘‘Fairness in Health 

5 Care Claims, Guidance, and Investigations Act’’. 


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1 SEC. 2. RULES FOR ACTIONS UNDER FALSE CLAIMS PROVI2 SIONS BASED ON CLAIMS SUBMITTED UNDER 

3 CERTAIN HEALTH CARE PROGRAMS. 

4 (a) IN GENERAL.—Subchapter III of chapter 37 of 

5 title 31, United States Code, is amended by adding at the 

6 end the following: 

7 ‘‘§ 3734. Rules for certain actions based on health 

8 care claims 

9 ‘‘(a) IN GENERAL.—In the case of any action that 

10 is brought under section 3730 and is based on a claim 

11 submitted with respect to a Federal health care program, 

12 sections 3729 through 3733 shall apply only to the extent 

13 that such sections are consistent with the provisions of 

14 this section. 

15 ‘‘(b) INVESTIGATIONS OF FALSE CLAIMS TO FED16 ERAL HEALTH CARE PROGRAMS.— 

17 ‘‘(1) IN GENERAL.—Before requesting any in18 formation from a physician, hospital, or other pro19 vider or supplier of health care services, by any for20 mal or informal means, directly or in cooperation 

21 with an investigating law enforcement agency, in 

22 connection with an investigation reasonably expected 

23 to concern 10 or more claims submitted to a Federal 

24 health care program by or on behalf of a single enti25 ty, the Attorney General shall certify, in writing, 

26 that— 


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1 ‘‘(A) each agency responsible for promul2 gating relevant regulations, guidelines, and bill3 ing instructions, directly or through inter4 mediaries, has examined all regulations, guide5 lines, and billing instructions relevant to the al6 legations, all communications between the al7 leged perpetrator and the agency and its inter8 mediaries, and each of the allegedly false 

9 claims; 

10 ‘‘(B) in the view of the responsible agency 

11 officials and the Attorney General, the allega12 tions under investigation are viable, and the rel13 evant regulations, guidelines and billing instruc14 tions were unambiguous during the relevant 

15 time period; and 

16 ‘‘(C) if proven to be true, the allegations 

17 are appropriately pursued under section 3729. 

18 ‘‘(2) IF CERTIFICATION NOT MADE.—If the At19 torney General (or his or her designee) is unable to 

20 make the certifications required under paragraph 

21 (1), and the allegations were included in an action 

22 brought by a person under section 3730(b), the At23 torney General shall notify the court and the court 

24 shall dismiss these allegations. 


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1 ‘‘(c) ACTIONS IF AMOUNT OF DAMAGES ARE MATE2 RIAL AMOUNT.—Notwithstanding sections 3729 through 

3 3733, no action may be brought under section 3730 that 

4 is based on a claim submitted or an overpayment retained 

5 with respect to a Federal health care program unless the 

6 amount of damages alleged to have been sustained by the 

7 United States Government with respect to such claim or 

8 overpayment is a material amount. 

9 ‘‘(d) ACTIONS FOR CLAIMS SUBMITTED IN RELIANCE

10 ON OFFICIAL GUIDANCE.—Notwithstanding sections 3729 

11 through 3733, no action may be brought under section 

12 3730 based on a claim submitted or an overpayment re13 tained with respect to a Federal health care program— 

14 ‘‘(1) in good faith reliance on erroneous infor15 mation supplied by an agency (or an agent thereof) 

16 about matters of fact at issue; 

17 ‘‘(2) in good faith reliance on written state18 ments of Federal policy that affects the claim or 

19 overpayment that were provided by a Federal agency 

20 (or an agent thereof); or 

21 ‘‘(3) in good faith reliance on an audit or re22 view by an agency of the person submitting the 

23 claim or on whose behalf the claim was submitted, 

24 or of the person retaining the overpayment, in which 

25 no findings were made that the claim or overpayVerDate Mar 15 2010 23:37 Aug 06, 2013 Jkt 029200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H2931.IH H2931

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1 ment violated the regulations, guidelines, or instruc2 tions applicable to the Federal health care program 

3 at issue in the claim or overpayment. 

4 ‘‘(e) ACTION FOR CLAIMS SUBMITTED BY PERSONS

5 IN SUBSTANTIAL COMPLIANCE WITH MODEL COMPLI6 ANCE PLAN.—Notwithstanding sections 3729 through 

7 3733, no action may be brought under section 3730 based 

8 on a claim submitted by or on behalf of a person, or an 

9 overpayment retained, with respect to a Federal health 

10 care program if the claim is submitted, or the overpay11 ment retained, in substantial compliance with a model 

12 compliance plan issued by the Secretary of Health and 

13 Human Services with respect to that Federal health care 

14 program. 

15 ‘‘(f) STANDARD OF PROOF.—In any action brought 

16 under section 3730 with respect to a claim submitted, or 

17 an overpayment retained, with respect to a Federal health 

18 care program, section 3731(c) shall be applied by sub19 stituting ‘clear and convincing evidence’ for ‘a preponder20 ance of the evidence’. 

21 ‘‘(g) RULE OF CONSTRUCTION.—Nothing in this sec22 tion shall be construed to limit the authority of the Gov23 ernment of the United States to recover damages with re24 spect to a claim submitted, or an overpayment retained, 


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1 with respect to a Federal health care program under provi2 sions of law other than section 3729. 

3 ‘‘(h) DEFINITIONS; SPECIAL RULES.—For purposes 

4 of this section— 

5 ‘‘(1) the term ‘claim’ means a claim as defined 

6 in section 3729(c); 

7 ‘‘(2) the term ‘Federal health care program’ 

8 means— 

9 ‘‘(A) any plan or program that provides 

10 health care benefits, whether directly, through 

11 insurance, or otherwise, and that is funded di12 rectly, in whole or in part, by the United States 

13 Government; 

14 ‘‘(B) any State health care program, as de15 fined in section 1128(h) of the Social Security 

16 Act; or 

17 ‘‘(C) any qualifying health plan offered 

18 through an Exchange established under, or any 

19 other health plan established under, the Patient 

20 Protection and Affordable Care Act (Public 

21 Law 111–148); 

22 ‘‘(3) the amount of damages alleged to have 

23 been sustained by the United States Government 

24 with respect to a claim submitted by (or on behalf 

25 of) a person shall be treated as a ‘material amount’ 


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1 only if such amount exceeds a proportion (specified 

2 in regulations promulgated by the Secretary of 

3 Health and Human Services in consultation with the 

4 Secretary of Defense) of the total of the amounts for 

5 which claims were submitted by (or on behalf of) 

6 such person— 

7 ‘‘(A) to the same Federal health care pro8 gram, and 

9 ‘‘(B) for the same calendar year, 

10 as the claim upon which an action under section 

11 3730 is based; 

12 ‘‘(4) in determining whether an amount of dam13 ages is a ‘material amount’ under paragraph (3), 

14 with respect to a person— 

15 ‘‘(A) the amount of damages for more than 

16 1 claim may be aggregated only if the acts or 

17 omissions resulting in such damages were part 

18 of a pattern of related acts or omissions by 

19 such person; and 

20 ‘‘(B) if damages for more than 1 claim are 

21 aggregated in accordance with subparagraph 

22 (A), the proportion referred to in paragraph (3) 

23 shall be determined by comparing the amount 

24 of such aggregate damages to the total of the 

25 amounts for which claims were submitted by (or 


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1 on behalf of) such person to the same Federal 

2 health care program for each of the calendar 

3 years for which any claim upon which such ag4 gregate damages were based was submitted; 

5 ‘‘(5) the term ‘intermediary’ means, with re6 spect to a Federal health care program, a contractor 

7 with an agency, a State, or other entity that is en8 gaged in the implementation of that Federal health 

9 care program; and 

10 ‘‘(6) the term ‘State’ means each of the several 

11 States, the District of Columbia, and any territory 

12 or possession of the United States.’’. 

13 (b) CONFORMING AMENDMENT.—The table of sec14 tions for chapter 37 of title 31, United States Code, is 

15 amended by adding at the end the following new item: 

‘‘3734. Rules for certain actions based on health care claims.’’. 

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

17 this section shall apply to any action or investigation 

18 under sections 3729 through 3733 of title 31, United 

19 States Code, that is pending on, or commenced on or after, 

20 the date of the enactment of this Act. 

Æ 


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