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[Congressional Bills 103th Congress]
[From the U.S. Government Publishing Office]
[H.R. 1255 Introduced in House (IH)]

103d CONGRESS
  1st Session
                                H. R. 1255

 To amend title XI of the Social Security Act to extend the penalties 
   for fraud and abuse assessed against providers under the medicare 
 program and State health care programs to providers under all health 
                  care plans, and for other purposes.

_______________________________________________________________________

                    IN THE HOUSE OF REPRESENTATIVES

                             March 9, 1993

   Mr. Stark (for himself, Mr. Levin, Mr. McDermott, and Mr. Cardin) 
   introduced the following bill; which was referred jointly to the 
          Committees on Ways and Means and Energy and Commerce

                             April 28, 1993

      Additional sponsors: Mr. Owens, and Mr. Miller of California

_______________________________________________________________________

                                 A BILL

 
 To amend title XI of the Social Security Act to extend the penalties 
   for fraud and abuse assessed against providers under the medicare 
 program and State health care programs to providers under all health 
                  care plans, and for other purposes.

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

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``National Health 
Care Anti-Fraud and Abuse Act of 1993''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Section 1. Short title; table of contents.
               TITLE I--ALL-PAYER FRAUD AND ABUSE PROGRAM

Sec. 101. All-payer fraud and abuse control program
Sec. 102. Application of Federal health anti-fraud and abuse sanctions 
                            to all fraud and abuse against any health 
                            benefit plan.
Sec. 103. Public reporting of fraudulent actions.
      TITLE II--REVISIONS TO CURRENT SANCTIONS FOR FRAUD AND ABUSE

Sec. 201. Mandatory exclusion from participation in medicare and State 
                            health care programs.
Sec. 202. Establishment of minimum period of exclusion for certain 
                            individuals and entities subject to 
                            permissive exclusion from medicare and 
                            State health care programs.
Sec. 203. Permissive exclusion of individuals with ownership or control 
                            interest in sanctioned entities.
Sec. 204. Civil monetary penalties.
Sec. 205. Actions subject to criminal penalties.
Sec. 206. Sanctions against practitioners and persons for failure to 
                            follow corrective action plan of peer 
                            review organization.
Sec. 207. Restrictions on certain durable medical equipment marketing 
                            and sales activities.
Sec. 208. Intermediate sanctions for medicare health maintenance 
                            organizations.
Sec. 209. Effective date.
         TITLE III--ADMINISTRATIVE AND MISCELLANEOUS PROVISIONS

Sec. 301. Requirements for uniform claims and electronic claims data 
                            set.
Sec. 302. Quarterly publication of adverse actions taken.
Sec. 303. Study of electronic reporting of ownership information.

               TITLE I--ALL-PAYER FRAUD AND ABUSE PROGRAM

SEC. 101. ALL-PAYER FRAUD AND ABUSE CONTROL PROGRAM

    (a) Establishment of Program.--
            (1) Establishment.--Not later than January 1, 1995, the 
        Secretary shall establish in the Office of the Inspector 
        General of the Department of Health and Human Services a 
        program--
                    (A) to coordinate Federal, State, and local law 
                enforcement programs to control fraud and abuse with 
                respect to the delivery of and payment for health care 
                in the United States,
                    (B) to conduct investigations, audits, evaluations, 
                and inspections relating to the delivery of and payment 
                for health care in the United States, and
                    (C) to facilitate the enforcement of the provisions 
                of sections 1128, 1128A, and 1128B of the Social 
                Security Act and other statutes applicable to health 
                care fraud and abuse.
            (2) Coordination with law enforcement agencies.--In 
        carrying out the program established under paragraph (1), the 
        Secretary shall consult with, and arrange for the sharing of 
        data and resources with the Attorney General, State law 
        enforcement agencies, State medicaid fraud and abuse units, and 
        State agencies responsible for the licensing and certification 
        of health care providers.
            (3) Coordination with third party insurers.--In carrying 
        out the program established under paragraph (1), the Secretary 
        shall consult with, and arrange for the sharing of data with 
        representatives of private sponsors of health benefit plans and 
        other providers of health insurance.
            (4) Regulations.--
                    (A) In general.--The Secretary shall by regulation 
                establish standards to carry out the program under 
                paragraph (1).
                    (B) Information standards.--
                            (i) In general.--Such standards shall 
                        include standards relating to the furnishing of 
                        information by health insurers (including self-
                        insured health benefit plans), providers, and 
                        others to enable the Secretary to carry out the 
                        program (including coordination with law 
                        enforcement agencies under paragraph (2) and 
                        third party insurers under paragraph (3)).
                            (ii) Confidentiality.--Such standards shall 
                        include procedures to assure that such 
                        information is provided and utilized in a 
                        manner that protects the confidentiality of the 
                        information and the privacy of individuals 
                        receiving health care services.
                            (iii) Qualified immunity for providing 
                        information.--The provisions of section 1157(a) 
                        of the Social Security Act (relating to 
                        limitation on liability) shall apply to a 
                        person providing information to the Secretary 
                        under the program under this section, with 
                        respect to the Secretary's performance of 
                        duties under the program, in the same manner as 
                        such section applies to information provided to 
                        organizations with a contract under part B of 
                        title XI of such Act, with respect to the 
                        performance of such a contract.
                    (C) Disclosure of ownership information.--
                            (i) In general.--Such standards shall 
                        include standards relating to the disclosure of 
                        ownership information described in clause (ii).
                            (ii) Ownership information described.--The 
                        ownership information described in this clause 
                        includes--
                                    (I) covered items and services 
                                provided by an entity;
                                    (II) the names and unique physician 
                                identification numbers of all 
                                physicians with an ownership or 
                                investment interest in the entity (as 
                                described in section 1877(a)(2)(A) of 
                                the Social Security Act) or whose 
                                immediate relatives have such an 
                                ownership or investment interest;
                                    (III) the names of all other 
                                individuals with such an ownership or 
                                investment interest in the entity; and
                                    (IV) any other ownership and 
                                related information required to be 
                                disclosed by the entity under section 
                                1124 or section 1124A of the Social 
                                Security Act.
                    (D) Integrity of issuance of provider 
                identification codes.--Such standards shall, insofar as 
                they relate to the issuance of unique provider codes 
                (described in section 301(c)(4))--
                            (i) include standards relating to the 
                        information (including ownership information 
                        described in subparagraph (C)(ii) and other 
                        information needed in the administration of the 
                        program) to be required for the issuance of 
                        such codes, and
                            (ii) provide for the issuance of such a 
                        code upon the presentation of such information 
                        as would be sufficient to provide for the 
                        issuance of similar codes under the medicare 
                        program.
            (5) Authorization of appropriations for investigators and 
        other personnel.--
                    (A) In general.--In addition to any other amounts 
                authorized to be appropriated to the Secretary for 
                health care anti-fraud and abuse activities for a 
                fiscal year, there are authorized to be appropriated 
                additional amounts described in subparagraph (B) to 
                enable the Secretary to conduct investigations of 
                allegations of health care fraud and otherwise carry 
                out the program established under paragraph (1) in a 
                fiscal year.
                    (B) Amounts described.--The amounts referred to in 
                subparagraph (A) are as follows:
                            (i) For fiscal year 1995, $300,000,000.
                            (ii) For fiscal year 1996, $350,000,000.
                            (iii) For fiscal year 1997, $400,000,000.
                            (iv) For fiscal year 1998, $450,000,000.
            (6) Ensuring access to documentation.--(A) The Inspector 
        General of the Department of Health and Human Services is 
        authorized to exercise the authority described in paragraphs 
        (4) and (5) of section 6 of the Inspector General Act of 1978 
        (relating to subpoenas and administration of oaths) with 
        respect to the activities under the all-payor fraud and abuse 
        control program established under this subsection to the same 
        extent as such Inspector General may exercise such authorities 
        to perform the functions assigned to such official by such Act.
            (B) Section 1128(b) of the Social Security Act (42 U.S.C. 
        1320a-7(b)) is amended by adding at the end the following new 
        paragraph:
                    ``(15) Failure to supply requested information to 
                the inspector general.--Any individual or entity that 
                fails fully and accurately to provide, upon request of 
                the Inspector General of the Department of Health and 
                Human Services, records, documents, and other 
                information necessary for the purposes of carrying out 
                activities under the all-payor fraud and abuse control 
                program established under section 101 of the National 
                Health Care Anti-Fraud and Abuse Act of 1993.''.
    (b) Establishment of Anti-Fraud and Abuse Trust Fund.--
            (1) Establishment.--
                    (A) In general.--There is hereby created on the 
                books of the Treasury of the United States a trust fund 
                to be known as the ``Anti-Fraud and Abuse Trust Fund'' 
                (in this section referred to as the ``Trust Fund''). 
                The Trust Fund shall consist of such gifts and bequests 
                as may be made as provided in subparagraph (B) and such 
                amounts as may be deposited in, or appropriated to, 
                such Trust Fund as provided in this subtitle, section 
                143(b), and title XI of the Social Security Act.
                    (B) Authorization to accept gifts.--The Managing 
                Trustee of the Trust Fund is authorized to accept on 
                behalf of the United States money gifts and bequests 
                made unconditionally to the Trust Fund, for the benefit 
                of the Trust Fund, or any activity financed through the 
                Trust Fund.
            (2) Management.--
                    (A) In general.--The Trust Fund shall be managed by 
                the Secretary through a Managing Trustee designated by 
                the Secretary.
                    (B) Investment of funds.--It shall be the duty of 
                the Managing Trustee to invest such portion of the 
                Trust Fund as is not, in the trustee's judgment, 
                required to meet current withdrawals. Such investments 
                may be made only in interest-bearing obligations of the 
                United States or in obligations guaranteed as to both 
                principal and interest by the United States. For such 
                purpose such obligations may be acquired (i) on 
                original issue at the issue price, or (ii) by purchase 
                of outstanding obligations at market price. The 
                purposes for which obligations of the United States may 
                be issued under chapter 31 of title 31, United States 
                Code, are hereby extended to authorize the issuance at 
                par of public-debt obligations for purchase by the 
                Trust Fund. Such obligations issued for purchase by the 
                Trust Fund shall have maturities fixed with due regard 
                for the needs of the Trust Fund and shall bear interest 
                at a rate equal to the average market yield (computed 
                by the Managing Trustee on the basis of market 
                quotations as of the end of the calendar month next 
                preceding the date of such issue) on all marketable 
                interest-bearing obligations of the United States then 
                forming a part of the public debt which are not due or 
                callable until after the expiration of 4 years from the 
                end of such calendar month, except that where such 
                average is not a multiple of \1/8\ of 1 percent, the 
                rate of interest on such obligations shall be the 
                multiple of \1/8\ of 1 percent nearest such market 
                yield. The Managing Trustee may purchase other 
                interest-bearing obligations of the United States or 
                obligations guaranteed as to both principal and 
                interest by the United States, on original issue or at 
                the market price, only where the Trustee determines 
                that the purchase of such other obligations is in the 
                public interest.
                    (C) Any obligations acquired by the Trust Fund 
                (except public-debt obligations issued exclusively to 
                the Trust Fund) may be sold by the Managing Trustee at 
                the market price, and such public-debt obligations may 
                be redeemed at par plus accrued interest.
                    (D) The interest on, and the proceeds from the sale 
                or redemption of, any obligations held in the Trust 
                Fund shall be credited to and form a part of the Trust 
                Fund.
                    (E) The receipts and disbursements of the Secretary 
                in the discharge of the functions of the Secretary 
                shall not be included in the totals of the budget of 
                the United States Government. For purposes of part C of 
                the Balanced Budget and Emergency Deficit Control Act 
                of 1985, the Secretary and the Trust Fund shall be 
                treated in the same manner as the Federal Retirement 
                Thrift Investment Board and the Thrift Savings Fund, 
                respectively. The United States is not liable for any 
                obligation or liability incurred by the Trust Fund.
            (3) Use of funds.--Amounts in the Trust Fund shall be used 
        to assist the Inspector General of the Department of Health and 
        Human Services in carrying out the all-payor fraud and abuse 
        control program established under subsection (a) in the fiscal 
        year involved.

SEC. 102. APPLICATION OF FEDERAL HEALTH ANTI-FRAUD AND ABUSE SANCTIONS 
              TO ALL FRAUD AND ABUSE AGAINST ANY HEALTH BENEFIT PLAN.

    (a) Civil Monetary Penalties.--Section 1128A of the Social Security 
Act (42 U.S.C. 1320a-7a) is amended as follows:
            (1) In subsection (a)(1), in the matter before subparagraph 
        (A), by inserting ``or of any health benefit plan,'' after 
        ``subsection (i)(1)),''.
            (2) In subsection (b)(1)(A), by inserting ``or under a 
        health benefit plan'' after ``title XIX''.
            (3) In subsection (f)--
                    (A) by redesignating paragraph (3) as paragraph 
                (4); and
                    (B) by inserting after paragraph (2) the following 
                new paragraph:
            ``(3) With respect to amounts recovered arising out of a 
        claim under a health benefit plan, the portion of such amounts 
        as is determined to have been paid by the plan shall be repaid 
        to the plan.''.
            (4) In subsection (i)--
                    (A) in paragraph (2), by inserting ``or under a 
                health benefit plan'' before the period at the end, and
                    (B) in paragraph (5), by inserting ``or under a 
                health benefit plan'' after ``or XX''.
    (b) Crimes.--
            (1) Social security act.--Section 1128B of such Act (42 
        U.S.C. 1320a-7b) is amended as follows:
                    (A) In the heading, by adding at the end the 
                following: ``or health benefit plans''.
                    (B) In subsection (a)(1)--
                            (i) by striking ``title XVIII or'' and 
                        inserting ``title XVIII,'', and
                            (ii) by adding at the end the following: 
                        ``or a health benefit plan (as defined in 
                        section 1128(i)),''.
                    (C) In subsection (a)(5), by striking ``title XVIII 
                or a State health care program'' and inserting ``title 
                XVIII, a State health care program, or a health benefit 
                plan''.
                    (D) In the second sentence of subsection (a)--
                            (i) by inserting after ``title XIX'' the 
                        following: ``or a health benefit plan'', and
                            (ii) by inserting after ``the State'' the 
                        following: ``or the plan''.
                    (E) In subsection (b)(1), by striking ``title XVIII 
                or a State health care program'' each place it appears 
                and inserting ``title XVIII, a State health care 
                program, or a health benefit plan''.
                    (F) In subsection (b)(2), by striking ``title XVIII 
                or a State health care program'' each place it appears 
                and inserting ``title XVIII, a State health care 
                program, or a health benefit plan''.
                    (G) In subsection (b)(3), by striking ``title XVIII 
                or a State health care program'' each place it appears 
                in subparagraphs (A) and (C) and inserting ``title 
                XVIII, a State health care program, or a health benefit 
                plan''.
                    (H) In subsection (d)(2)--
                            (i) by striking ``title XIX,'' and 
                        inserting ``title XIX or under a health benefit 
                        plan,'', and
                            (ii) by striking ``State plan,'' and 
                        inserting ``State plan or the health benefit 
                        plan,''.
            (2) Treble damages for criminal sanctions.--Section 1128B 
        of such Act (42 U.S.C. 1320a-7b) is amended by adding at the 
        end the following new subsection:
    ``(f) In addition to the fines that may be imposed under subsection 
(a), (b), or (c), any individual found to have violated the provisions 
of any of such subsections may be subject to treble damages.''.
            (3) Identification of community service opportunities.--
        Section 1128B of such Act (42 U.S.C. 1320a-7b) is further 
        amended by adding at the end the following new subsection:
    ``(g) The Secretary shall--
            ``(1) in consultation with State and local health care 
        officials, identify opportunities for the satisfaction of 
        community service obligations that a court may impose upon the 
        conviction of an offense under this section, and
            ``(2) make information concerning such opportunities 
        available to Federal and State law enforcement officers and 
        State and local health care officials.''.
    (c) Health Benefit Plan Defined.--Section 1128 of such Act (42 
U.S.C. 1320a-7) is amended by redesignating subsection (i) as 
subsection (j) and by inserting after subsection (h) the following new 
subsection:
    ``(i) Health Benefit Plan Defined.--For purposes of sections 1128A 
and 1128B, the term `health benefit plan' means a health benefit 
program other than the medicare program, the medicaid program, or a 
State health care program.''.
    (d) Conforming Amendment.--Section 1128(b)(8)(B)(ii) of such Act 
(42 U.S.C. 1320a-7(b)(8)(B)(ii)) is amended by striking ``1128A'' and 
inserting ``1128A (other than a penalty arising from a health benefit 
plan, as defined in subsection (i))''.
    (e) Effective Date.--The amendments made by this section shall take 
effect January 1, 1995.

SEC. 103. REPORTING OF FRAUDULENT ACTIONS UNDER MEDICARE.

    (a) Establishment of Program.--Not later than 1 year after the date 
of the enactment of this Act, the Secretary of Health and Human 
Services shall establish a program through which individuals entitled 
to benefits under the medicare program may report to the Secretary on a 
confidential basis (at the individual's request) instances of suspected 
fraudulent actions arising under the program by providers of items and 
services under the program.
    (b) Notice to Medicare Beneficiaries.--
            (1) Included in annual notice of benefits.--Section 1804 of 
        the Social Security Act (42 U.S.C. 1395b-2) is amended--
                    (A) in paragraph (2), by striking ``and'' at the 
                end;
                    (B) in paragraph (3), by striking the period at the 
                end and inserting ``, and''; and
                    (C) by inserting after paragraph (3) the following 
                new paragraph:
            ``(4) a description of the Secretary's program for the 
        reporting by individuals entitled to benefits under this title 
        of suspected instances of fraudulent actions arising under the 
        program by providers of items and services under the program, 
        and of information to alert such individuals to the existence 
        of problems of fraud and abuse under the program.''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall take effect on the first day of the first calendar year 
        that begins after the expiration of the 1-year period that 
        begins on the date of the enactment of this Act.

      TITLE II--REVISIONS TO CURRENT SANCTIONS FOR FRAUD AND ABUSE

SEC. 201. MANDATORY EXCLUSION FROM PARTICIPATION IN MEDICARE AND STATE 
              HEALTH CARE PROGRAMS.

    (a) Individual Convicted of Felony Relating to Fraud.--
            (1) In general.--Section 1128(a) of the Social Security Act 
        (42 U.S.C. 1320a-7(a)) is amended by adding at the end the 
        following new paragraph:
            ``(3) Felony conviction relating to fraud.--Any individual 
        or entity that has been convicted, under Federal or State law, 
        in connection with the delivery of a health care item or 
        service or with respect to any act or omission in a program 
        operated by or financed in whole or in part by any Federal, 
        State, or local government agency, of a criminal offense 
        consisting of a felony relating to fraud, theft, embezzlement, 
        breach of fiduciary responsibility, or other financial 
        misconduct.''.
            (2) Conforming amendment.--Section 1128(b)(1) of such Act 
        (42 U.S.C. 1320a-7(b)(1)) is amended--
                    (A) in the heading, by striking ``Conviction'' and 
                inserting ``Misdemeanor conviction''; and
                    (B) by striking ``criminal offense'' and inserting 
                ``criminal offense consisting of a misdemeanor''.
    (b) Individual Convicted of Felony Relating to Controlled 
Substance.--
            (1) In general.--Section 1128(a) of the Social Security Act 
        (42 U.S.C. 1320a-7(a)), as amended by subsection (a), is 
        amended by adding at the end the following new paragraph:
            ``(4) Felony conviction relating to controlled substance.--
        Any individual or entity that has been convicted, under Federal 
        or State law, of a criminal offense consisting of a felony 
        relating to the unlawful manufacture, distribution, 
        prescription, or dispensing of a controlled substance.''.
            (2) Conforming amendment.--Section 1128(b)(3) of such Act 
        (42 U.S.C. 1320a-7(b)(3)) is amended--
                    (A) in the heading, by striking ``Conviction'' and 
                inserting ``Misdemeanor conviction''; and
                    (B) by striking ``criminal offense'' and inserting 
                ``criminal offense consisting of a misdemeanor''.

SEC. 202. ESTABLISHMENT OF MINIMUM PERIOD OF EXCLUSION FOR CERTAIN 
              INDIVIDUALS AND ENTITIES SUBJECT TO PERMISSIVE EXCLUSION 
              FROM MEDICARE AND STATE HEALTH CARE PROGRAMS.

    (a) In General.--Section 1128(c)(3) of the Social Security Act (42 
U.S.C. 1320a-7(c)(3)) is amended by adding at the end the following new 
subparagraphs:
    ``(D) In the case of an exclusion of an individual or entity under 
paragraph (1), (2), or (3) of subsection (b), the period of the 
exclusion shall be 3 years, unless the Secretary determines that a 
shorter period is appropriate because of mitigating circumstances or 
that a longer period is appropriate because of aggravating 
circumstances.
    ``(E) In the case of an exclusion of an individual or entity under 
subsection (b)(4) or (b)(5), the period of the exclusion shall not be 
less than the period during which the individual's or entity''s license 
to provide health care is revoked, suspended, or surrendered.
    ``(F) In the case of an exclusion of an individual or entity under 
subsection (b)(6)(B), the period of the exclusion shall be not less 
than 1 year.''.
    (b) Conforming Amendment.--Section 1128(c)(3)(A) of such Act (42 
U.S.C. 1320a-7(c)(3)(A)) is amended by striking ``subsection (b)(12)'' 
and inserting ``paragraph (1), (2), (3), (4), (6)(B), or (12) of 
subsection (b)''.

SEC. 203. PERMISSIVE EXCLUSION OF INDIVIDUALS WITH OWNERSHIP OR CONTROL 
              INTEREST IN SANCTIONED ENTITIES.

    Section 1128(b) of the Social Security Act (42 U.S.C. 1320a-7(b)) 
is amended by adding at the end the following new paragraph:
            ``(15) Individuals controlling a sanctioned entity.--Any 
        individual who has a direct or indirect ownership or control 
        interest of 5 percent or more, or an ownership or control 
        interest (as defined in section 1124(a)(3)) in, or who is an 
        officer, director, agent, or managing employee (as defined in 
        section 1126(b)) of, an entity--
                    ``(A) that has been convicted of any offense 
                described in subsection (a) or in paragraph (1), (2), 
                or (3);
                    ``(B) against which a civil monetary penalty has 
                been assessed under section 1128A; or
                    ``(C) that has been excluded from participation 
                under a program under title XVIII or under a State 
                health care program.''.

SEC. 204. CIVIL MONETARY PENALTIES.

    (a) Prohibition Against Offering Inducements To Individuals 
Enrolled Under or Employed By Programs or Plans.--
            (1) Inducements to individuals enrolled under medicare.--
        Section 1128A(a) of the Social Security Act (42 U.S.C. 1320a-
        7a(a)) is amended--
                    (A) by striking ``or'' at the end of paragraph 
                (1)(D);
                    (B) by striking ``, or'' at the end of paragraph 
                (2) and inserting a semicolon;
                    (C) by striking the semicolon at the end of 
                paragraph (3) and inserting ``; or''; and
                    (D) by inserting after paragraph (3) the following 
                new paragraph:
            ``(4) routinely transfers anything for less than fair 
        market value to (or for the benefit of) an individual entitled 
        to benefits under the medicare program in order to influence 
        the individual to receive from a particular provider, 
        practitioner, or supplier a covered item or service for which 
        payment may be made under such program, including the routine 
        waiver of the payment of any amounts owed by the individual to 
        the person for an item or service furnished under part B of 
        such program;''.
            (2) Inducements to employees.--Section 1128A(a) of such Act 
        (42 U.S.C. 1320a-7a(a)), as amended by paragraph (1), is 
        further amended--
                    (A) by striking ``or'' at the end of paragraph (3);
                    (B) by striking the semicolon at the end of 
                paragraph (4) and inserting ``; or''; and
                    (C) by inserting after paragraph (4) the following 
                new paragraph:
            ``(5) pays a bonus, reward, or other incentive to an 
        employee to induce the employee to encourage individuals to 
        seek or obtain covered items or services for which payment may 
        be made under the medicare program, a State health care 
        program, or a health benefit plan where the amount of the 
        incentive is in proportion to the activities of the employee in 
        encouraging individuals to seek or obtain covered items or 
        services;''.
    (b) Excluded Individual Retaining Ownership or Control Interest in 
Participating Entity.--Section 1128A(a) of such Act, as amended by 
subsection (a), is further amended--
            (A) by striking ``or'' at the end of paragraph (4);
            (B) by striking the semicolon at the end of paragraph (5) 
        and inserting ``; or''; and
            (C) by inserting after paragraph (5) the following new 
        paragraph:
            ``(6) in the case of a person who is not an organization, 
        agency, or other entity, is excluded from participating in a 
        program under title XVIII or a State health care program in 
        accordance with this subsection or under section 1128 and who, 
        during the period of exclusion, retains a direct or indirect 
        ownership or control interest of 5 percent or more, or an 
        ownership or control interest (as defined in section 
        1124(a)(3)) in, or who is an officer, director, agent, or 
        managing employee (as defined in section 1126(b)) of, an entity 
        that is participating in a program under title XVIII or a State 
        health care program;''.
    (c) Increase in Maximum Amount of Penalties and Assessments.--
Section 1128A(a) of such Act (42 U.S.C. 1320a-7a(a)), as amended by 
subsections (a) and (b), is amended in the matter following paragraph 
(6)--
            (1) by striking ``$2,000'' and inserting ``$10,000''; and
            (2) by striking ``twice the amount'' and inserting ``three 
        times the amount''.
    (d) Claim for Item or Service Based on Incorrect Coding.--Section 
1128A(a)(1)(A) of such Act (42 U.S.C. 1320a-7a(a)(1)(A)) is amended by 
striking ``claimed,'' and inserting the following: ``claimed, including 
any person who on a repeated basis presents or causes to be presented a 
claim for an item or service that is based on a code (in the case of a 
physician's service) or a diagnosis-related group (in the case of 
inpatient hospital services) that results in a greater payment to the 
person than the code or diagnosis-related group that actually applies 
to the item or service,''.
    (e) Permitting Parties To Bring Actions on Own Behalf.--Section 
1128A of such Act (42 U.S.C. 1320a-7a) is amended by adding at the end 
the following new subsection:
    ``(m)(1) Subject to paragraphs (2) and (3), any person (including 
an organization, agency, or other entity, but excluding a beneficiary, 
as defined in subsection (i)(5)) that suffers harm as a direct result 
of any activity of an individual or entity which makes the individual 
or entity subject to a civil monetary penalty under this section may, 
in a civil action against the individual or entity in the United States 
District Court, obtain damages against the individual or entity and 
such equitable relief as is appropriate.
    ``(2) A person may bring a civil action under this subsection only 
if the person provides the Secretary with written notice of the 
person's intent to bring an action under this subsection, the 
identities of the individuals or entities the person intends to name as 
defendants to the action, and all information the person possesses 
regarding the activity that is the subject of the action that may 
materially affect the Secretary's decision to initiate a proceeding to 
impose a civil monetary penalty under this section against the 
defendants.
    ``(3) A person may bring a civil action under this subsection only 
if any of the following conditions are met:
            ``(A) During the 60-day period that begins on the date the 
        Secretary receives the written notice described in paragraph 
        (2), the Secretary does not notify the person that the 
        Secretary intends to initiate a proceeding to impose a civil 
        monetary penalty under this section against the defendants.
            ``(B) If the Secretary notifies the person during the 60-
        day period described in subparagraph (A) that the Secretary 
        intends to initiate a proceeding to impose a civil monetary 
        penalty under this section against the defendants, the 
        Secretary subsequently notifies the person that the Secretary 
        no longer intends to initiate such a proceeding against the 
        defendants.
            ``(C) After the expiration of the 2-year period that begins 
        on the date the Secretary notifies the person that the 
        Secretary intends to initiate a proceeding to impose a civil 
        monetary penalty under this section against the defendants, the 
        Secretary has not made a good faith effort to initiate such a 
        proceeding against the defendants.
    ``(4) If a person is awarded any amounts in an action brought under 
this subsection that are in excess of the damages suffered by the 
person as a result of the defendant's activities, 10 percent of such 
amounts shall be withheld from the person for payment into the Anti-
Fraud and Abuse Trust Fund established under section 101(b) of the 
National Health Care Anti-Fraud and Abuse Act of 1993.
    ``(5) No action may be brought under this subsection more than 6 
years after the date of the activity with respect to which the action 
is brought.''.

SEC. 205. ACTIONS SUBJECT TO CRIMINAL PENALTIES.

    (a) Anti-Kickback Sanctions.--
            (1) Permitting secretary to impose civil monetary 
        penalty.--Section 1128A(a) of the Social Security Act (42 
        U.S.C. 1320a-7a(a)), as amended by subsections (a) and (b) of 
        section 204, is further amended--
                    (A) by striking ``or'' at the end of paragraph (5);
                    (B) by striking the semicolon at the end of 
                paragraph (6) and inserting ``; or''; and
                    (C) by inserting after paragraph (6) the following 
                new paragraph:
            ``(7) carries out any activity in violation of paragraph 
        (1) or (2) of section 1128B(b);''.
            (2) Restriction on application of exception for amounts 
        paid to employees.--Section 1128B(b)(3)(B) of such Act (42 
        U.S.C. 1320a-7b(b)(3)(B)) is amended by striking ``services;'' 
        and inserting the following: ``services, but only if such 
        amount is not contingent upon the employee referring 
        individuals to the employer for the furnishing (or arranging 
        for the furnishing) of such items or services and is not 
        determined in a manner that takes into account (directly or 
        indirectly) the volume or value of any referrals by the 
        employee to the employer for the furnishing (or arranging for 
        the furnishing) of such items or services;''.
    (b) Authority to Enjoin Sanctioned Individual or Entity From 
Disposing of Assets Required to Pay Criminal Penalty.--Section 1128B of 
such Act (42 U.S.C. 1320a-7b), as amended by paragraphs (2) and (3) of 
section 102(b), is further amended by adding at the end the following 
new subsection:
    ``(h) The provisions of section 1128A(k) shall apply to any person 
subject to a fine under this section in the same manner as such 
provisions apply to a person subject to a civil monetary penalty under 
such section.''.

SEC. 206. SANCTIONS AGAINST PRACTITIONERS AND PERSONS FOR FAILURE TO 
              FOLLOW CORRECTIVE ACTION PLAN OF PEER REVIEW 
              ORGANIZATION.

    (a) Minimum Period of Exclusion for Practitioners and Persons 
Failing to Meet Corrective Plan of Peer Review Organization.--
            (1) In general.--The second sentence of section 1156(b)(1) 
        of the Social Security Act (42 U.S.C. 1320c-5(b)(1)) is amended 
        by striking ``may prescribe)'' and inserting ``may prescribe, 
        except that such period may not be less than 1 year)''.
            (2) Conforming amendment.--Section 1156(b)(2) of such Act 
        (42 U.S.C. 1320c-5(b)(2)) is amended by striking ``shall 
        remain'' and inserting ``shall (subject to the minimum period 
        specified in the second sentence of paragraph (1))''.
    (b) Repeal of ``Unwilling or Unable'' Condition for Imposition of 
Sanction.--Section 1156(b)(1) of such Act (42 U.S.C. 1320c-5(b)(1)) is 
amended--
            (1) in the second sentence, by striking ``and determines'' 
        and all that follows through ``such obligations,''; and
            (2) by striking the third sentence.
    (c) Amount of Civil Money Penalty.--Section 1156(b)(3) of such Act 
(42 U.S.C. 1320c-5(b)(3)) is amended by striking ``the actual or 
estimated cost'' and inserting the following: ``$10,000 for each 
instance''.

SEC. 207. RESTRICTIONS ON CERTAIN DURABLE MEDICAL EQUIPMENT MARKETING 
              AND SALES ACTIVITIES.

    (a) Prohibiting Unsolicited Telephone Contacts From Suppliers of 
Durable Medical Equipment to Medicare Beneficiaries.--
            (1) In general.--Section 1834(a) of the Social Security Act 
        (42 U.S.C. 1395m(a)) is amended by adding at the end the 
        following new paragraph:
            ``(17) Prohibition against unsolicited telephone contacts 
        by suppliers.--
                    ``(A) In general.--A supplier of a covered item 
                under this subsection may not contact an individual 
                enrolled under this part by telephone regarding the 
                furnishing of a covered item to the individual (other 
                than a covered item the supplier has already furnished 
                to the individual) unless--
                            ``(i) the individual gives permission to 
                        the supplier to make contact by telephone for 
                        such purpose; or
                            ``(ii) the supplier has furnished a covered 
                        item under this subsection to the individual 
                        during the 15-month period preceding the date 
                        on which the supplier contacts the individual 
                        for such purpose.
                    ``(B) Prohibiting payment for items furnished 
                subsequent to unsolicited contacts.--If a supplier 
                knowingly contacts an individual in violation of 
                subparagraph (A), no payment may be made under this 
                part for any item subsequently furnished to the 
                individual by the supplier.
                    ``(C) Exclusion from program for suppliers engaging 
                in pattern of unsolicited contacts.--If a supplier 
                knowingly contacts individuals in violation of 
                subparagraph (A) to such an extent that the supplier's 
                conduct establishes a pattern of contacts in violation 
                of such subparagraph, the Secretary shall exclude the 
                supplier from participation in the programs under this 
                Act, in accordance with the procedures set forth in 
                subsections (c), (f), and (g) of section 1128.''.
            (2) Requiring refund of amounts collected for disallowed 
        items.--Section 1834(a) of such Act (42 U.S.C. 1395m(a)), as 
        amended by paragraph (1), is amended by adding at the end the 
        following new paragraph:
            ``(18) Refund of amounts collected for certain disallowed 
        items.--
                    ``(A) In general.--If a nonparticipating supplier 
                furnishes to an individual enrolled under this part a 
                covered item for which no payment may be made under 
                this part by reason of paragraph (17)(B), the supplier 
                shall refund on a timely basis to the patient (and 
                shall be liable to the patient for) any amounts 
                collected from the patient for the item, unless--
                            ``(i) the supplier establishes that the 
                        supplier did not know and could not reasonably 
                        have been expected to know that payment may not 
                        be made for the item by reason of paragraph 
                        (17)(B), or
                            ``(ii) before the item was furnished, the 
                        patient was informed that payment under this 
                        part may not be made for that item and the 
                        patient has agreed to pay for that item.
                    ``(B) Sanctions.--If a supplier knowingly and 
                willfully fails to make refunds in violation of 
                subparagraph (A), the Secretary may apply sanctions 
                against the supplier in accordance with section 
                1842(j)(2).
                    ``(C) Notice.--Each carrier with a contract in 
                effect under this part with respect to suppliers of 
                covered items shall send any notice of denial of 
                payment for covered items by reason of paragraph 
                (17)(B) and for which payment is not requested on an 
                assignment-related basis to the supplier and the 
                patient involved.
                    ``(D) Timely basis defined.--A refund under 
                subparagraph (A) is considered to be on a timely basis 
                only if--
                            ``(i) in the case of a supplier who does 
                        not request reconsideration or seek appeal on a 
                        timely basis, the refund is made within 30 days 
                        after the date the supplier receives a denial 
                        notice under subparagraph (C), or
                            ``(ii) in the case in which such a 
                        reconsideration or appeal is taken, the refund 
                        is made within 15 days after the date the 
                        supplier receives notice of an adverse 
                        determination on reconsideration or appeal.''.
    (b) Conforming Amendment.--Section 1834(h)(3) (42 U.S.C. 
1395m(h)(3)) of such Act is amended by striking ``Paragraph (12)'' and 
inserting ``Paragraphs (12) and (17)''.
    (c) Effective Date.--The amendments made by subsections (a) and (b) 
shall apply to items furnished after the expiration of the 60-day 
period that begins on the date of the enactment of this Act.

SEC. 208. INTERMEDIATE SANCTIONS FOR MEDICARE HEALTH MAINTENANCE 
              ORGANIZATIONS.

    (a) Application of Intermediate Sanctions for Any Program 
Violations.--
            (1) In general.--Section 1876(i)(1) of the Social Security 
        Act (42 U.S.C. 1395mm(i)(1)) is amended by striking ``the 
        Secretary may terminate'' and all that follows and inserting 
        the following: ``in accordance with procedures established 
        under paragraph (9), the Secretary may at any time terminate 
        any such contract or may impose the intermediate sanctions 
        described in paragraph (6)(B) or (6)(C) (whichever is 
        applicable) on the eligible organization if the Secretary 
        determines that the organization--
            ``(A) has failed substantially to carry out the contract;
            ``(B) is carrying out the contract in a manner inconsistent 
        with the efficient and effective administration of this 
        section;
            ``(C) is operating in a manner that is not in the best 
        interests of the individuals covered under the contract; or
            ``(D) no longer substantially meets the applicable 
        conditions of subsections (b), (c), (e), and (f).''.
            (2) Other intermediate sanctions for miscellaneous program 
        violations.--Section 1876(i)(6) of such Act (42 U.S.C. 
        1395mm(i)(6)) is amended by adding at the end the following new 
        subparagraph:
    ``(C) In the case of an eligible organization for which the 
Secretary makes a determination under paragraph (1) the basis of which 
is not described in subparagraph (A), the Secretary may apply the 
following intermediate sanctions:
            ``(i) civil money penalties of not more than $25,000 for 
        each determination under paragraph (1) if the deficiency that 
        is the basis of the determination has directly adversely 
        affected (or has the substantial likelihood of adversely 
        affecting) an individual covered under the organization's 
        contract;
            ``(ii) civil money penalties of not more than $10,000 for 
        each week beginning after the initiation of procedures by the 
        Secretary under paragraph (9) during which the deficiency that 
        is the basis of a determination under paragraph (1) exists; and
            ``(iii) suspension of enrollment of individuals under this 
        section after the date the Secretary notifies the organization 
        of a determination under paragraph (1) and until the Secretary 
        is satisfied that the deficiency that is the basis for the 
        determination has been corrected and is not likely to recur.''.
            (3) Procedures for imposing sanctions.--Section 1876(i) of 
        such Act (42 U.S.C. 1395mm(i)) is amended by adding at the end 
        the following new paragraph:
    ``(9) The Secretary may terminate a contract with an eligible 
organization under this section or may impose the intermediate 
sanctions described in paragraph (6) on the organization in accordance 
with formal investigation and compliance procedures established by the 
Secretary under which--
            ``(A) the Secretary provides the organization with the 
        opportunity to develop and implement a corrective action plan 
        to correct the deficiencies that were the basis of the 
        Secretary's determination under paragraph (1);
            ``(B) the Secretary shall impose more severe sanctions on 
        organizations that have a history of deficiencies or that have 
        not taken steps to correct deficiencies the Secretary has 
        brought to their attention;
            ``(C) there are no unreasonable or unnecessary delays 
        between the finding of a deficiency and the imposition of 
        sanctions; and
            ``(D) the Secretary provides the organization with 
        reasonable notice and opportunity for hearing (including the 
        right to appeal an initial decision) before imposing any 
        sanction or terminating the contract.''.
            (4) Conforming amendments.--(A) Section 1876(i)(6)(B) of 
        such Act (42 U.S.C. 1395mm(i)(6)(B)) is amended by striking the 
        second sentence.
            (B) Section 1876(i)(6) of such Act (42 U.S.C. 1395mm(i)(6)) 
        is further amended by adding at the end the following new 
        subparagraph:
    ``(D) The provisions of section 1128A (other than subsections (a) 
and (b)) shall apply to a civil money penalty under subparagraph (A) or 
(B) in the same manner as they apply to a civil money penalty or 
proceeding under section 1128A(a).''.
    (b) Agreements With Peer Review Organizations.--
            (1) Requirement for written agreement.--Section 
        1876(i)(7)(A) of the Social Security Act (42 U.S.C. 
        1395mm(i)(7)(A)) is amended by striking ``an agreement'' and 
        inserting ``a written agreement''.
            (2) Development of model agreement.--Not later than July 1, 
        1994, the Secretary of Health and Human Services shall develop 
        a model of the agreement that an eligible organization with a 
        risk-sharing contract under section 1876 of the Social Security 
        Act must enter into with an entity providing peer review 
        services with respect to services provided by the organization 
        under section 1876(i)(7)(A) of such Act.
            (3) Report by gao.--
                    (A) Study.--The Comptroller General shall conduct a 
                study of the costs incurred by eligible organizations 
                with risk-sharing contracts under section 1876(b) of 
                such Act of complying with the requirement of entering 
                into a written agreement with an entity providing peer 
                review services with respect to services provided by 
                the organization, together with an analysis of how 
                information generated by such entities is used by the 
                Secretary of Health and Human Services to assess the 
                quality of services provided by such eligible 
                organizations.
                    (B) Report to congress.--Not later than July 1, 
                1996, the Comptroller General shall submit a report to 
                the Committee on Ways and Means and the Committee on 
                Energy and Commerce of the House of Representatives and 
                the Committee on Finance of the Senate on the study 
                conducted under subparagraph (A).
    (c) Effective Date.--The amendments made by this section shall 
apply with respect to contract years beginning on or after January 1, 
1995.

SEC. 209. EFFECTIVE DATE.

    Except as otherwise provided in section 207(c), the amendments made 
by this title shall take effect January 1, 1995.

         TITLE III--ADMINISTRATIVE AND MISCELLANEOUS PROVISIONS

SEC. 301. REQUIREMENTS FOR UNIFORM CLAIMS AND ELECTRONIC CLAIMS DATA 
              SET.

    (a) Requirements.--
            (1) Submission of claims.--Each health service provider 
        that furnishes services in the United States for which payment 
        may be made under a health benefit plan shall submit any claim 
        for payment for such services only in a form and manner 
        consistent with standards established under subsection (c).
            (2) Acceptance of claims.--A health benefit plan may not 
        reject a claim for payment under the plan on the basis of the 
        form or manner in which the claim is submitted if the claim is 
        submitted in accordance with the standards established under 
        subsection (c).
            (3) Effective date.--This subsection shall apply to claims 
        for services furnished on or after the date that is 6 months 
        after the date standards are established under subsection (c).
    (b) Enforcement Through Civil Money Penalties.--
            (1) In general.--
                    (A) Providers.--In the case of a health service 
                provider that submits a claim in violation of 
                subsection (a)(1), the provider is subject to a civil 
                money penalty of not to exceed $100 (or, if greater, 
                the amount of the claim) for each such 
                violation.rejects a claim in violation of subsection 
                (a)(2), the plan is subject to a civil money penalty of 
                not to exceed $100 (or, if greater, the amount of the 
                claim) for each such violation.
                    (B) Plans.--In the case of a health benefit plan 
                that rejects a claim in violation of subsection (a)(2), 
                the plan is subject to a civil monetary penalty of not 
                to exceed $100 (or, if greater, the amount of the 
                claim) for each such violation.
            (2) Process.--The provisions of section 1128A of the Social 
        Security Act (other than subsections (a) and (b)) shall apply 
        to a civil money penalty under paragraph (1) in the same manner 
        as such provisions apply to a penalty or proceeding under 
        section 1128A(a) of such Act.
            (3) Sunset for penalty.--No civil money penalty may be 
        imposed under this subsection for submission (or rejection) of 
        any claim on or after the date that is 36 months after the 
        effective date specified in subsection (a)(3).
    (c) Standards Relating to Uniform Claims.--
            (1) Establishment of standards.--The Secretary of Health 
        and Human Services shall establish standards that relate to the 
        form and manner of submission of claims for benefits under a 
        health benefit plan.
            (2) Scope of information.--
                    (A) In general.--The standards under this 
                subsection are intended to cover substantially most 
                claims that are filed under health benefit plans. Such 
                information need not include all elements that may 
                potentially be required to be reported under 
                utilization review provisions of plans.
                    (B) Ensuring accountability for claims submitted 
                electronically.--In establishing such standards, the 
                Secretary, in consultation with appropriate agencies, 
                shall include such methods of ensuring provider 
                responsibility and accountability for claims submitted 
                electronically that are designed to control fraud and 
                abuse in the submission of such claims.
                    (C) Components.--In establishing such standards the 
                Secretary shall--
                            (i) with respect to data elements, define 
                        data fields, formats, and medical nomenclature, 
                        and plan benefit and insurance information; and
                            (ii) develop a single, uniform coding 
                        system for diagnostic and procedure codes.
            (3) Use of task forces.--In adopting standards under this 
        subsection, the Secretary shall take into account the 
        recommendations of current task forces, including at least the 
        Workgroup on Electronic Data Interchange, National Uniform 
        Billing Committee, the Uniform Claim Task Force, and the 
        Computer-based Patient Record Institute.
            (4) Uniform, unique provider identification codes.--In 
        establishing standards under this subsection--
                    (A) the Secretary shall provide for a unique 
                identifier code for each health service provider that 
                furnishes services for which a claim may be submitted 
                under a health benefit plan, and
                    (B) in the case of a provider that has a unique 
                identifier issued for purposes of the medicare program, 
                the code provided under subparagraph (A) shall be the 
                same as such unique identifier.
            (5) Deadline.--The Secretary shall first provide for the 
        standards for the uniform claims under this subsection by not 
        later than 1 year after the date of the enactment of this Act.
    (d) Use Under Medicare and Medicaid Programs.--
            (1) Requirement for providers.--In the case of a health 
        service provider that submits a claim for services furnished 
        under the medicare program or medicaid program in violation of 
        subsection (a)(1), no payment shall be made under such program 
        for such services.
            (2) Requirements of intermediaries and carriers under 
        medicare program.--The Secretary shall provide, in regulations 
        promulgated to carry out title XVIII of the Social Security 
        Act, that the claims process provided under that title is 
        modified to the extent required to conform to the standards 
        established under subsection (c).
            (3) Requirements of state medicaid plans.--As a condition 
        for the approval of State plans under the medicaid program, 
        effective as of the effective date specified in subsection 
        (a)(3), each such plan shall provide, in accordance with 
        regulations of the Secretary, that the claims process provided 
        under the plan is modified to the extent required to conform to 
        the standards established under subsection (c).
    (e) Definitions.--
            (1) Health benefit plan.--In this section:
                    (A) In general.--The term ``health benefit plan'' 
                means, except as provided in subparagraphs (B) through 
                (D), any public or private entity or program that 
                provides for payments for health care services, 
                including--
                            (i) a group health plan (as defined in 
                        section 5000(b)(1) of the Internal Revenue Code 
                        of 1986), and
                            (ii) any other health insurance 
                        arrangement, including any arrangement 
                        consisting of a hospital or medical expense 
                        incurred policy or certificate, hospital or 
                        medical service plan contract, or health 
                        maintenance organization subscriber contract.
                    (B) Plans excluded.--Such term does not include--
                            (i) accident-only, credit, or disability 
                        income insurance;
                            (ii) coverage issued as a supplement to 
                        liability insurance;
                            (iii) an individual making payment on the 
                        individual's own behalf (or on behalf of a 
                        relative or other individual) for deductibles, 
                        coinsurance, or services not covered under a 
                        health benefit plan; and
                            (iv) such other plans as the Secretary may 
                        determine, because of the limitation of 
                        benefits to a single type or kind of health 
                        care, such as dental services, or other reasons 
                        should not be subject to the requirements of 
                        this section.
                    (C) Plans included.--Such term includes--
                            (i) worker's compensation or similar 
                        insurance, and
                            (ii) automobile medical-payment insurance.
                    (D) Treatment of direct federal provision of 
                services.--Such term does not include a Federal program 
                that provides directly for the provision of health 
                services to beneficiaries.
            (2) Health service provider.--In this section, the term 
        ``health service provider'' includes a provider of services (as 
        defined in section 1861(u) of the Social Security Act), 
        physician, supplier, and other person furnishing health care 
        services.
            (3) Secretary.--In this section, the term ``Secretary'' 
        means the secretary of health and human services.

SEC. 302. QUARTERLY PUBLICATION OF ADVERSE ACTIONS TAKEN.

    (a) In General.--Part A of title XI of the Social Security Act (42 
U.S.C. 1301 et seq.) is amended by adding at the end the following new 
section:

            ``quarterly publication of adverse actions taken

    ``Sec. 1144. Not later than 30 days after the end of each calendar 
quarter, the Secretary shall publish in the Federal Register a listing 
of all final adverse actions taken during the quarter under this part 
(including penalties imposed under section 1107, exclusions under 
section 1128, the imposition of civil monetary penalties under section 
1128A, and the imposition of criminal penalties under section 1128B) 
and under section 1156.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to calendar quarters beginning on or after January 1, 1995.

SEC. 303. STUDY OF ELECTRONIC REPORTING OF OWNERSHIP INFORMATION.

    (a) Study.--The Secretary of Health and Human Services shall 
conduct a study on the feasibility and desirability of establishing a 
method by which the information required to be reported under the all-
payer anti-fraud program established under section 101 on the ownership 
of entities providing health care services may be reported 
electronically.
    (b) Report.--Not later than 1 year after the date of the enactment 
of this Act, the Secretary shall submit a report on the study conducted 
under subsection (a) to the Committee on Ways and Means and the 
Committee on Energy and Commerce of the House of Representatives and 
the Committee on Finance of the Senate.

                                 <all>

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