II 

111TH CONGRESS 

2D SESSION S. 2964 

To amend titles XVIII, XIX, and XXI of the Social Security Act to prevent 

fraud, waste, and abuse under Medicare, Medicaid, and CHIP, and 

for other purposes. 

IN THE SENATE OF THE UNITED STATES 

JANUARY 28, 2010 

Mr. GRASSLEY introduced the following bill; which was read twice and referred 

to the Committee on Finance 

A BILL 

To amend titles XVIII, XIX, and XXI of the Social Security 

Act to prevent fraud, waste, and abuse under Medicare, 

Medicaid, and CHIP, and for other purposes. 

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

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

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

5 ‘‘Strengthening Program Integrity and Accountability in 

6 Health Care Act’’. 

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

8 this title is as follows: 

Sec. 1. Short title; table of contents. 


tjames on DSKG8SOYB1PROD with BILLS
2 

•S 2964 IS

TITLE I—MEDICARE, MEDICAID, AND CHIP 

Sec. 101. Provider screening and other enrollment requirements under Medicare, Medicaid, and CHIP. 

Sec. 102. Enhanced Medicare and Medicaid program integrity provisions. 

Sec. 103. Elimination of duplication between the Healthcare Integrity and Protection Data Bank and the National Practitioner Data Bank. 

Sec. 104. Maximum period for submission of Medicare claims reduced to not 

more than 12 months. 

Sec. 105. Physicians who order items or services required to be Medicare enrolled physicians or eligible professionals. 

Sec. 106. Requirement for physicians to provide documentation on referrals to 

programs at high risk of waste and abuse. 

Sec. 107. Face to face encounter with patient required before physicians may 

certify eligibility for home health services or durable medical 

equipment under Medicare. 

Sec. 108. Enhanced penalties. 

Sec. 109. Medicare self-referral disclosure protocol. 

Sec. 110. Expansion of the Recovery Audit Contractor (RAC) program. 

Sec. 111. Requirements for the transmission of management implication reports 

by the HHS OIG. 

Sec. 112. Medical ID theft information sharing program and clearinghouse. 

TITLE II—ADDITIONAL MEDICAID PROVISIONS 

Sec. 201. Termination of provider participation under Medicaid if terminated 

under Medicare or other State plan. 

Sec. 202. Medicaid exclusion from participation relating to certain ownership, 

control, and management affiliations. 

Sec. 203. Billing agents, clearinghouses, or other alternate payees required to 

register under Medicaid. 

Sec. 204. Requirement to report expanded set of data elements under MMIS 

to detect fraud and abuse. 

Sec. 205. Prohibition on payments to institutions or entities located outside of 

the United States. 

Sec. 206. Overpayments. 

Sec. 207. Mandatory State use of national correct coding initiative. 

Sec. 208. Payment for illegal unapproved drugs. 

Sec. 209. General effective date. 

TITLE III—ADDITIONAL PROVISIONS 

Sec. 301. Requiring individuals or entities that participate in or conduct activities under Federal health care programs to comply with certain 

Congressional requests. 

Sec. 302. Amendments to the False Claims Act. 

Sec. 303. Dismissal of certain actions or claims under the False Claims Act. 


tjames on DSKG8SOYB1PROD with BILLS
3 

•S 2964 IS

1 TITLE I—MEDICARE, MEDICAID, 

2 AND CHIP 

3 SEC. 101. PROVIDER SCREENING AND OTHER ENROLLMENT 

4 REQUIREMENTS UNDER MEDICARE, MED5 ICAID, AND CHIP. 

6 (a) MEDICARE.—Section 1866(j) of the Social Secu7 rity Act (42 U.S.C. 1395cc(j)) is amended— 

8 (1) in paragraph (1)(A), by adding at the end 

9 the following: ‘‘Such process shall include screening 

10 of providers and suppliers in accordance with para11 graph (2), a provisional period of enhanced oversight 

12 in accordance with paragraph (3), disclosure require13 ments in accordance with paragraph (4), the imposi14 tion of temporary enrollment moratoria in accord15 ance with paragraph (5), and the establishment of 

16 compliance programs in accordance with paragraph 

17 (6).’’; 

18 (2) by redesignating paragraph (2) as para19 graph (7); and 

20 (3) by inserting after paragraph (1) the fol21 lowing: 

22 ‘‘(2) PROVIDER SCREENING.— 

23 ‘‘(A) PROCEDURES.—Not later than 180 

24 days after the date of enactment of this para25 graph, the Secretary, in consultation with the 


tjames on DSKG8SOYB1PROD with BILLS
4 

•S 2964 IS

1 Inspector General of the Department of Health 

2 and Human Services, shall establish procedures 

3 under which screening is conducted with respect 

4 to providers of medical or other items or serv5 ices and suppliers under the program under this 

6 title, the Medicaid program under title XIX, 

7 and the CHIP program under title XXI. 

8 ‘‘(B) LEVEL OF SCREENING.—The Sec9 retary shall determine the level of screening 

10 conducted under this paragraph according to 

11 the risk of fraud, waste, and abuse, as deter12 mined by the Secretary, with respect to the cat13 egory of provider of medical or other items or 

14 services or supplier. Such screening— 

15 ‘‘(i) shall include a licensure check, 

16 which may include such checks across 

17 States; and 

18 ‘‘(ii) may, as the Secretary determines 

19 appropriate based on the risk of fraud, 

20 waste, and abuse described in the pre21 ceding sentence, include— 

22 ‘‘(I) a criminal background 

23 check; 

24 ‘‘(II) fingerprinting; 


tjames on DSKG8SOYB1PROD with BILLS
5 

•S 2964 IS

1 ‘‘(III) unscheduled and unan2 nounced site visits, including 

3 preenrollment site visits; 

4 ‘‘(IV) database checks (including 

5 such checks across States); and 

6 ‘‘(V) such other screening as the 

7 Secretary determines appropriate. 

8 ‘‘(C) APPLICATION FEES.— 

9 ‘‘(i) INSTITUTIONAL PROVIDERS.—Ex10 cept as provided in clause (ii), the Sec11 retary shall impose a fee on each institu12 tional provider of medical or other items or 

13 services or supplier (such as a hospital or 

14 skilled nursing facility) with respect to 

15 which screening is conducted under this 

16 paragraph in an amount equal to— 

17 ‘‘(I) for 2011, $500; and 

18 ‘‘(II) for 2012 and each subse19 quent year, the amount determined 

20 under this clause for the preceding 

21 year, adjusted by the percentage 

22 change in the consumer price index 

23 for all urban consumers (all items; 

24 United States city average) for the 


tjames on DSKG8SOYB1PROD with BILLS
6 

•S 2964 IS

1 12-month period ending with June of 

2 the previous year. 

3 ‘‘(ii) HARDSHIP EXCEPTION; WAIVER

4 FOR CERTAIN MEDICAID PROVIDERS.—The 

5 Secretary may, on a case-by-case basis, ex6 empt a provider of medical or other items 

7 or services or supplier from the imposition 

8 of an application fee under this subpara9 graph if the Secretary determines that the 

10 imposition of the application fee would re11 sult in a hardship. The Secretary may 

12 waive the application fee under this sub13 paragraph for providers enrolled in a State 

14 Medicaid program for whom the State 

15 demonstrates that imposition of the fee 

16 would impede beneficiary access to care. 

17 ‘‘(iii) USE OF FUNDS.—Amounts col18 lected as a result of the imposition of a fee 

19 under this subparagraph shall be used by 

20 the Secretary for program integrity efforts, 

21 including to cover the costs of conducting 

22 screening under this paragraph and to 

23 carry out this subsection and section 

24 1128J. 

25 ‘‘(D) APPLICATION AND ENFORCEMENT.— 


tjames on DSKG8SOYB1PROD with BILLS
7 

•S 2964 IS

1 ‘‘(i) NEW PROVIDERS OF SERVICES

2 AND SUPPLIERS.—The screening under 

3 this paragraph shall apply, in the case of 

4 a provider of medical or other items or 

5 services or supplier who is not enrolled in 

6 the program under this title, title XIX, or 

7 title XXI as of the date of enactment of 

8 this paragraph, on or after the date that is 

9 1 year after such date of enactment. 

10 ‘‘(ii) CURRENT PROVIDERS OF SERV11 ICES AND SUPPLIERS.—The screening 

12 under this paragraph shall apply, in the 

13 case of a provider of medical or other 

14 items or services or supplier who is en15 rolled in the program under this title, title 

16 XIX, or title XXI as of such date of enact17 ment, on or after the date that is 2 years 

18 after such date of enactment. 

19 ‘‘(iii) REVALIDATION OF ENROLL20 MENT.—Effective beginning on the date 

21 that is 180 days after such date of enact22 ment, the screening under this paragraph 

23 shall apply with respect to the revalidation 

24 of enrollment of a provider of medical or 

25 other items or services or supplier in the 


tjames on DSKG8SOYB1PROD with BILLS
8 

•S 2964 IS

1 program under this title, title XIX, or title 

2 XXI. 

3 ‘‘(iv) LIMITATION ON ENROLLMENT

4 AND REVALIDATION OF ENROLLMENT.—In 

5 no case may a provider of medical or other 

6 items or services or supplier who has not 

7 been screened under this paragraph be ini8 tially enrolled or reenrolled in the program 

9 under this title, title XIX, or title XXI on 

10 or after the date that is 3 years after such 

11 date of enactment. 

12 ‘‘(E) EXPEDITED RULEMAKING.—The Sec13 retary may promulgate an interim final rule to 

14 carry out this paragraph. 

15 ‘‘(3) PROVISIONAL PERIOD OF ENHANCED

16 OVERSIGHT FOR NEW PROVIDERS OF SERVICES AND

17 SUPPLIERS.— 

18 ‘‘(A) IN GENERAL.—The Secretary shall 

19 establish procedures to provide for a provisional 

20 period of not less than 30 days and not more 

21 than 1 year during which new providers of med22 ical or other items or services and suppliers, as 

23 the Secretary determines appropriate, including 

24 categories of providers or suppliers, would be 

25 subject to enhanced oversight, such as prepayVerDate Nov 24 2008 02:01 Jan 29, 2010 Jkt 089200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\S2964.IS S2964

tjames on DSKG8SOYB1PROD with BILLS
9 

•S 2964 IS

1 ment review and payment caps, under the pro2 gram under this title, the Medicaid program 

3 under title XIX, and the CHIP program under 

4 title XXI. 

5 ‘‘(B) IMPLEMENTATION.—The Secretary 

6 may establish by program instruction or other7 wise the procedures under this paragraph. 

8 ‘‘(4) INCREASED DISCLOSURE REQUIRE9 MENTS.— 

10 ‘‘(A) DISCLOSURE.—A provider of medical 

11 or other items or services or supplier who sub12 mits an application for enrollment or revalida13 tion of enrollment in the program under this 

14 title, title XIX, or title XXI on or after the date 

15 that is 1 year after the date of enactment of 

16 this paragraph shall disclose (in a form and 

17 manner and at such time as determined by the 

18 Secretary) any current or previous affiliation 

19 (directly or indirectly) with a provider of med20 ical or other items or services or supplier that 

21 has uncollected debt, has been or is subject to 

22 a payment suspension under a Federal health 

23 care program (as defined in section 1128B(f)), 

24 has been excluded from participation under the 

25 program under this title, the Medicaid program 


tjames on DSKG8SOYB1PROD with BILLS
10 

•S 2964 IS

1 under title XIX, or the CHIP program under 

2 title XXI, or has had its billing privileges de3 nied or revoked. 

4 ‘‘(B) AUTHORITY TO DENY ENROLL5 MENT.—If the Secretary determines that such 

6 previous affiliation poses an undue risk of 

7 fraud, waste, or abuse, the Secretary may deny 

8 such application. Such a denial shall be subject 

9 to appeal in accordance with paragraph (7). 

10 ‘‘(5) AUTHORITY TO ADJUST PAYMENTS OF

11 PROVIDERS OF SERVICES AND SUPPLIERS WITH THE

12 SAME TAX IDENTIFICATION NUMBER FOR PAST-DUE

13 OBLIGATIONS.— 

14 ‘‘(A) IN GENERAL.—Notwithstanding any 

15 other provision of this title, in the case of an 

16 applicable provider of services or supplier, the 

17 Secretary may make any necessary adjustments 

18 to payments to the applicable provider of serv19 ices or supplier under the program under this 

20 title in order to satisfy any past-due obligations 

21 described in subparagraph (B)(ii) of an obli22 gated provider of services or supplier. 

23 ‘‘(B) DEFINITIONS.—In this paragraph: 

24 ‘‘(i) IN GENERAL.—The term ‘applica25 ble provider of services or supplier’ means 


tjames on DSKG8SOYB1PROD with BILLS
11 

•S 2964 IS

1 a provider of services or supplier that has 

2 the same taxpayer identification number 

3 assigned under section 6109 of the Inter4 nal Revenue Code of 1986 as is assigned 

5 to the obligated provider of services or sup6 plier under such section, regardless of 

7 whether the applicable provider of services 

8 or supplier is assigned a different billing 

9 number or national provider identification 

10 number under the program under this title 

11 than is assigned to the obligated provider 

12 of services or supplier. 

13 ‘‘(ii) OBLIGATED PROVIDER OF SERV14 ICES OR SUPPLIER.—The term ‘obligated 

15 provider of services or supplier’ means a 

16 provider of services or supplier that owes a 

17 past-due obligation under the program 

18 under this title (as determined by the Sec19 retary). 

20 ‘‘(6) TEMPORARY MORATORIUM ON ENROLL21 MENT OF NEW PROVIDERS.— 

22 ‘‘(A) IN GENERAL.—The Secretary may 

23 impose a temporary moratorium on the enroll24 ment of new providers of services and suppliers, 

25 including categories of providers of services and 


tjames on DSKG8SOYB1PROD with BILLS
12 

•S 2964 IS

1 suppliers, in the program under this title, under 

2 the Medicaid program under title XIX, or 

3 under the CHIP program under title XXI if the 

4 Secretary determines such moratorium is nec5 essary to prevent or combat fraud, waste, or 

6 abuse under either such program. 

7 ‘‘(B) LIMITATION ON REVIEW.—There 

8 shall be no judicial review under section 1869, 

9 section 1878, or otherwise, of a temporary mor10 atorium imposed under subparagraph (A). 

11 ‘‘(7) COMPLIANCE PROGRAMS.— 

12 ‘‘(A) IN GENERAL.—On or after the date 

13 of implementation determined by the Secretary 

14 under subparagraph (C), a provider of medical 

15 or other items or services or supplier within a 

16 particular industry sector or category shall, as 

17 a condition of enrollment in the program under 

18 this title, title XIX, or title XXI, establish a 

19 compliance program that contains the core ele20 ments established under subparagraph (B) with 

21 respect to that provider or supplier and indus22 try or category. 

23 ‘‘(B) ESTABLISHMENT OF CORE ELE24 MENTS.—The Secretary, in consultation with 

25 the Inspector General of the Department of 


tjames on DSKG8SOYB1PROD with BILLS
13 

•S 2964 IS

1 Health and Human Services, shall establish 

2 core elements for a compliance program under 

3 subparagraph (A) for providers or suppliers 

4 within a particular industry or category. 

5 ‘‘(C) TIMELINE FOR IMPLEMENTATION.— 

6 The Secretary shall determine the timeline for 

7 the establishment of the core elements under 

8 subparagraph (B) and the date of the imple9 mentation of subparagraph (A) for providers or 

10 suppliers within a particular industry or cat11 egory. The Secretary shall, in determining such 

12 date of implementation, consider the extent to 

13 which the adoption of compliance programs by 

14 a provider of medical or other items or services 

15 or supplier is widespread in a particular indus16 try sector or with respect to a particular pro17 vider or supplier category.’’. 

18 (b) MEDICAID.— 

19 (1) STATE PLAN AMENDMENT.—Section 

20 1902(a) of the Social Security Act (42 U.S.C. 

21 1396a(a)) is amended— 

22 (A) in subsection (a)— 

23 (i) by striking ‘‘and’’ at the end of 

24 paragraph (72); 


tjames on DSKG8SOYB1PROD with BILLS
14 

•S 2964 IS

1 (ii) by striking the period at the end 

2 of paragraph (73) and inserting a semi3 colon; and 

4 (iii) by inserting after paragraph (73) 

5 the following: 

6 ‘‘(74) provide that the State shall comply with 

7 provider and supplier screening, oversight, and re8 porting requirements in accordance with subsection 

9 (ii);’’; and 

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

11 ‘‘(ii) PROVIDER AND SUPPLIER SCREENING, OVER12 SIGHT, AND REPORTING REQUIREMENTS.—For purposes 

13 of subsection (a)(74), the requirements of this subsection 

14 are the following: 

15 ‘‘(1) SCREENING.—The State complies with the 

16 process for screening providers and suppliers under 

17 this title, as established by the Secretary under sec18 tion 1886(j)(2). 

19 ‘‘(2) PROVISIONAL PERIOD OF ENHANCED

20 OVERSIGHT FOR NEW PROVIDERS AND SUPPLIERS.— 

21 The State complies with procedures to provide for a 

22 provisional period of enhanced oversight for new pro23 viders and suppliers under this title, as established 

24 by the Secretary under section 1886(j)(3). 


tjames on DSKG8SOYB1PROD with BILLS
15 

•S 2964 IS

1 ‘‘(3) DISCLOSURE REQUIREMENTS.—The State 

2 requires providers and suppliers under the State 

3 plan or under a waiver of the plan to comply with 

4 the disclosure requirements established by the Sec5 retary under section 1886(j)(4). 

6 ‘‘(4) TEMPORARY MORATORIUM ON ENROLL7 MENT OF NEW PROVIDERS OR SUPPLIERS.— 

8 ‘‘(A) TEMPORARY MORATORIUM IMPOSED

9 BY THE SECRETARY.— 

10 ‘‘(i) IN GENERAL.—Subject to clause 

11 (ii), the State complies with any temporary 

12 moratorium on the enrollment of new pro13 viders or suppliers imposed by the Sec14 retary under section 1886(j)(6). 

15 ‘‘(ii) EXCEPTION.—A State shall not 

16 be required to comply with a temporary 

17 moratorium described in clause (i) if the 

18 State determines that the imposition of 

19 such temporary moratorium would ad20 versely impact beneficiaries’ access to med21 ical assistance. 

22 ‘‘(B) MORATORIUM ON ENROLLMENT OF

23 PROVIDERS AND SUPPLIERS.—At the option of 

24 the State, the State imposes, for purposes of 

25 entering into participation agreements with proVerDate Nov 24 2008 02:01 Jan 29, 2010 Jkt 089200 PO 00000 Frm 00015 Fmt 6652 Sfmt 6201 E:\BILLS\S2964.IS S2964

tjames on DSKG8SOYB1PROD with BILLS
16 

•S 2964 IS

1 viders or suppliers under the State plan or 

2 under a waiver of the plan, periods of enroll3 ment moratoria, or numerical caps or other lim4 its, for providers or suppliers identified by the 

5 Secretary as being at high-risk for fraud, waste, 

6 or abuse as necessary to combat fraud, waste, 

7 or abuse, but only if the State determines that 

8 the imposition of any such period, cap, or other 

9 limits would not adversely impact beneficiaries’ 

10 access to medical assistance. 

11 ‘‘(5) COMPLIANCE PROGRAMS.—The State re12 quires providers and suppliers under the State plan 

13 or under a waiver of the plan to establish, in accord14 ance with the requirements of section 1866(j)(7), a 

15 compliance program that contains the core elements 

16 established under subparagraph (B) of that section 

17 1866(j)(7) for providers or suppliers within a par18 ticular industry or category. 

19 ‘‘(6) REPORTING OF ADVERSE PROVIDER AC20 TIONS.—The State complies with the national sys21 tem for reporting criminal and civil convictions, 

22 sanctions, negative licensure actions, and other ad23 verse provider actions to the Secretary, through the 

24 Administrator of the Centers for Medicare & MedVerDate Nov 24 2008 02:01 Jan 29, 2010 Jkt 089200 PO 00000 Frm 00016 Fmt 6652 Sfmt 6201 E:\BILLS\S2964.IS S2964

tjames on DSKG8SOYB1PROD with BILLS
17 

•S 2964 IS

1 icaid Services, in accordance with regulations of the 

2 Secretary. 

3 ‘‘(7) ENROLLMENT AND NPI OF ORDERING OR

4 REFERRING PROVIDERS.—The State requires— 

5 ‘‘(A) all ordering or referring physicians or 

6 other professionals to be enrolled under the 

7 State plan or under a waiver of the plan as a 

8 participating provider; and 

9 ‘‘(B) the national provider identifier of any 

10 ordering or referring physician or other profes11 sional to be specified on any claim for payment 

12 that is based on an order or referral of the phy13 sician or other professional. 

14 ‘‘(8) OTHER STATE OVERSIGHT.—Nothing in 

15 this subsection shall be interpreted to preclude or 

16 limit the ability of a State to engage in provider and 

17 supplier screening or enhanced provider and supplier 

18 oversight activities beyond those required by the Sec19 retary.’’. 

20 (2) DISCLOSURE OF MEDICARE TERMINATED

21 PROVIDERS AND SUPPLIERS TO STATES.—The Ad22 ministrator of the Centers for Medicare & Medicaid 

23 Services shall establish a process for making avail24 able to the each State agency with responsibility for 

25 administering a State Medicaid plan (or a waiver of 


tjames on DSKG8SOYB1PROD with BILLS
18 

•S 2964 IS

1 such plan) under title XIX of the Social Security 

2 Act or a child health plan under title XXI the name, 

3 national provider identifier, and other identifying in4 formation for any provider of medical or other items 

5 or services or supplier under the Medicare program 

6 under title XVIII or under the CHIP program under 

7 title XXI that is terminated from participation 

8 under that program within 30 days of the termi9 nation (and, with respect to all such providers or 

10 suppliers who are terminated from the Medicare pro11 gram on the date of enactment of this Act, within 

12 90 days of such date). 

13 (3) CONFORMING AMENDMENT.—Section 

14 1902(a)(23) of the Social Security Act (42 U.S.C. 

15 1396a), is amended by inserting before the semi16 colon at the end the following: ‘‘or by a provider or 

17 supplier to which a moratorium under subsection 

18 (ii)(4) is applied during the period of such morato19 rium’’. 

20 (c) CHIP.—Section 2107(e)(1) of the Social Security 

21 Act (42 U.S.C. 1397gg(e)(1)) is amended— 

22 (1) by redesignating subparagraphs (D) 

23 through (L) as subparagraphs (E) through (M), re24 spectively; and 


tjames on DSKG8SOYB1PROD with BILLS
19 

•S 2964 IS

1 (2) by inserting after subparagraph (C), the fol2 lowing: 

3 ‘‘(D) Subsections (a)(74) and (ii) of sec4 tion 1902 (relating to provider and supplier 

5 screening, oversight, and reporting require6 ments).’’. 

7 SEC. 102. ENHANCED MEDICARE AND MEDICAID PROGRAM 

8 INTEGRITY PROVISIONS. 

9 (a) IN GENERAL.—Part A of title XI of the Social 

10 Security Act (42 U.S.C. 1301 et seq.) is amended by in11 serting after section 1128F the following new section: 

12 ‘‘SEC. 1128G. MEDICARE AND MEDICAID PROGRAM INTEG13 RITY PROVISIONS. 

14 ‘‘(a) DATA MATCHING.— 

15 ‘‘(1) INTEGRATED DATA REPOSITORY.— 

16 ‘‘(A) INCLUSION OF CERTAIN DATA.— 

17 ‘‘(i) IN GENERAL.—The Integrated 

18 Data Repository of the Centers for Medi19 care & Medicaid Services shall include, at 

20 a minimum, claims and payment data from 

21 the following: 

22 ‘‘(I) The programs under titles 

23 XVIII and XIX (including parts A, B, 

24 C, and D of title XVIII). 


tjames on DSKG8SOYB1PROD with BILLS
20 

•S 2964 IS

1 ‘‘(II) The program under title 

2 XXI. 

3 ‘‘(III) Health-related programs 

4 administered by the Secretary of Vet5 erans Affairs. 

6 ‘‘(IV) Health-related programs 

7 administered by the Secretary of De8 fense. 

9 ‘‘(V) The program of old-age, 

10 survivors, and disability insurance 

11 benefits established under title II. 

12 ‘‘(VI) The Indian Health Service 

13 and the Contract Health Service pro14 gram. 

15 ‘‘(ii) PRIORITY FOR INCLUSION OF

16 CERTAIN DATA.—Inclusion of the data de17 scribed in subclause (I) of such clause in 

18 the Integrated Data Repository shall be a 

19 priority. Data described in subclauses (II) 

20 through (VI) of such clause shall be in21 cluded in the Integrated Data Repository 

22 as appropriate. 

23 ‘‘(B) DATA SHARING AND MATCHING.— 

24 ‘‘(i) IN GENERAL.—The Secretary 

25 shall enter into agreements with the indiVerDate Nov 24 2008 02:01 Jan 29, 2010 Jkt 089200 PO 00000 Frm 00020 Fmt 6652 Sfmt 6201 E:\BILLS\S2964.IS S2964

tjames on DSKG8SOYB1PROD with BILLS
21 

•S 2964 IS

1 viduals described in clause (ii) under which 

2 such individuals share and match data in 

3 the system of records of the respective 

4 agencies of such individuals with data in 

5 the system of records of the Department of 

6 Health and Human Services for the pur7 pose of identifying potential fraud, waste, 

8 and abuse under the programs under titles 

9 XVIII and XIX. 

10 ‘‘(ii) INDIVIDUALS DESCRIBED.—The 

11 following individuals are described in this 

12 clause: 

13 ‘‘(I) The Commissioner of Social 

14 Security. 

15 ‘‘(II) The Secretary of Veterans 

16 Affairs. 

17 ‘‘(III) The Secretary of Defense. 

18 ‘‘(IV) The Director of the Indian 

19 Health Service. 

20 ‘‘(iii) DEFINITION OF SYSTEM OF

21 RECORDS.—For purposes of this para22 graph, the term ‘system of records’ has the 

23 meaning given such term in section 

24 552a(a)(5) of title 5, United States Code. 


tjames on DSKG8SOYB1PROD with BILLS
22 

•S 2964 IS

1 ‘‘(2) ACCESS TO CLAIMS AND PAYMENT DATA2 BASES.—For purposes of conducting law enforce3 ment and oversight activities and to the extent con4 sistent with applicable information, privacy, security, 

5 and disclosure laws, including the regulations pro6 mulgated under the Health Insurance Portability 

7 and Accountability Act of 1996 and section 552a of 

8 title 5, United States Code, and subject to any infor9 mation systems security requirements under such 

10 laws or otherwise required by the Secretary, the In11 spector General of the Department of Health and 

12 Human Services and the Attorney General shall 

13 have access to claims and payment data of the De14 partment of Health and Human Services and its 

15 contractors related to titles XVIII, XIX, and XXI. 

16 ‘‘(b) OIG AUTHORITY TO OBTAIN INFORMATION.— 

17 ‘‘(1) IN GENERAL.—Notwithstanding and in ad18 dition to any other provision of law, the Inspector 

19 General of the Department of Health and Human 

20 Services may, for purposes of protecting the integ21 rity of the programs under titles XVIII and XIX, 

22 obtain information from any individual (including a 

23 beneficiary provided all applicable privacy protec24 tions are followed) or entity that— 


tjames on DSKG8SOYB1PROD with BILLS
23 

•S 2964 IS

1 ‘‘(A) is a provider of medical or other 

2 items or services, supplier, grant recipient, con3 tractor, or subcontractor; or 

4 ‘‘(B) directly or indirectly provides, orders, 

5 manufactures, distributes, arranges for, pre6 scribes, supplies, or receives medical or other 

7 items or services payable by any Federal health 

8 care program (as defined in section 1128B(f)) 

9 regardless of how the item or service is paid 

10 for, or to whom such payment is made. 

11 ‘‘(2) INCLUSION OF CERTAIN INFORMATION.— 

12 Information which the Inspector General may obtain 

13 under paragraph (1) includes any supporting docu14 mentation necessary to validate claims for payment 

15 or payments under title XVIII or XIX, including a 

16 prescribing physician’s medical records for an indi17 vidual who is prescribed an item or service which is 

18 covered under part B of title XVIII, a covered part 

19 D drug (as defined in section 1860D–2(e)) for which 

20 payment is made under an MA–PD plan under part 

21 C of such title, or a prescription drug plan under 

22 part D of such title, and any records necessary for 

23 evaluation of the economy, efficiency, and effective24 ness of the programs under titles XVIII and XIX. 


tjames on DSKG8SOYB1PROD with BILLS
24 

•S 2964 IS

1 ‘‘(c) ADMINISTRATIVE REMEDY FOR KNOWING PAR2 TICIPATION BY BENEFICIARY IN HEALTH CARE FRAUD

3 SCHEME.— 

4 ‘‘(1) IN GENERAL.—In addition to any other 

5 applicable remedies, if an applicable individual has 

6 knowingly participated in a Federal health care 

7 fraud offense or a conspiracy to commit a Federal 

8 health care fraud offense, the Secretary shall impose 

9 an appropriate administrative penalty commensurate 

10 with the offense or conspiracy. 

11 ‘‘(2) APPLICABLE INDIVIDUAL.—For purposes 

12 of paragraph (1), the term ‘applicable individual’ 

13 means an individual— 

14 ‘‘(A) entitled to, or enrolled for, benefits 

15 under part A of title XVIII or enrolled under 

16 part B of such title; 

17 ‘‘(B) eligible for medical assistance under 

18 a State plan under title XIX or under a waiver 

19 of such plan; or 

20 ‘‘(C) eligible for child health assistance 

21 under a child health plan under title XXI. 

22 ‘‘(d) REPORTING AND RETURNING OF OVERPAY23 MENTS.— 

24 ‘‘(1) IN GENERAL.—If a person has received an 

25 overpayment, the person shall— 


tjames on DSKG8SOYB1PROD with BILLS
25 

•S 2964 IS

1 ‘‘(A) report and return the overpayment to 

2 the Secretary, the State, an intermediary, a 

3 carrier, or a contractor, as appropriate, at the 

4 correct address; and 

5 ‘‘(B) notify the Secretary, State, inter6 mediary, carrier, or contractor to whom the 

7 overpayment was returned in writing of the rea8 son for the overpayment. 

9 ‘‘(2) DEADLINE FOR REPORTING AND RETURN10 ING OVERPAYMENTS.—An overpayment must be re11 ported and returned under paragraph (1) by the 

12 later of— 

13 ‘‘(A) the date which is 60 days after the 

14 date on which the overpayment was identified; 

15 or 

16 ‘‘(B) the date any corresponding cost re17 port is due, if applicable. 

18 ‘‘(3) ENFORCEMENT.—Any overpayment re19 tained by a person after the deadline for reporting 

20 and returning the overpayment under paragraph (2) 

21 is an obligation (as defined in section 3729(b)(3) of 

22 title 31, United States Code) for purposes of section 

23 3729 of such title. 

24 ‘‘(4) DEFINITIONS.—In this subsection: 


tjames on DSKG8SOYB1PROD with BILLS
26 

•S 2964 IS

1 ‘‘(A) KNOWING AND KNOWINGLY.—The 

2 terms ‘knowing’ and ‘knowingly’ have the mean3 ing given those terms in section 3729(b) of title 

4 31, United States Code. 

5 ‘‘(B) OVERPAYMENT.—The term ‘overpay6 ment’ means any funds that a person receives 

7 or retains under title XVIII or XIX to which 

8 the person, after applicable reconciliation, is not 

9 entitled under such title. 

10 ‘‘(C) PERSON.— 

11 ‘‘(i) IN GENERAL.—The term ‘person’ 

12 means a provider of services, supplier, 

13 Medicaid managed care organization (as 

14 defined in section 1903(m)(1)(A)), Medi15 care Advantage organization (as defined in 

16 section 1859(a)(1)), or PDP sponsor (as 

17 defined in section 1860D–41(a)(13)). 

18 ‘‘(ii) EXCLUSION.—Such term does 

19 not include a beneficiary. 

20 ‘‘(e) INCLUSION OF NATIONAL PROVIDER IDENTI21 FIER ON ALL APPLICATIONS AND CLAIMS.—The Sec22 retary shall promulgate a regulation that requires, not 

23 later than January 1, 2011, all providers of medical or 

24 other items or services and suppliers under the programs 

25 under titles XVIII and XIX that qualify for a national 


tjames on DSKG8SOYB1PROD with BILLS
27 

•S 2964 IS

1 provider identifier to include their national provider identi2 fier on all applications to enroll in such programs and on 

3 all claims for payment submitted under such programs.’’. 

4 (b) ACCESS TO DATA.— 

5 (1) MEDICARE PART D.—Section 1860D– 

6 15(f)(2) of the Social Security Act (42 U.S.C. 

7 1395w–116(f)(2)) is amended by striking ‘‘may be 

8 used by’’ and all that follows through the period at 

9 the end and inserting ‘‘may be used— 

10 ‘‘(A) by officers, employees, and contrac11 tors of the Department of Health and Human 

12 Services for the purposes of, and to the extent 

13 necessary in— 

14 ‘‘(i) carrying out this section; and 

15 ‘‘(ii) conducting oversight, evaluation, 

16 and enforcement under this title; and 

17 ‘‘(B) by the Attorney General and the 

18 Comptroller General of the United States for 

19 the purposes of, and to the extent necessary in, 

20 carrying out health oversight activities.’’. 

21 (2) DATA MATCHING.—Section 552a(a)(8)(B) 

22 of title 5, United States Code, is amended— 

23 (A) in clause (vii), by striking ‘‘or’’ at the 

24 end; 


tjames on DSKG8SOYB1PROD with BILLS
28 

•S 2964 IS

1 (B) in clause (viii), by inserting ‘‘or’’ after 

2 the semicolon; and 

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

4 clause: 

5 ‘‘(ix) matches performed by the Sec6 retary of Health and Human Services or 

7 the Inspector General of the Department 

8 of Health and Human Services with re9 spect to potential fraud, waste, and abuse, 

10 including matches of a system of records 

11 with non-Federal records;’’. 

12 (3) MATCHING AGREEMENTS WITH THE COM13 MISSIONER OF SOCIAL SECURITY.—Section 205(r) of 

14 the Social Security Act (42 U.S.C. 405(r)) is amend15 ed by adding at the end the following new para16 graph: 

17 ‘‘(9)(A) The Commissioner of Social Security 

18 shall, upon the request of the Secretary or the In19 spector General of the Department of Health and 

20 Human Services— 

21 ‘‘(i) enter into an agreement with the Sec22 retary or such Inspector General for the pur23 pose of matching data in the system of records 

24 of the Social Security Administration and the 


tjames on DSKG8SOYB1PROD with BILLS
29 

•S 2964 IS

1 system of records of the Department of Health 

2 and Human Services; and 

3 ‘‘(ii) include in such agreement safeguards 

4 to assure the maintenance of the confidentiality 

5 of any information disclosed. 

6 ‘‘(B) For purposes of this paragraph, the term 

7 ‘system of records’ has the meaning given such term 

8 in section 552a(a)(5) of title 5, United States 

9 Code.’’. 

10 (c) WITHHOLDING OF FEDERAL MATCHING PAY11 MENTS FOR STATES THAT FAIL TO REPORT ENROLLEE

12 ENCOUNTER DATA IN THE MEDICAID STATISTICAL IN13 FORMATION SYSTEM.—Section 1903(i) of the Social Secu14 rity Act (42 U.S.C. 1396b(i)) is amended— 

15 (1) in paragraph (23), by striking ‘‘or’’ at the 

16 end; 

17 (2) in paragraph (24), by striking the period at 

18 the end and inserting ‘‘; or’’; and 

19 (3) by adding at the end the following new 

20 paragraph:. 

21 ‘‘(25) with respect to any amounts expended for 

22 medical assistance for individuals for whom the 

23 State does not report enrollee encounter data (as de24 fined by the Secretary) to the Medicaid Statistical 


tjames on DSKG8SOYB1PROD with BILLS
30 

•S 2964 IS

1 Information System (MSIS) in a timely manner (as 

2 determined by the Secretary).’’. 

3 (d) PERMISSIVE EXCLUSIONS AND CIVIL MONETARY

4 PENALTIES.— 

5 (1) PERMISSIVE EXCLUSIONS.—Section 1128(b) 

6 of the Social Security Act (42 U.S.C. 1320a–7(b)) 

7 is amended— 

8 (A) by striking clauses (i) and (ii) of para9 graph (15)(A) and inserting the following: 

10 ‘‘(i) who has or had a direct or indi11 rect ownership or control interest in the 

12 sanctioned entity and who knew or should 

13 have known (as defined in section 

14 1128A(i)(7)) of the action constituting the 

15 basis for the conviction or exclusion de16 scribed in subparagraph (B); or 

17 ‘‘(ii) who is or was an officer or man18 aging employee (as defined in section 

19 1126(b)) of such an entity at the time of 

20 the action constituting the basis for the 

21 conviction or exclusion so described.’’; and 

22 (B) by adding at the end the following new 

23 paragraph: 

24 ‘‘(16) MAKING FALSE STATEMENTS OR MIS25 REPRESENTATION OF MATERIAL FACTS.—Any indiVerDate Nov 24 2008 02:01 Jan 29, 2010 Jkt 089200 PO 00000 Frm 00030 Fmt 6652 Sfmt 6201 E:\BILLS\S2964.IS S2964

tjames on DSKG8SOYB1PROD with BILLS
31 

•S 2964 IS

1 vidual or entity that knowingly makes or causes to 

2 be made any false statement, omission, or misrepre3 sentation of a material fact in any application, 

4 agreement, bid, or contract to participate or enroll 

5 as a provider of services or supplier under a Federal 

6 health care program (as defined in section 

7 1128B(f)), including Medicare Advantage organiza8 tions under part C of title XVIII, prescription drug 

9 plan sponsors under part D of title XVIII, Medicaid 

10 managed care organizations under title XIX, and en11 tities that apply to participate as providers of serv12 ices or suppliers in such managed care organizations 

13 and such plans.’’. 

14 (2) CIVIL MONETARY PENALTIES.— 

15 (A) IN GENERAL.—Section 1128A(a) of 

16 the Social Security Act (42 U.S.C. 1320a– 

17 7a(a)) is amended— 

18 (i) in paragraph (1)(D), by striking 

19 ‘‘was excluded’’ and all that follows 

20 through the period at the end and insert21 ing ‘‘was excluded from the Federal health 

22 care program (as defined in section 

23 1128B(f)) under which the claim was 

24 made pursuant to Federal law.’’; 


tjames on DSKG8SOYB1PROD with BILLS
32 

•S 2964 IS

1 (ii) in paragraph (6), by striking ‘‘or’’ 

2 at the end; 

3 (iii) by inserting after paragraph (7), 

4 the following new paragraphs: 

5 ‘‘(8) orders or prescribes a medical or other 

6 item or service during a period in which the person 

7 was excluded from a Federal health care program 

8 (as so defined), in the case where the person knows 

9 or should know that a claim for such medical or 

10 other item or service will be made under such a pro11 gram; 

12 ‘‘(9) knowingly makes or causes to be made any 

13 false statement, omission, or misrepresentation of a 

14 material fact in any application, bid, or contract to 

15 participate or enroll as a provider of services or a 

16 supplier under a Federal health care program (as so 

17 defined), including Medicare Advantage organiza18 tions under part C of title XVIII, prescription drug 

19 plan sponsors under part D of title XVIII, Medicaid 

20 managed care organizations under title XIX, and en21 tities that apply to participate as providers of serv22 ices or suppliers in such managed care organizations 

23 and such plans; 

24 ‘‘(10) knows of an overpayment (as defined in 

25 paragraph (4) of section 1128G(d)) and does not reVerDate Nov 24 2008 02:01 Jan 29, 2010 Jkt 089200 PO 00000 Frm 00032 Fmt 6652 Sfmt 6201 E:\BILLS\S2964.IS S2964

tjames on DSKG8SOYB1PROD with BILLS
33 

•S 2964 IS

1 port and return the overpayment in accordance with 

2 such section;’’; 

3 (iv) in the first sentence— 

4 (I) by striking the ‘‘or’’ after 

5 ‘‘prohibited relationship occurs;’’; and 

6 (II) by striking ‘‘act)’’ and in7 serting ‘‘act; or in cases under para8 graph (9), $50,000 for each false 

9 statement or misrepresentation of a 

10 material fact)’’; and 

11 (v) in the second sentence, by striking 

12 ‘‘purpose)’’ and inserting ‘‘purpose; or in 

13 cases under paragraph (9), an assessment 

14 of not more than 3 times the total amount 

15 claimed for each item or service for which 

16 payment was made based upon the applica17 tion containing the false statement or mis18 representation of a material fact)’’. 

19 (B) CLARIFICATION OF TREATMENT OF

20 CERTAIN CHARITABLE AND OTHER INNOCUOUS

21 PROGRAMS.—Section 1128A(i)(6) of the Social 

22 Security Act (42 U.S.C. 1320a–7a(i)(6)) is 

23 amended— 

24 (i) in subparagraph (C), by striking 

25 ‘‘or’’ at the end; 


tjames on DSKG8SOYB1PROD with BILLS
34 

•S 2964 IS

1 (ii) in subparagraph (D), as redesig2 nated by section 4331(e) of the Balanced 

3 Budget Act of 1997 (Public Law 105–33), 

4 by striking the period at the end and in5 serting a semicolon; 

6 (iii) by redesignating subparagraph 

7 (D), as added by section 4523(c) of such 

8 Act, as subparagraph (E) and striking the 

9 period at the end and inserting ‘‘; or’’; and 

10 (iv) by adding at the end the following 

11 new subparagraphs: 

12 ‘‘(F) any other remuneration which pro13 motes access to care and poses a low risk of 

14 harm to patients and Federal health care pro15 grams (as defined in section 1128B(f) and des16 ignated by the Secretary under regulations); 

17 ‘‘(G) the offer or transfer of items or serv18 ices for free or less than fair market value by 

19 a person, if— 

20 ‘‘(i) the items or services consist of 

21 coupons, rebates, or other rewards from a 

22 retailer; 

23 ‘‘(ii) the items or services are offered 

24 or transferred on equal terms available to 


tjames on DSKG8SOYB1PROD with BILLS
35 

•S 2964 IS

1 the general public, regardless of health in2 surance status; and 

3 ‘‘(iii) the offer or transfer of the items 

4 or services is not tied to the provision of 

5 other items or services reimbursed in whole 

6 or in part by the program under title 

7 XVIII or a State health care program (as 

8 defined in section 1128(h)); 

9 ‘‘(H) the offer or transfer of items or serv10 ices for free or less than fair market value by 

11 a person, if— 

12 ‘‘(i) the items or services are not of13 fered as part of any advertisement or solic14 itation; 

15 ‘‘(ii) the items or services are not tied 

16 to the provision of other services reim17 bursed in whole or in part by the program 

18 under title XVIII or a State health care 

19 program (as so defined); 

20 ‘‘(iii) there is a reasonable connection 

21 between the items or services and the med22 ical care of the individual; and 

23 ‘‘(iv) the person provides the items or 

24 services after determining in good faith 

25 that the individual is in financial need; or 


tjames on DSKG8SOYB1PROD with BILLS
36 

•S 2964 IS

1 ‘‘(I) effective on a date specified by the 

2 Secretary (but not earlier than January 1, 

3 2011), the waiver by a PDP sponsor of a pre4 scription drug plan under part D of title XVIII 

5 or an MA organization offering an MA–PD 

6 plan under part C of such title of any copay7 ment for the first fill of a covered part D drug 

8 (as defined in section 1860D–2(e)) that is a ge9 neric drug for individuals enrolled in the pre10 scription drug plan or MA–PD plan, respec11 tively.’’. 

12 (e) TESTIMONIAL SUBPOENA AUTHORITY IN EXCLU13 SION-ONLY CASES.—Section 1128(f) of the Social Secu14 rity Act (42 U.S.C. 1320a–7(f)) is amended by adding at 

15 the end the following new paragraph: 

16 ‘‘(4) The provisions of subsections (d) and (e) 

17 of section 205 shall apply with respect to this sec18 tion to the same extent as they are applicable with 

19 respect to title II. The Secretary may delegate the 

20 authority granted by section 205(d) (as made appli21 cable to this section) to the Inspector General of the 

22 Department of Health and Human Services for pur23 poses of any investigation under this section.’’. 

24 (f) REVISING THE INTENT REQUIREMENT FOR

25 HEALTH CARE FRAUD.—Section 1128B of the Social SeVerDate Nov 24 2008 02:01 Jan 29, 2010 Jkt 089200 PO 00000 Frm 00036 Fmt 6652 Sfmt 6201 E:\BILLS\S2964.IS S2964

tjames on DSKG8SOYB1PROD with BILLS
37 

•S 2964 IS

1 curity Act (42 U.S.C. 1320a–7b) is amended by adding 

2 at the end the following new subsection: 

3 ‘‘(g) With respect to violations of this section, a per4 son need not have actual knowledge of this section or spe5 cific intent to commit a violation of this section.’’. 

6 (g) SURETY BOND REQUIREMENTS.— 

7 (1) DURABLE MEDICAL EQUIPMENT.—Section 

8 1834(a)(16)(B) of the Social Security Act (42 

9 U.S.C. 1395m(a)(16)(B)) is amended by inserting 

10 ‘‘that the Secretary determines is commensurate 

11 with the volume of the billing of the supplier’’ before 

12 the period at the end. 

13 (2) HOME HEALTH AGENCIES.—Section 

14 1861(o)(7)(C) of the Social Security Act (42 U.S.C. 

15 1395x(o)(7)(C)) is amended by inserting ‘‘that the 

16 Secretary determines is commensurate with the vol17 ume of the billing of the home health agency’’ before 

18 the semicolon at the end. 

19 (3) REQUIREMENTS FOR CERTAIN OTHER PRO20 VIDERS OF SERVICES AND SUPPLIERS.—Section 

21 1862 of the Social Security Act (42 U.S.C. 1395y) 

22 is amended by adding at the end the following new 

23 subsection: 

24 ‘‘(n) REQUIREMENT OF A SURETY BOND FOR CER25 TAIN PROVIDERS OF SERVICES AND SUPPLIERS.— 


tjames on DSKG8SOYB1PROD with BILLS
38 

•S 2964 IS

1 ‘‘(1) IN GENERAL.—The Secretary may require 

2 a provider of services or supplier described in para3 graph (2) to provide the Secretary on a continuing 

4 basis with a surety bond in a form specified by the 

5 Secretary in an amount (not less than $50,000) that 

6 the Secretary determines is commensurate with the 

7 volume of the billing of the provider of services or 

8 supplier. The Secretary may waive the requirement 

9 of a bond under the preceding sentence in the case 

10 of a provider of services or supplier that provides a 

11 comparable surety bond under State law. 

12 ‘‘(2) PROVIDER OF SERVICES OR SUPPLIER DE13 SCRIBED.—A provider of services or supplier de14 scribed in this paragraph is a provider of services or 

15 supplier the Secretary determines appropriate based 

16 on the level of risk involved with respect to the pro17 vider of services or supplier, and consistent with the 

18 surety bond requirements under sections 

19 1834(a)(16)(B) and 1861(o)(7)(C).’’. 

20 (h) SUSPENSION OF MEDICARE AND MEDICAID PAY21 MENTS PENDING INVESTIGATION OF CREDIBLE ALLEGA22 TIONS OF FRAUD.— 

23 (1) MEDICARE.—Section 1862 of the Social Se24 curity Act (42 U.S.C. 1395y), as amended by subVerDate Nov 24 2008 02:01 Jan 29, 2010 Jkt 089200 PO 00000 Frm 00038 Fmt 6652 Sfmt 6201 E:\BILLS\S2964.IS S2964

tjames on DSKG8SOYB1PROD with BILLS
39 

•S 2964 IS

1 section (g)(3), is amended by adding at the end the 

2 following new subsection: 

3 ‘‘(o) SUSPENSION AUTHORITY.— 

4 ‘‘(1) IN GENERAL.—The Secretary shall sus5 pend payment to a provider of services or supplier 

6 under this title pending an investigation of credible 

7 allegations of fraud against the provider of services 

8 or supplier, unless the Secretary finds good cause 

9 not to suspend such payment. 

10 ‘‘(2) CONSULTATION.—The Secretary shall con11 sult with the Inspector General of the Department 

12 of Health and Human Services in determining 

13 whether there is a credible allegation of fraud 

14 against a provider of services or supplier. 

15 ‘‘(3) PROMULGATION OF REGULATIONS.—The 

16 Secretary shall promulgate regulations to carry out 

17 this subsection and section 1903(i)(2)(C).’’. 

18 (2) MEDICAID.—Section 1903(i)(2) of such Act 

19 (42 U.S.C. 1396b(i)(2)) is amended— 

20 (A) in subparagraph (A), by striking ‘‘or’’ 

21 at the end; and 

22 (B) by inserting after subparagraph (B), 

23 the following: 

24 ‘‘(C) by any individual or entity to whom 

25 the State has failed to suspend payments under 


tjames on DSKG8SOYB1PROD with BILLS
40 

•S 2964 IS

1 the plan during any period when there is pend2 ing an investigation of a credible allegation of 

3 fraud against the individual or entity, as deter4 mined by the State in accordance with regula5 tions promulgated by the Secretary for pur6 poses of section 1862(o) and this subparagraph, 

7 unless the State determines in accordance with 

8 such regulations there is good cause not to sus9 pend such payments; or’’. 

10 (i) EXTENSION OF NUMBER OF DAYS IN WHICH

11 MEDICARE CLAIMS ARE REQUIRED TO BE PAID IN

12 ORDER TO PREVENT OR COMBAT FRAUD, WASTE, OR

13 ABUSE.— 

14 (1) PART A CLAIMS.—Section 1816(c)(2) of the 

15 Social Security Act (42 U.S.C. 1395h(c)(2)) is 

16 amended— 

17 (A) in subparagraph (B)(ii)(V), by striking 

18 ‘‘with respect’’ and inserting ‘‘subject to sub19 paragraph (D), with respect’’; and 

20 (B) by adding at the end the following new 

21 subparagraph: 

22 ‘‘(D)(i) Upon a determination by the Sec23 retary that there is a likelihood of fraud, waste, 

24 or abuse involving a particular category of pro25 viders of services or suppliers, categories of proVerDate Nov 24 2008 02:01 Jan 29, 2010 Jkt 089200 PO 00000 Frm 00040 Fmt 6652 Sfmt 6201 E:\BILLS\S2964.IS S2964

tjames on DSKG8SOYB1PROD with BILLS
41 

•S 2964 IS

1 viders of services or suppliers in a certain geo2 graphic area, or individual providers of services 

3 or suppliers, the Secretary shall extend the 

4 number of calendar days described in subpara5 graph (B)(ii)(V) to— 

6 ‘‘(I) up to 365 calendar days with re7 spect to claims submitted by— 

8 ‘‘(aa) categories of providers of 

9 services or suppliers; or 

10 ‘‘(bb) categories of providers of 

11 services or suppliers in a certain geo12 graphic area; or 

13 ‘‘(II) such time that the Secretary de14 termines is necessary to ensure that the 

15 claims with respect to individual providers 

16 of services or suppliers are clean claims. 

17 ‘‘(ii) During the extended period of time 

18 under subclauses (I) and (II) of clause (ii), the 

19 Secretary shall engage in heightened scrutiny of 

20 claims, such as prepayment review and other 

21 methods the Secretary determines to be appro22 priate. 

23 ‘‘(iii) Not later than 90 days after the date 

24 of enactment of this subparagraph and not less 

25 than annually thereafter, the Inspector General 


tjames on DSKG8SOYB1PROD with BILLS
42 

•S 2964 IS

1 of the Department of Health and Human Serv2 ices shall submit to the Secretary a report con3 taining recommendations with respect to the 

4 application of this subparagraph and section 

5 1842(c)(2)(D). Not later than 60 days after re6 ceiving such a report, the Secretary shall sub7 mit to the Inspector General a written response 

8 to the recommendations contained in the report. 

9 ‘‘(iv) There shall be no administrative or 

10 judicial review under section 1869, section 

11 1878, or otherwise of the implementation of 

12 this subparagraph by the Secretary.’’. 

13 (2) PART B CLAIMS.—Section 1842(c)(2) of the 

14 Social Security Act (42 U.S.C. 1395u(c)(2)) is 

15 amended— 

16 (A) in subparagraph (B)(ii)(V), by striking 

17 ‘‘with respect’’ and inserting ‘‘subject to sub18 paragraph (D), with respect’’; and 

19 (B) by adding at the end the following new 

20 subparagraph: 

21 ‘‘(D)(i) Upon a determination by the Sec22 retary that there is a likelihood of fraud, waste, 

23 or abuse involving a particular category of pro24 viders of services or suppliers, categories of pro25 viders of services or suppliers in a certain geoVerDate Nov 24 2008 02:01 Jan 29, 2010 Jkt 089200 PO 00000 Frm 00042 Fmt 6652 Sfmt 6201 E:\BILLS\S2964.IS S2964

tjames on DSKG8SOYB1PROD with BILLS
43 

•S 2964 IS

1 graphic area, or individual providers of services 

2 or suppliers, the Secretary shall extend the 

3 number of calendar days described in subpara4 graph (B)(ii)(V) to— 

5 ‘‘(I) up to 365 calendar days with re6 spect to claims submitted by— 

7 ‘‘(aa) categories of providers of 

8 services or suppliers; or 

9 ‘‘(bb) categories of providers of 

10 services or suppliers in a certain geo11 graphic area; or 

12 ‘‘(II) such time that the Secretary de13 termines is necessary to ensure that the 

14 claims with respect to individual providers 

15 of services or suppliers are clean claims. 

16 ‘‘(ii) During the extended period of time 

17 under subclauses (I) and (II) of clause (ii), the 

18 Secretary shall engage in heightened scrutiny of 

19 claims, such as prepayment review and other 

20 methods the Secretary determines to be appro21 priate. 

22 ‘‘(iii) There shall be no administrative or 

23 judicial review under section 1869, section 

24 1878, or otherwise of the implementation of 

25 this subparagraph by the Secretary.’’. 


tjames on DSKG8SOYB1PROD with BILLS
44 

•S 2964 IS

1 (3) EFFECTIVE DATE.— 

2 (A) IN GENERAL.—The amendments made 

3 by this subsection shall take effect on the day 

4 that is 6 months after the date of the enact5 ment of this Act. 

6 (B) EXPEDITING IMPLEMENTATION.—The 

7 Secretary shall promulgate regulations to carry 

8 out the amendments made by this subsection 

9 which may be effective and final immediately on 

10 an interim basis as of the date of publication of 

11 the interim final regulation. If the Secretary 

12 provides for an interim final regulation, the 

13 Secretary shall provide for a period of public 

14 comment on such regulation after the date of 

15 publication. The Secretary may change or revise 

16 such regulation after completion of the period 

17 of public comment. 

18 (j) INCREASED FUNDING TO FIGHT FRAUD AND

19 ABUSE.— 

20 (1) IN GENERAL.—Section 1817(k) of the So21 cial Security Act (42 U.S.C. 1395i(k)) is amended— 

22 (A) by adding at the end the following new 

23 paragraph: 

24 ‘‘(7) ADDITIONAL FUNDING.—In addition to the 

25 funds otherwise appropriated to the Account from 


tjames on DSKG8SOYB1PROD with BILLS
45 

•S 2964 IS

1 the Trust Fund under paragraphs (3) and (4) and 

2 for purposes described in paragraphs (3)(C) and 

3 (4)(A), there are hereby appropriated an additional 

4 $10,000,000 to such Account from such Trust Fund 

5 for each of fiscal years 2011 through 2020. The 

6 funds appropriated under this paragraph shall be al7 located in the same proportion as the total funding 

8 appropriated with respect to paragraphs (3)(A) and 

9 (4)(A) was allocated with respect to fiscal year 

10 2010, and shall be available without further appro11 priation until expended.’’; and 

12 (B) in paragraph (4)(A), by inserting 

13 ‘‘until expended’’ after ‘‘appropriation’’. 

14 (2) INDEXING OF AMOUNTS APPROPRIATED.— 

15 (A) DEPARTMENTS OF HEALTH AND

16 HUMAN SERVICES AND JUSTICE.—Section 

17 1817(k)(3)(A)(i) of the Social Security Act (42 

18 U.S.C. 1395i(k)(3)(A)(i)) is amended— 

19 (i) in subclause (III), by inserting 

20 ‘‘and’’ at the end; 

21 (ii) in subclause (IV)— 

22 (I) by striking ‘‘for each of fiscal 

23 years 2007, 2008, 2009, and 2010’’ 

24 and inserting ‘‘for each fiscal year 

25 after fiscal year 2006’’; and 


tjames on DSKG8SOYB1PROD with BILLS
46 

•S 2964 IS

1 (II) by striking ‘‘; and’’ and in2 serting a period; and 

3 (iii) by striking subclause (V). 

4 (B) OFFICE OF THE INSPECTOR GENERAL

5 OF THE DEPARTMENT OF HEALTH AND HUMAN

6 SERVICES.—Section 1817(k)(3)(A)(ii) of such 

7 Act (42 U.S.C. 1395i(k)(3)(A)(ii)) is amend8 ed— 

9 (i) in subclause (VIII), by inserting 

10 ‘‘and’’ at the end; 

11 (ii) in subclause (IX)— 

12 (I) by striking ‘‘for each of fiscal 

13 years 2008, 2009, and 2010’’ and in14 serting ‘‘for each fiscal year after fis15 cal year 2007’’; and 

16 (II) by striking ‘‘; and’’ and in17 serting a period; and 

18 (iii) by striking subclause (X). 

19 (C) FEDERAL BUREAU OF INVESTIGA20 TION.—Section 1817(k)(3)(B) of the Social Se21 curity Act (42 U.S.C. 1395i(k)(3)(B)) is 

22 amended— 

23 (i) in clause (vii), by inserting ‘‘and’’ 

24 at the end; 

25 (ii) in clause (viii)— 


tjames on DSKG8SOYB1PROD with BILLS
47 

•S 2964 IS

1 (I) by striking ‘‘for each of fiscal 

2 years 2007, 2008, 2009, and 2010’’ 

3 and inserting ‘‘for each fiscal year 

4 after fiscal year 2006’’; and 

5 (II) by striking ‘‘; and’’ and in6 serting a period; and 

7 (iii) by striking clause (ix). 

8 (D) MEDICARE INTEGRITY PROGRAM.— 

9 Section 1817(k)(4)(C) of the Social Security 

10 Act (42 U.S.C. 1395i(k)(4)(C)) is amended by 

11 adding at the end the following new clause: 

12 ‘‘(ii) For each fiscal year after 2010, 

13 by the percentage increase in the consumer 

14 price index for all urban consumers (all 

15 items; United States city average) over the 

16 previous year.’’. 

17 (k) MEDICARE INTEGRITY PROGRAM AND MEDICAID

18 INTEGRITY PROGRAM.— 

19 (1) MEDICARE INTEGRITY PROGRAM.— 

20 (A) REQUIREMENT TO PROVIDE PERFORM21 ANCE STATISTICS.—Section 1893(c) of the So22 cial Security Act (42 U.S.C. 1395ddd(c)) is 

23 amended— 

24 (i) in paragraph (3), by striking 

25 ‘‘and’’ at the end; 


tjames on DSKG8SOYB1PROD with BILLS
48 

•S 2964 IS

1 (ii) by redesignating paragraph (4) as 

2 paragraph (5); and 

3 (iii) by inserting after paragraph (3) 

4 the following new paragraph: 

5 ‘‘(4) the entity agrees to provide the Secretary 

6 and the Inspector General of the Department of 

7 Health and Human Services with such performance 

8 statistics (including the number and amount of over9 payments recovered, the number of fraud referrals, 

10 and the return on investment of such activities by 

11 the entity) as the Secretary or the Inspector General 

12 may request; and’’. 

13 (B) EVALUATIONS AND ANNUAL RE14 PORT.—Section 1893 of the Social Security Act 

15 (42 U.S.C. 1395ddd) is amended by adding at 

16 the end the following new subsection: 

17 ‘‘(i) EVALUATIONS AND ANNUAL REPORT.— 

18 ‘‘(1) EVALUATIONS.—The Secretary shall con19 duct evaluations of eligible entities which the Sec20 retary contracts with under the Program not less 

21 frequently than every 3 years. 

22 ‘‘(2) ANNUAL REPORT.—Not later than 180 

23 days after the end of each fiscal year (beginning 

24 with fiscal year 2011), the Secretary shall submit a 

25 report to Congress which identifies— 


tjames on DSKG8SOYB1PROD with BILLS
49 

•S 2964 IS

1 ‘‘(A) the use of funds, including funds 

2 transferred from the Federal Hospital Insur3 ance Trust Fund under section 1817 and the 

4 Federal Supplementary Insurance Trust Fund 

5 under section 1841, to carry out this section; 

6 and 

7 ‘‘(B) the effectiveness of the use of such 

8 funds.’’. 

9 (C) FLEXIBILITY IN PURSUING FRAUD

10 AND ABUSE.—Section 1893(a) of the Social Se11 curity Act (42 U.S.C. 1395ddd(a)) is amended 

12 by inserting ‘‘, or otherwise,’’ after ‘‘entities’’. 

13 (2) MEDICAID INTEGRITY PROGRAM.— 

14 (A) REQUIREMENT TO PROVIDE PERFORM15 ANCE STATISTICS.—Section 1936(c)(2) of the 

16 Social Security Act (42 U.S.C. 1396u–6(c)(2)) 

17 is amended— 

18 (i) by redesignating subparagraph (D) 

19 as subparagraph (E); and 

20 (ii) by inserting after subparagraph 

21 (C) the following new subparagraph: 

22 ‘‘(D) The entity agrees to provide the Sec23 retary and the Inspector General of the Depart24 ment of Health and Human Services with such 

25 performance statistics (including the number 


tjames on DSKG8SOYB1PROD with BILLS
50 

•S 2964 IS

1 and amount of overpayments recovered, the 

2 number of fraud referrals, and the return on in3 vestment of such activities by the entity) as the 

4 Secretary or the Inspector General may re5 quest.’’. 

6 (B) EVALUATIONS AND ANNUAL RE7 PORT.—Section 1936(e) of the Social Security 

8 Act (42 U.S.C. 1396u–7(e)) is amended— 

9 (i) by redesignating paragraph (4) as 

10 paragraph (5); and 

11 (ii) by inserting after paragraph (3) 

12 the following new paragraph: 

13 ‘‘(4) EVALUATIONS.—The Secretary shall con14 duct evaluations of eligible entities which the Sec15 retary contracts with under the Program not less 

16 frequently than every 3 years.’’. 

17 (l) EXPANDED APPLICATION OF HARDSHIP WAIVERS

18 FOR EXCLUSIONS.—Section 1128(c)(3)(B) of the Social 

19 Security Act (42 U.S.C. 1320a–7(c)(3)(B)) is amended by 

20 striking ‘‘individuals entitled to benefits under part A of 

21 title XVIII or enrolled under part B of such title, or both’’ 

22 and inserting ‘‘beneficiaries (as defined in section 

23 1128A(i)(5)) of that program’’. 


tjames on DSKG8SOYB1PROD with BILLS
51 

•S 2964 IS

1 SEC. 103. ELIMINATION OF DUPLICATION BETWEEN THE 

2 HEALTHCARE INTEGRITY AND PROTECTION 

3 DATA BANK AND THE NATIONAL PRACTI4 TIONER DATA BANK. 

5 (a) INFORMATION REPORTED BY FEDERAL AGEN6 CIES AND HEALTH PLANS.—Section 1128E of the Social 

7 Security Act (42 U.S.C. 1320a–7e) is amended— 

8 (1) by striking subsection (a) and inserting the 

9 following: 

10 ‘‘(a) IN GENERAL.—The Secretary shall maintain a 

11 national health care fraud and abuse data collection pro12 gram under this section for the reporting of certain final 

13 adverse actions (not including settlements in which no 

14 findings of liability have been made) against health care 

15 providers, suppliers, or practitioners as required by sub16 section (b), with access as set forth in subsection (d), and 

17 shall furnish the information collected under this section 

18 to the National Practitioner Data Bank established pursu19 ant to the Health Care Quality Improvement Act of 1986 

20 (42 U.S.C. 11101 et seq.).’’; 

21 (2) by striking subsection (d) and inserting the 

22 following: 

23 ‘‘(d) ACCESS TO REPORTED INFORMATION.— 

24 ‘‘(1) AVAILABILITY.—The information collected 

25 under this section shall be available from the Na26 tional Practitioner Data Bank to the agencies, auVerDate Nov 24 2008 02:01 Jan 29, 2010 Jkt 089200 PO 00000 Frm 00051 Fmt 6652 Sfmt 6201 E:\BILLS\S2964.IS S2964

tjames on DSKG8SOYB1PROD with BILLS
52 

•S 2964 IS

1 thorities, and officials which are provided under sec2 tion 1921(b) information reported under section 

3 1921(a). 

4 ‘‘(2) FEES FOR DISCLOSURE.—The Secretary 

5 may establish or approve reasonable fees for the dis6 closure of information under this section. The 

7 amount of such a fee may not exceed the costs of 

8 processing the requests for disclosure and of pro9 viding such information. Such fees shall be available 

10 to the Secretary to cover such costs.’’; 

11 (3) by striking subsection (f) and inserting the 

12 following: 

13 ‘‘(f) APPROPRIATE COORDINATION.—In imple14 menting this section, the Secretary shall provide for the 

15 maximum appropriate coordination with part B of the 

16 Health Care Quality Improvement Act of 1986 (42 U.S.C. 

17 11131 et seq.) and section 1921.’’; and 

18 (4) in subsection (g)— 

19 (A) in paragraph (1)(A)— 

20 (i) in clause (iii)— 

21 (I) by striking ‘‘or State’’ each 

22 place it appears; 

23 (II) by redesignating subclauses 

24 (II) and (III) as subclauses (III) and 

25 (IV), respectively; and 


tjames on DSKG8SOYB1PROD with BILLS
53 

•S 2964 IS

1 (III) by inserting after subclause 

2 (I) the following new subclause: 

3 ‘‘(II) any dismissal or closure of 

4 the proceedings by reason of the pro5 vider, supplier, or practitioner surren6 dering their license or leaving the 

7 State or jurisdiction’’; and 

8 (ii) by striking clause (iv) and insert9 ing the following: 

10 ‘‘(iv) Exclusion from participation in a 

11 Federal health care program (as defined in 

12 section 1128B(f)).’’; 

13 (B) in paragraph (3)— 

14 (i) by striking subparagraphs (D) and 

15 (E); and 

16 (ii) by redesignating subparagraph 

17 (F) as subparagraph (D); and 

18 (C) in subparagraph (D) (as so redesig19 nated), by striking ‘‘or State’’. 

20 (b) INFORMATION REPORTED BY STATE LAW OR

21 FRAUD ENFORCEMENT AGENCIES.—Section 1921 of the 

22 Social Security Act (42 U.S.C. 1396r–2) is amended— 

23 (1) in subsection (a)— 

24 (A) in paragraph (1)— 


tjames on DSKG8SOYB1PROD with BILLS
54 

•S 2964 IS

1 (i) by striking ‘‘SYSTEM.—The State’’ 

2 and all that follows through the semicolon 

3 and inserting SYSTEM.— 

4 ‘‘(A) LICENSING OR CERTIFICATION AC5 TIONS.—The State must have in effect a system 

6 of reporting the following information with re7 spect to formal proceedings (as defined by the 

8 Secretary in regulations) concluded against a 

9 health care practitioner or entity by a State li10 censing or certification agency:’’; 

11 (ii) by redesignating subparagraphs 

12 (A) through (D) as clauses (i) through 

13 (iv), respectively, and indenting appro14 priately; 

15 (iii) in subparagraph (A)(iii) (as so 

16 redesignated)— 

17 (I) by striking ‘‘the license of’’ 

18 and inserting ‘‘license or the right to 

19 apply for, or renew, a license by’’; and 

20 (II) by inserting ‘‘nonrenew21 ability,’’ after ‘‘voluntary surrender,’’; 

22 and 

23 (iv) by adding at the end the following 

24 new subparagraph: 


tjames on DSKG8SOYB1PROD with BILLS
55 

•S 2964 IS

1 ‘‘(B) OTHER FINAL ADVERSE ACTIONS.— 

2 The State must have in effect a system of re3 porting information with respect to any final 

4 adverse action (not including settlements in 

5 which no findings of liability have been made) 

6 taken against a health care provider, supplier, 

7 or practitioner by a State law or fraud enforce8 ment agency.’’; and 

9 (B) in paragraph (2), by striking ‘‘the au10 thority described in paragraph (1)’’ and insert11 ing ‘‘a State licensing or certification agency or 

12 State law or fraud enforcement agency’’; 

13 (2) in subsection (b)— 

14 (A) by striking paragraph (2) and insert15 ing the following: 

16 ‘‘(2) to State licensing or certification agencies 

17 and Federal agencies responsible for the licensing 

18 and certification of health care providers, suppliers, 

19 and licensed health care practitioners;’’; 

20 (B) in each of paragraphs (4) and (6), by 

21 inserting ‘‘, but only with respect to information 

22 provided pursuant to subsection (a)(1)(A)’’ be23 fore the comma at the end; 

24 (C) by striking paragraph (5) and insert25 ing the following: 


tjames on DSKG8SOYB1PROD with BILLS
56 

•S 2964 IS

1 ‘‘(5) to State law or fraud enforcement agen2 cies,’’; 

3 (D) by redesignating paragraphs (7) and 

4 (8) as paragraphs (8) and (9), respectively; and 

5 (E) by inserting after paragraph (6) the 

6 following new paragraph: 

7 ‘‘(7) to health plans (as defined in section 

8 1128C(c));’’; 

9 (3) by redesignating subsection (d) as sub10 section (h), and by inserting after subsection (c) the 

11 following new subsections: 

12 ‘‘(d) DISCLOSURE AND CORRECTION OF INFORMA13 TION.— 

14 ‘‘(1) DISCLOSURE.—With respect to informa15 tion reported pursuant to subsection (a)(1), the Sec16 retary shall— 

17 ‘‘(A) provide for disclosure of the informa18 tion, upon request, to the health care practi19 tioner who, or the entity that, is the subject of 

20 the information reported; and 

21 ‘‘(B) establish procedures for the case 

22 where the health care practitioner or entity dis23 putes the accuracy of the information reported. 

24 ‘‘(2) CORRECTIONS.—Each State licensing or 

25 certification agency and State law or fraud enforceVerDate Nov 24 2008 02:01 Jan 29, 2010 Jkt 089200 PO 00000 Frm 00056 Fmt 6652 Sfmt 6201 E:\BILLS\S2964.IS S2964

tjames on DSKG8SOYB1PROD with BILLS
57 

•S 2964 IS

1 ment agency shall report corrections of information 

2 already reported about any formal proceeding or 

3 final adverse action described in subsection (a), in 

4 such form and manner as the Secretary prescribes 

5 by regulation. 

6 ‘‘(e) FEES FOR DISCLOSURE.—The Secretary may 

7 establish or approve reasonable fees for the disclosure of 

8 information under this section. The amount of such a fee 

9 may not exceed the costs of processing the requests for 

10 disclosure and of providing such information. Such fees 

11 shall be available to the Secretary to cover such costs. 

12 ‘‘(f) PROTECTION FROM LIABILITY FOR REPORT13 ING.—No person or entity, including any agency des14 ignated by the Secretary in subsection (b), shall be held 

15 liable in any civil action with respect to any reporting of 

16 information as required under this section, without knowl17 edge of the falsity of the information contained in the re18 port. 

19 ‘‘(g) REFERENCES.—For purposes of this section: 

20 ‘‘(1) STATE LICENSING OR CERTIFICATION

21 AGENCY.—The term ‘State licensing or certification 

22 agency’ includes any authority of a State (or of a 

23 political subdivision thereof) responsible for the li24 censing of health care practitioners (or any peer re25 view organization or private accreditation entity reVerDate Nov 24 2008 02:01 Jan 29, 2010 Jkt 089200 PO 00000 Frm 00057 Fmt 6652 Sfmt 6201 E:\BILLS\S2964.IS S2964

tjames on DSKG8SOYB1PROD with BILLS
58 

•S 2964 IS

1 viewing the services provided by health care practi2 tioners) or entities. 

3 ‘‘(2) STATE LAW OR FRAUD ENFORCEMENT

4 AGENCY.—The term ‘State law or fraud enforcement 

5 agency’ includes— 

6 ‘‘(A) a State law enforcement agency; and 

7 ‘‘(B) a State Medicaid fraud control unit 

8 (as defined in section 1903(q)). 

9 ‘‘(3) FINAL ADVERSE ACTION.— 

10 ‘‘(A) IN GENERAL.—Subject to subpara11 graph (B), the term ‘final adverse action’ in12 cludes— 

13 ‘‘(i) civil judgments against a health 

14 care provider, supplier, or practitioner in 

15 State court related to the delivery of a 

16 health care item or service; 

17 ‘‘(ii) State criminal convictions related 

18 to the delivery of a health care item or 

19 service; 

20 ‘‘(iii) exclusion from participation in 

21 State health care programs (as defined in 

22 section 1128(h)); 

23 ‘‘(iv) any licensing or certification ac24 tion described in subsection (a)(1)(A) 


tjames on DSKG8SOYB1PROD with BILLS
59 

•S 2964 IS

1 taken against a supplier by a State licens2 ing or certification agency; and 

3 ‘‘(v) any other adjudicated actions or 

4 decisions that the Secretary shall establish 

5 by regulation. 

6 ‘‘(B) EXCEPTION.—Such term does not in7 clude any action with respect to a malpractice 

8 claim.’’; and 

9 (4) in subsection (h), as so redesignated, by 

10 striking ‘‘The Secretary’’ and all that follows 

11 through the period at the end and inserting ‘‘In im12 plementing this section, the Secretary shall provide 

13 for the maximum appropriate coordination with part 

14 B of the Health Care Quality Improvement Act of 

15 1986 (42 U.S.C. 11131 et seq.) and section 

16 1128E.’’. 

17 (c) CONFORMING AMENDMENT.—Section 

18 1128C(a)(1) of the Social Security Act (42 U.S.C. 1320a– 

19 7c(a)(1)) is amended— 

20 (1) in subparagraph (C), by adding ‘‘and’’ after 

21 the comma at the end; 

22 (2) in subparagraph (D), by striking ‘‘, and’’ 

23 and inserting a period; and 

24 (3) by striking subparagraph (E). 

25 (d) TRANSITION PROCESS; EFFECTIVE DATE.— 


tjames on DSKG8SOYB1PROD with BILLS
60 

•S 2964 IS

1 (1) IN GENERAL.—Effective on the date of en2 actment of this Act, the Secretary of Health and 

3 Human Services (in this section referred to as the 

4 ‘‘Secretary’’) shall implement a transition process 

5 under which, by not later than the end of the transi6 tion period described in paragraph (5), the Secretary 

7 shall cease operating the Healthcare Integrity and 

8 Protection Data Bank established under section 

9 1128E of the Social Security Act (as in effect before 

10 the effective date specified in paragraph (6)) and 

11 shall transfer all data collected in the Healthcare In12 tegrity and Protection Data Bank to the National 

13 Practitioner Data Bank established pursuant to the 

14 Health Care Quality Improvement Act of 1986 (42 

15 U.S.C. 11101 et seq.). During such transition proc16 ess, the Secretary shall have in effect appropriate 

17 procedures to ensure that data collection and access 

18 to the Healthcare Integrity and Protection Data 

19 Bank and the National Practitioner Data Bank are 

20 not disrupted. 

21 (2) REGULATIONS.—The Secretary shall pro22 mulgate regulations to carry out the amendments 

23 made by subsections (a) and (b). 

24 (3) FUNDING.— 


tjames on DSKG8SOYB1PROD with BILLS
61 

•S 2964 IS

1 (A) AVAILABILITY OF FEES.—Fees col2 lected pursuant to section 1128E(d)(2) of the 

3 Social Security Act prior to the effective date 

4 specified in paragraph (6) for the disclosure of 

5 information in the Healthcare Integrity and 

6 Protection Data Bank shall be available to the 

7 Secretary, without fiscal year limitation, for 

8 payment of costs related to the transition proc9 ess described in paragraph (1). Any such fees 

10 remaining after the transition period is com11 plete shall be available to the Secretary, without 

12 fiscal year limitation, for payment of the costs 

13 of operating the National Practitioner Data 

14 Bank. 

15 (B) AVAILABILITY OF ADDITIONAL

16 FUNDS.—In addition to the fees described in 

17 subparagraph (A), any funds available to the 

18 Secretary or to the Inspector General of the 

19 Department of Health and Human Services for 

20 a purpose related to combating health care 

21 fraud, waste, or abuse shall be available to the 

22 extent necessary for operating the Healthcare 

23 Integrity and Protection Data Bank during the 

24 transition period, including systems testing and 

25 other activities necessary to ensure that inforVerDate Nov 24 2008 02:01 Jan 29, 2010 Jkt 089200 PO 00000 Frm 00061 Fmt 6652 Sfmt 6201 E:\BILLS\S2964.IS S2964

tjames on DSKG8SOYB1PROD with BILLS
62 

•S 2964 IS

1 mation formerly reported to the Healthcare In2 tegrity and Protection Data Bank will be acces3 sible through the National Practitioner Data 

4 Bank after the end of such transition period. 

5 (4) SPECIAL PROVISION FOR ACCESS TO THE

6 NATIONAL PRACTITIONER DATA BANK BY THE DE7 PARTMENT OF VETERANS AFFAIRS.— 

8 (A) IN GENERAL.—Notwithstanding any 

9 other provision of law, during the 1-year period 

10 that begins on the effective date specified in 

11 paragraph (6), the information described in 

12 subparagraph (B) shall be available from the 

13 National Practitioner Data Bank to the Sec14 retary of Veterans Affairs without charge. 

15 (B) INFORMATION DESCRIBED.—For pur16 poses of subparagraph (A), the information de17 scribed in this subparagraph is the information 

18 that would, but for the amendments made by 

19 this section, have been available to the Sec20 retary of Veterans Affairs from the Healthcare 

21 Integrity and Protection Data Bank. 

22 (5) TRANSITION PERIOD DEFINED.—For pur23 poses of this subsection, the term ‘‘transition pe24 riod’’ means the period that begins on the date of 

25 enactment of this Act and ends on the later of— 


tjames on DSKG8SOYB1PROD with BILLS
63 

•S 2964 IS

1 (A) the date that is 1 year after such date 

2 of enactment; or 

3 (B) the effective date of the regulations 

4 promulgated under paragraph (2). 

5 (6) EFFECTIVE DATE.—The amendments made 

6 by subsections (a), (b), and (c) shall take effect on 

7 the first day after the final day of the transition pe8 riod. 

9 SEC. 104. MAXIMUM PERIOD FOR SUBMISSION OF MEDI10 CARE CLAIMS REDUCED TO NOT MORE THAN 

11 12 MONTHS. 

12 (a) REDUCING MAXIMUM PERIOD FOR SUBMIS13 SION.— 

14 (1) PART A.—Section 1814(a) of the Social Se15 curity Act (42 U.S.C. 1395f(a)(1)) is amended— 

16 (A) in paragraph (1), by striking ‘‘period 

17 of 3 calendar years’’ and all that follows 

18 through the semicolon and inserting ‘‘period 

19 ending 1 calendar year after the date of serv20 ice;’’; and 

21 (B) by adding at the end the following new 

22 sentence: ‘‘In applying paragraph (1), the Sec23 retary may specify exceptions to the 1 calendar 

24 year period specified in such paragraph.’’ 

25 (2) PART B.— 


tjames on DSKG8SOYB1PROD with BILLS
64 

•S 2964 IS

1 (A) Section 1842(b)(3) of such Act (42 

2 U.S.C. 1395u(b)(3)(B)) is amended— 

3 (i) in subparagraph (B), in the flush 

4 language following clause (ii), by striking 

5 ‘‘close of the calendar year following the 

6 year in which such service is furnished 

7 (deeming any service furnished in the last 

8 3 months of any calendar year to have 

9 been furnished in the succeeding calendar 

10 year)’’ and inserting ‘‘period ending 1 cal11 endar year after the date of service’’; and 

12 (ii) by adding at the end the following 

13 new sentence: ‘‘In applying subparagraph 

14 (B), the Secretary may specify exceptions 

15 to the 1 calendar year period specified in 

16 such subparagraph.’’ 

17 (B) Section 1835(a) of such Act (42 

18 U.S.C. 1395n(a)) is amended— 

19 (i) in paragraph (1), by striking ‘‘pe20 riod of 3 calendar years’’ and all that fol21 lows through the semicolon and inserting 

22 ‘‘period ending 1 calendar year after the 

23 date of service;’’; and 

24 (ii) by adding at the end the following 

25 new sentence: ‘‘In applying paragraph (1), 


tjames on DSKG8SOYB1PROD with BILLS
65 

•S 2964 IS

1 the Secretary may specify exceptions to the 

2 1 calendar year period specified in such 

3 paragraph.’’ 

4 (b) EFFECTIVE DATE.— 

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

6 subsection (a) shall apply to services furnished on or 

7 after March 1, 2010. 

8 (2) SERVICES FURNISHED BEFORE MARCH

9 2010.—In the case of services furnished before 

10 March 1, 2010, a bill or request for payment under 

11 section 1814(a)(1), 1842(b)(3)(B), or 1835(a) shall 

12 be filed not later that December 31, 2010. 

13 SEC. 105. PHYSICIANS WHO ORDER ITEMS OR SERVICES RE14 QUIRED TO BE MEDICARE ENROLLED PHYSI15 CIANS OR ELIGIBLE PROFESSIONALS. 

16 (a) DME.—Section 1834(a)(11)(B) of the Social Se17 curity Act (42 U.S.C. 1395m(a)(11)(B)) is amended by 

18 striking ‘‘physician’’ and inserting ‘‘physician enrolled 

19 under section 1866(j) or an eligible professional under sec20 tion 1848(k)(3)(B) that is enrolled under section 

21 1866(j)’’. 

22 (b) HOME HEALTH SERVICES.— 

23 (1) PART A.—Section 1814(a)(2) of such Act 

24 (42 U.S.C. 1395(a)(2)) is amended in the matter 

25 preceding subparagraph (A) by inserting ‘‘in the 


tjames on DSKG8SOYB1PROD with BILLS
66 

•S 2964 IS

1 case of services described in subparagraph (C), a 

2 physician enrolled under section 1866(j) or an eligi3 ble professional under section 1848(k)(3)(B),’’ be4 fore ‘‘or, in the case of services’’. 

5 (2) PART B.—Section 1835(a)(2) of such Act 

6 (42 U.S.C. 1395n(a)(2)) is amended in the matter 

7 preceding subparagraph (A) by inserting ‘‘, or in the 

8 case of services described in subparagraph (A), a 

9 physician enrolled under section 1866(j) or an eligi10 ble professional under section 1848(k)(3)(B),’’ after 

11 ‘‘a physician’’. 

12 (c) APPLICATION TO OTHER ITEMS OR SERVICES.— 

13 The Secretary may extend the requirement applied by the 

14 amendments made by subsections (a) and (b) to durable 

15 medical equipment and home health services (relating to 

16 requiring certifications and written orders to be made by 

17 enrolled physicians and health professions) to all other 

18 categories of items or services under title XVIII of the 

19 Social Security Act (42 U.S.C. 1395 et seq.), including 

20 covered part D drugs as defined in section 1860D–2(e) 

21 of such Act (42 U.S.C. 1395w–102), that are ordered, pre22 scribed, or referred by a physician enrolled under section 

23 1866(j) of such Act (42 U.S.C. 1395cc(j)) or an eligible 

24 professional under section 1848(k)(3)(B) of such Act (42 

25 U.S.C. 1395w–4(k)(3)(B)). 


tjames on DSKG8SOYB1PROD with BILLS
67 

•S 2964 IS

1 (d) EFFECTIVE DATE.—The amendments made by 

2 this section shall apply to written orders and certifications 

3 made on or after July 1, 2010. 

4 SEC. 106. REQUIREMENT FOR PHYSICIANS TO PROVIDE 

5 DOCUMENTATION ON REFERRALS TO PRO6 GRAMS AT HIGH RISK OF WASTE AND ABUSE. 

7 (a) PHYSICIANS AND OTHER SUPPLIERS.—Section 

8 1842(h) of the Social Security Act (42 U.S.C. 1395u(h)) 

9 is amended by adding at the end the following new para10 graph: 

11 ‘‘(9) The Secretary may revoke enrollment, for a pe12 riod of not more than one year for each act, for a physi13 cian or supplier under section 1866(j) if such physician 

14 or supplier fails to maintain and, upon request of the Sec15 retary, provide access to documentation relating to written 

16 orders or requests for payment for durable medical equip17 ment, certifications for home health services, or referrals 

18 for other items or services written or ordered by such phy19 sician or supplier under this title, as specified by the Sec20 retary.’’. 

21 (b) PROVIDERS OF SERVICES.—Section 1866(a)(1) 

22 of such Act (42 U.S.C. 1395cc) is further amended— 

23 (1) in subparagraph (U), by striking at the end 

24 ‘‘and’’; 


tjames on DSKG8SOYB1PROD with BILLS
68 

•S 2964 IS

1 (2) in subparagraph (V), by striking the period 

2 at the end and adding ‘‘; and’’; and 

3 (3) by adding at the end the following new sub4 paragraph: 

5 ‘‘(W) maintain and, upon request of the 

6 Secretary, provide access to documentation re7 lating to written orders or requests for payment 

8 for durable medical equipment, certifications for 

9 home health services, or referrals for other 

10 items or services written or ordered by the pro11 vider under this title, as specified by the Sec12 retary.’’. 

13 (c) OIG PERMISSIVE EXCLUSION AUTHORITY.—Sec14 tion 1128(b)(11) of the Social Security Act (42 U.S.C. 

15 1320a–7(b)(11)) is amended by inserting ‘‘, ordering, re16 ferring for furnishing, or certifying the need for’’ after 

17 ‘‘furnishing’’. 

18 (d) EFFECTIVE DATE.—The amendments made by 

19 this section shall apply to orders, certifications, and refer20 rals made on or after March 1, 2010. 


tjames on DSKG8SOYB1PROD with BILLS
69 

•S 2964 IS

1 SEC. 107. FACE TO FACE ENCOUNTER WITH PATIENT RE2 QUIRED BEFORE PHYSICIANS MAY CERTIFY 

3 ELIGIBILITY FOR HOME HEALTH SERVICES 

4 OR DURABLE MEDICAL EQUIPMENT UNDER 

5 MEDICARE. 

6 (a) CONDITION OF PAYMENT FOR HOME HEALTH

7 SERVICES.— 

8 (1) PART A.—Section 1814(a)(2)(C) of such 

9 Act is amended— 

10 (A) by striking ‘‘and such services’’ and in11 serting ‘‘such services’’; and 

12 (B) by inserting after ‘‘care of a physi13 cian’’ the following: ‘‘, and, in the case of a cer14 tification made by a physician after March 1, 

15 2010, prior to making such certification the 

16 physician must document that the physician 

17 himself or herself has had a face-to-face en18 counter (including through use of telehealth, 

19 subject to the requirements in section 1834(m), 

20 and other than with respect to encounters that 

21 are incident to services involved) with the indi22 vidual within a reasonable timeframe as deter23 mined by the Secretary’’. 

24 (2) PART B.—Section 1835(a)(2)(A) of the So25 cial Security Act is amended— 

26 (A) by striking ‘‘and’’ before ‘‘(iii)’’; and 


tjames on DSKG8SOYB1PROD with BILLS
70 

•S 2964 IS

1 (B) by inserting after ‘‘care of a physi2 cian’’ the following: ‘‘, and (iv) in the case of 

3 a certification after March 1, 2010, prior to 

4 making such certification the physician must 

5 document that the physician has had a face-to6 face encounter (including through use of tele7 health and other than with respect to encoun8 ters that are incident to services involved) with 

9 the individual during the 6-month period pre10 ceding such certification, or other reasonable 

11 timeframe as determined by the Secretary’’. 

12 (b) CONDITION OF PAYMENT FOR DURABLE MED13 ICAL EQUIPMENT.—Section 1834(a)(11)(B) of the Social 

14 Security Act (42 U.S.C. 1395m(a)(11)(B)) is amended— 

15 (1) by striking ‘‘ORDER.—The Secretary’’ and 

16 inserting ‘‘ORDER.— 

17 ‘‘(i) IN GENERAL.—The Secretary’’; 

18 and 

19 (2) by adding at the end the following new 

20 clause: 

21 ‘‘(ii) REQUIREMENT FOR FACE TO

22 FACE ENCOUNTER.—The Secretary shall 

23 require that such an order be written pur24 suant to the physician documenting that a 

25 physician, a physician assistant, a nurse 


tjames on DSKG8SOYB1PROD with BILLS
71 

•S 2964 IS

1 practitioner, or a clinical nurse specialist 

2 (as those terms are defined in section 

3 1861(aa)(5)) has had a face-to-face en4 counter (including through use of tele5 health under subsection (m) and other 

6 than with respect to encounters that are 

7 incident to services involved) with the indi8 vidual involved during the 6-month period 

9 preceding such written order, or other rea10 sonable timeframe as determined by the 

11 Secretary.’’. 

12 (c) APPLICATION TO OTHER AREAS UNDER MEDI13 CARE.—The Secretary may apply the face-to-face encoun14 ter requirement described in the amendments made by 

15 subsections (a) and (b) to other items and services for 

16 which payment is provided under title XVIII of the Social 

17 Security Act based upon a finding that such an decision 

18 would reduce the risk of waste, fraud, or abuse. 

19 (d) APPLICATION TO MEDICAID.—The requirements 

20 pursuant to the amendments made by subsections (a) and 

21 (b) shall apply in the case of physicians making certifi22 cations for home health services under title XIX of the 

23 Social Security Act in the same manner and to the same 

24 extent as such requirements apply in the case of physiVerDate Nov 24 2008 02:01 Jan 29, 2010 Jkt 089200 PO 00000 Frm 00071 Fmt 6652 Sfmt 6201 E:\BILLS\S2964.IS S2964

tjames on DSKG8SOYB1PROD with BILLS
72 

•S 2964 IS

1 cians making such certifications under title XVIII of such 

2 Act. 

3 SEC. 108. ENHANCED PENALTIES. 

4 (a) CIVIL MONETARY PENALTIES FOR FALSE STATE5 MENTS OR DELAYING INSPECTIONS.—Section 1128A(a) 

6 of the Social Security Act (42 U.S.C. 1320a–7a(a)), as 

7 amended by section 102(d)(2)(A), is amended— 

8 (1) by inserting after paragraph (10) the fol9 lowing new paragraphs: 

10 ‘‘(11) knowingly makes, uses, or causes to be 

11 made or used, a false record or statement material 

12 to a false or fraudulent claim for payment for items 

13 and services furnished under a Federal health care 

14 program; or 

15 ‘‘(12) fails to grant timely access, upon reason16 able request (as defined by the Secretary in regula17 tions), to the Inspector General of the Department 

18 of Health and Human Services, for the purpose of 

19 audits, investigations, evaluations, or other statutory 

20 functions of the Inspector General of the Depart21 ment of Health and Human Services;’’; and 

22 (2) in the first sentence (as so amended)— 

23 (A) by striking ‘‘or in cases under para24 graph (9)’’ and inserting ‘‘in cases under para25 graph (9)’’; and 


tjames on DSKG8SOYB1PROD with BILLS
73 

•S 2964 IS

1 (B) by striking ‘‘a material fact)’’ and in2 serting ‘‘a material fact, in cases under para3 graph (11), $50,000 for each false record or 

4 statement, or in cases under paragraph (12), 

5 $15,000 for each day of the failure described in 

6 such paragraph)’’. 

7 (b) MEDICARE ADVANTAGE AND PART D PLANS.— 

8 (1) ENSURING TIMELY INSPECTIONS RELATING

9 TO CONTRACTS WITH MA ORGANIZATIONS.—Section 

10 1857(d)(2) of such Act (42 U.S.C. 1395w–27(d)(2)) 

11 is amended— 

12 (A) in subparagraph (A), by inserting 

13 ‘‘timely’’ before ‘‘inspect’’; and 

14 (B) in subparagraph (B), by inserting 

15 ‘‘timely’’ before ‘‘audit and inspect’’. 

16 (2) MARKETING VIOLATIONS.—Section 

17 1857(g)(1) of the Social Security Act (42 U.S.C. 

18 1395w–27(g)(1)) is amended— 

19 (A) in subparagraph (F), by striking ‘‘or’’ 

20 at the end; 

21 (B) by inserting after subparagraph (G) 

22 the following new subparagraphs: 

23 ‘‘(H) except as provided under subpara24 graph (C) or (D) of section 1860D–1(b)(1), en25 rolls an individual in any plan under this part 


tjames on DSKG8SOYB1PROD with BILLS
74 

•S 2964 IS

1 without the prior consent of the individual or 

2 the designee of the individual; 

3 ‘‘(I) transfers an individual enrolled under 

4 this part from one plan to another without the 

5 prior consent of the individual or the designee 

6 of the individual or solely for the purpose of 

7 earning a commission; 

8 ‘‘(J) fails to comply with marketing re9 strictions described in subsections (h) and (j) of 

10 section 1851 or applicable implementing regula11 tions or guidance; or 

12 ‘‘(K) employs or contracts with any indi13 vidual or entity who engages in the conduct de14 scribed in subparagraphs (A) through (J) of 

15 this paragraph;’’; and 

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

17 sentence: ‘‘The Secretary may provide, in addi18 tion to any other remedies authorized by law, 

19 for any of the remedies described in paragraph 

20 (2), if the Secretary determines that any em21 ployee or agent of such organization, or any 

22 provider or supplier who contracts with such or23 ganization, has engaged in any conduct de24 scribed in subparagraphs (A) through (K) of 

25 this paragraph.’’. 


tjames on DSKG8SOYB1PROD with BILLS
75 

•S 2964 IS

1 (3) PROVISION OF FALSE INFORMATION.—Sec2 tion 1857(g)(2)(A) of the Social Security Act (42 

3 U.S.C. 1395w–27(g)(2)(A)) is amended by inserting 

4 ‘‘except with respect to a determination under sub5 paragraph (E), an assessment of not more than the 

6 amount claimed by such plan or plan sponsor based 

7 upon the misrepresentation or falsified information 

8 involved,’’ after ‘‘for each such determination,’’. 

9 (c) OBSTRUCTION OF PROGRAM AUDITS.—Section 

10 1128(b)(2) of the Social Security Act (42 U.S.C. 1320a– 

11 7(b)(2)) is amended— 

12 (1) in the heading, by inserting ‘‘OR AUDIT’’ 

13 after ‘‘INVESTIGATION’’; and 

14 (2) by striking ‘‘investigation into’’ and all that 

15 follows through the period and inserting ‘‘investiga16 tion or audit related to— 

17 ‘‘(i) any offense described in para18 graph (1) or in subsection (a); or 

19 ‘‘(ii) the use of funds received, directly 

20 or indirectly, from any Federal health care 

21 program (as defined in section 

22 1128B(f)).’’. 

23 (d) EFFECTIVE DATE.— 

24 (1) IN GENERAL.—Except as provided in para25 graph (2), the amendments made by this section 


tjames on DSKG8SOYB1PROD with BILLS
76 

•S 2964 IS

1 shall apply to acts committed on or after January 1, 

2 2010. 

3 (2) EXCEPTION.—The amendments made by 

4 subsection (b)(1) take effect on the date of enact5 ment of this Act. 

6 SEC. 109. MEDICARE SELF-REFERRAL DISCLOSURE PRO7 TOCOL. 

8 (a) DEVELOPMENT OF SELF-REFERRAL DISCLO9 SURE PROTOCOL.— 

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

11 Human Services, in cooperation with the Inspector 

12 General of the Department of Health and Human 

13 Services, shall establish, not later than 6 months 

14 after the date of the enactment of this Act, a pro15 tocol to enable health care providers of services and 

16 suppliers to disclose an actual or potential violation 

17 of section 1877 of the Social Security Act (42 

18 U.S.C. 1395nn) pursuant to a self-referral disclosure 

19 protocol (in this section referred to as an ‘‘SRDP’’). 

20 The SRDP shall include direction to health care pro21 viders of services and suppliers on— 

22 (A) a specific person, official, or office to 

23 whom such disclosures shall be made; and 


tjames on DSKG8SOYB1PROD with BILLS
77 

•S 2964 IS

1 (B) instruction on the implication of the 

2 SRDP on corporate integrity agreements and 

3 corporate compliance agreements. 

4 (2) PUBLICATION ON INTERNET WEBSITE OF

5 SRDP INFORMATION.—The Secretary of Health and 

6 Human Services shall post information on the public 

7 Internet website of the Centers for Medicare & Med8 icaid Services to inform relevant stakeholders of how 

9 to disclose actual or potential violations pursuant to 

10 an SRDP. 

11 (3) RELATION TO ADVISORY OPINIONS.—The 

12 SRDP shall be separate from the advisory opinion 

13 process set forth in regulations implementing section 

14 1877(g) of the Social Security Act. 

15 (b) REDUCTION IN AMOUNTS OWED.—The Secretary 

16 of Health and Human Services is authorized to reduce the 

17 amount due and owing for all violations under section 

18 1877 of the Social Security Act to an amount less than 

19 that specified in subsection (g) of such section. In estab20 lishing such amount for a violation, the Secretary may 

21 consider the following factors: 

22 (1) The nature and extent of the improper or 

23 illegal practice. 

24 (2) The timeliness of such self-disclosure. 


tjames on DSKG8SOYB1PROD with BILLS
78 

•S 2964 IS

1 (3) The cooperation in providing additional in2 formation related to the disclosure. 

3 (4) Such other factors as the Secretary con4 siders appropriate. 

5 (c) REPORT.—Not later than 18 months after the 

6 date on which the SRDP protocol is established under sub7 section (a)(1), the Secretary shall submit to Congress a 

8 report on the implementation of this section. Such report 

9 shall include— 

10 (1) the number of health care providers of serv11 ices and suppliers making disclosures pursuant to 

12 the SRDP; 

13 (2) the amounts collected pursuant to the 

14 SRDP; 

15 (3) the types of violations reported under the 

16 SRDP; and 

17 (4) such other information as may be necessary 

18 to evaluate the impact of this section. 

19 SEC. 110. EXPANSION OF THE RECOVERY AUDIT CON20 TRACTOR (RAC) PROGRAM. 

21 (a) EXPANSION TO MEDICAID.— 

22 (1) STATE PLAN AMENDMENT.—Section 

23 1902(a)(42) of the Social Security Act (42 U.S.C. 

24 1396a(a)(42)) is amended— 


tjames on DSKG8SOYB1PROD with BILLS
79 

•S 2964 IS

1 (A) by striking ‘‘that the records’’ and in2 serting ‘‘that— 

3 ‘‘(A) the records’’; 

4 (B) by inserting ‘‘and’’ after the semicolon; 

5 and 

6 (C) by adding at the end the following: 

7 ‘‘(B) not later than December 31, 2010, 

8 the State shall— 

9 ‘‘(i) establish a program under which 

10 the State contracts (consistent with State 

11 law and in the same manner as the Sec12 retary enters into contracts with recovery 

13 audit contractors under section 1893(h), 

14 subject to such exceptions or requirements 

15 as the Secretary may require for purposes 

16 of this title or a particular State) with 1 

17 or more recovery audit contractors for the 

18 purpose of identifying underpayments and 

19 overpayments and recouping overpayments 

20 under the State plan and under any waiver 

21 of the State plan with respect to all serv22 ices for which payment is made to any en23 tity under such plan or waiver; and 

24 ‘‘(ii) provide assurances satisfactory 

25 to the Secretary that— 


tjames on DSKG8SOYB1PROD with BILLS
80 

•S 2964 IS

1 ‘‘(I) under such contracts, pay2 ment shall be made to such a con3 tractor only from amounts recovered; 

4 ‘‘(II) from such amounts recov5 ered, payment— 

6 ‘‘(aa) shall be made on a 

7 contingent basis for collecting 

8 overpayments; and 

9 ‘‘(bb) may be made in such 

10 amounts as the State may specify 

11 for identifying underpayments; 

12 ‘‘(III) the State has an adequate 

13 process for entities to appeal any ad14 verse determination made by such 

15 contractors; and 

16 ‘‘(IV) such program is carried 

17 out in accordance with such require18 ments as the Secretary shall specify, 

19 including— 

20 ‘‘(aa) for purposes of section 

21 1903(a)(7), that amounts ex22 pended by the State to carry out 

23 the program shall be considered 

24 amounts expended as necessary 

25 for the proper and efficient adVerDate Nov 24 2008 02:01 Jan 29, 2010 Jkt 089200 PO 00000 Frm 00080 Fmt 6652 Sfmt 6201 E:\BILLS\S2964.IS S2964

tjames on DSKG8SOYB1PROD with BILLS
81 

•S 2964 IS

1 ministration of the State plan or 

2 a waiver of the plan; 

3 ‘‘(bb) that section 1903(d) 

4 shall apply to amounts recovered 

5 under the program; and 

6 ‘‘(cc) that the State and any 

7 such contractors under contract 

8 with the State shall coordinate 

9 such recovery audit efforts with 

10 other contractors or entities per11 forming audits of entities receiv12 ing payments under the State 

13 plan or waiver in the State, in14 cluding efforts with Federal and 

15 State law enforcement with re16 spect to the Department of Jus17 tice, including the Federal Bu18 reau of Investigations, the In19 spector General of the Depart20 ment of Health and Human 

21 Services, and the State Medicaid 

22 fraud control unit; and’’. 

23 (2) COORDINATION; REGULATIONS.— 

24 (A) IN GENERAL.—The Secretary of 

25 Health and Human Services, acting through the 


tjames on DSKG8SOYB1PROD with BILLS
82 

•S 2964 IS

1 Administrator of the Centers for Medicare & 

2 Medicaid Services, shall coordinate the expan3 sion of the Recovery Audit Contractor program 

4 to Medicaid with States, particularly with re5 spect to each State that enters into a contract 

6 with a recovery audit contractor for purposes of 

7 the State’s Medicaid program prior to Decem8 ber 31, 2010. 

9 (B) REGULATIONS.—The Secretary of 

10 Health and Human Services shall promulgate 

11 regulations to carry out this subsection and the 

12 amendments made by this subsection, including 

13 with respect to conditions of Federal financial 

14 participation, as specified by the Secretary. 

15 (b) EXPANSION TO MEDICARE PARTS C AND D.— 

16 Section 1893(h) of the Social Security Act (42 U.S.C. 

17 1395ddd(h)) is amended— 

18 (1) in paragraph (1), in the matter preceding 

19 subparagraph (A), by striking ‘‘part A or B’’ and in20 serting ‘‘this title’’; 

21 (2) in paragraph (2), by striking ‘‘parts A and 

22 B’’ and inserting ‘‘this title’’; 

23 (3) in paragraph (3), by inserting ‘‘(not later 

24 than December 31, 2010, in the case of contracts reVerDate Nov 24 2008 02:01 Jan 29, 2010 Jkt 089200 PO 00000 Frm 00082 Fmt 6652 Sfmt 6201 E:\BILLS\S2964.IS S2964

tjames on DSKG8SOYB1PROD with BILLS
83 

•S 2964 IS

1 lating to payments made under part C or D)’’ after 

2 ‘‘2010’’; 

3 (4) in paragraph (4), in the matter preceding 

4 subparagraph (A), by striking ‘‘part A or B’’ and in5 serting ‘‘this title’’; and 

6 (5) by adding at the end the following: 

7 ‘‘(9) SPECIAL RULES RELATING TO PARTS C

8 AND D.—The Secretary shall enter into contracts 

9 under paragraph (1) to require recovery audit con10 tractors to— 

11 ‘‘(A) ensure that each MA plan under part 

12 C has an anti- fraud plan in effect and to re13 view the effectiveness of each such anti-fraud 

14 plan; 

15 ‘‘(B) ensure that each prescription drug 

16 plan under part D has an anti- fraud plan in 

17 effect and to review the effectiveness of each 

18 such anti-fraud plan; 

19 ‘‘(C) examine claims for reinsurance pay20 ments under section 1860D–15(b) to determine 

21 whether prescription drug plans submitting 

22 such claims incurred costs in excess of the al23 lowable reinsurance costs permitted under para24 graph (2) of that section; and 


tjames on DSKG8SOYB1PROD with BILLS
84 

•S 2964 IS

1 ‘‘(D) review estimates submitted by pre2 scription drug plans by private plans with re3 spect to the enrollment of high cost bene4 ficiaries (as defined by the Secretary) and to 

5 compare such estimates with the numbers of 

6 such beneficiaries actually enrolled by such 

7 plans.’’. 

8 (c) ANNUAL REPORT.—The Secretary of Health and 

9 Human Services, acting through the Administrator of the 

10 Centers for Medicare & Medicaid Services, shall submit 

11 an annual report to Congress concerning the effectiveness 

12 of the Recovery Audit Contractor program under Medicaid 

13 and Medicare and shall include such reports recommenda14 tions for expanding or improving the program. 

15 SEC. 111. REQUIREMENTS FOR THE TRANSMISSION OF 

16 MANAGEMENT IMPLICATION REPORTS BY 

17 THE HHS OIG. 

18 Section 1128G of the Social Security Act, as added 

19 by section 102(a), is amended by adding at the end the 

20 following new subsection: 

21 ‘‘(f) TRANSMISSION OF MANAGEMENT IMPLICATION

22 REPORTS BY THE HHS OIG.— 

23 ‘‘(1) CONGRESSIONAL NOTIFICATION.—Not 

24 later than 30 days after the transmission by the In25 spector General of the Department of Health and 


tjames on DSKG8SOYB1PROD with BILLS
85 

•S 2964 IS

1 Human Services to another agency of the Depart2 ment of Health and Human Services of a manage3 ment implication report, the Inspector General shall 

4 notify the relevant committees of Congress of such 

5 transmission. 

6 ‘‘(2) SECRETARIAL RESPONSE.—The Secretary 

7 shall respond to a management implication report 

8 transmitted under paragraph (1) not later than 90 

9 days after such transmission. 

10 ‘‘(3) RELEVANT COMMITTEES OF CONGRESS

11 DEFINED.—In this subsection, the term ‘relevant 

12 committees of Congress’ means the Committees on 

13 Ways and Means and Energy and Commerce of the 

14 House of Representatives and the Committee on Fi15 nance of the Senate.’’. 

16 SEC. 112. MEDICAL ID THEFT INFORMATION SHARING PRO17 GRAM AND CLEARINGHOUSE. 

18 (a) ESTABLISHMENT.—Not later than 24 months 

19 after the date of enactment of this Act, the Secretary of 

20 Health and Human Services (in this section referred to 

21 as the ‘‘Secretary’’), acting through the Administrator of 

22 the Centers for Medicare & Medicaid Services and in co23 ordination with the Chairman of the Federal Trade Com24 mission, shall establish an information sharing program 

25 regarding beneficiary medical ID theft under the proVerDate Nov 24 2008 02:01 Jan 29, 2010 Jkt 089200 PO 00000 Frm 00085 Fmt 6652 Sfmt 6201 E:\BILLS\S2964.IS S2964

tjames on DSKG8SOYB1PROD with BILLS
86 

•S 2964 IS

1 grams under titles XVIII, XIX, and XXI of the Social Se2 curity Act (in this section referred to as the ‘‘program’’). 

3 (b) CONTENTS OF PROGRAM.—The program shall in4 clude— 

5 (1) the establishment of methods to identify 

6 and detect relevant warning signs of medical ID 

7 theft; 

8 (2) the establishment of appropriate responses 

9 to such warning signs that would mitigate and pre10 vent beneficiary medical ID theft; and 

11 (3) the development of a detailed plan to up12 date the program as appropriate, taking into consid13 eration such warning signs and appropriate re14 sponses. 

15 (c) ESTABLISHMENT OF CLEARINGHOUSE.—The 

16 Secretary, in coordination with the Chairman of the Fed17 eral Trade Commission, shall establish a clearinghouse at 

18 the Centers for Medicare & Medicaid Services that collects 

19 reports of ID theft against beneficiaries under the pro20 grams under titles XVIII, XIX, and XXI of the Social Se21 curity Act from the Federal Trade Commission and other 

22 sources determined appropriate by the Secretary. Such 

23 clearinghouse shall be used to fight medical ID theft 

24 against beneficiaries and to prevent the improper payment 

25 of claims under such programs. 


tjames on DSKG8SOYB1PROD with BILLS
87 

•S 2964 IS

1 TITLE II—ADDITIONAL 

2 MEDICAID PROVISIONS 

3 SEC. 201. TERMINATION OF PROVIDER PARTICIPATION 

4 UNDER MEDICAID IF TERMINATED UNDER 

5 MEDICARE OR OTHER STATE PLAN. 

6 Section 1902(a)(39) of the Social Security Act (42 

7 U.S.C. 42 U.S.C. 1396a(a)) is amended by inserting after 

8 ‘‘1128A,’’ the following: ‘‘terminate the participation of 

9 any individual or entity in such program if (subject to 

10 such exceptions as are permitted with respect to exclusion 

11 under sections 1128(c)(3)(B) and 1128(d)(3)(B)) partici12 pation of such individual or entity is terminated under title 

13 XVIII or any other State plan under this title,’’. 

14 SEC. 202. MEDICAID EXCLUSION FROM PARTICIPATION RE15 LATING TO CERTAIN OWNERSHIP, CONTROL, 

16 AND MANAGEMENT AFFILIATIONS. 

17 Section 1902(a) of the Social Security Act (42 U.S.C. 

18 1396a(a)), as amended by section 101(b), is amended by 

19 inserting after paragraph (74) the following: 

20 ‘‘(75) provide that the State agency described 

21 in paragraph (9) exclude, with respect to a period, 

22 any individual or entity from participation in the 

23 program under the State plan if such individual or 

24 entity owns, controls, or manages an entity that (or 


tjames on DSKG8SOYB1PROD with BILLS
88 

•S 2964 IS

1 if such entity is owned, controlled, or managed by an 

2 individual or entity that)— 

3 ‘‘(A) has unpaid overpayments (as defined 

4 by the Secretary) under this title during such 

5 period determined by the Secretary or the State 

6 agency to be delinquent; 

7 ‘‘(B) is suspended or excluded from par8 ticipation under or whose participation is termi9 nated under this title during such period; or 

10 ‘‘(C) is affiliated with an individual or enti11 ty that has been suspended or excluded from 

12 participation under this title or whose participa13 tion is terminated under this title during such 

14 period;’’. 

15 SEC. 203. BILLING AGENTS, CLEARINGHOUSES, OR OTHER 

16 ALTERNATE PAYEES REQUIRED TO REG17 ISTER UNDER MEDICAID. 

18 (a) IN GENERAL.—Section 1902(a) of the Social Se19 curity Act (42 U.S.C. 42 U.S.C. 1396a(a)), as amended 

20 by section 202(a), is amended by inserting after para21 graph (75) the following: 

22 ‘‘(76) provide that any agent, clearinghouse, or 

23 other alternate payee (as defined by the Secretary) 

24 that submits claims on behalf of a health care pro25 vider must register with the State and the Secretary 


tjames on DSKG8SOYB1PROD with BILLS
89 

•S 2964 IS

1 in a form and manner specified by the Secretary; 

2 and’’. 

3 SEC. 204. REQUIREMENT TO REPORT EXPANDED SET OF 

4 DATA ELEMENTS UNDER MMIS TO DETECT 

5 FRAUD AND ABUSE. 

6 (a) IN GENERAL.—Section 1903(r)(1)(F) of the So7 cial Security Act (42 U.S.C. 1396b(r)(1)(F)) is amended 

8 by inserting after ‘‘necessary’’ the following: ‘‘and includ9 ing, for data submitted to the Secretary on or after March 

10 1, 2010, data elements from the automated data system 

11 that the Secretary determines to be necessary for program 

12 integrity, program oversight, and administration, at such 

13 frequency as the Secretary shall determine’’. 

14 (b) MANAGED CARE ORGANIZATIONS.— 

15 (1) IN GENERAL.—Section 1903(m)(2)(A)(xi) 

16 of the Social Security Act (42 U.S.C. 

17 1396b(m)(2)(A)(xi)) is amended by inserting ‘‘and 

18 for the provision of such data to the State at a fre19 quency and level of detail to be specified by the Sec20 retary’’ after ‘‘patients’’. 

21 (2) EFFECTIVE DATE.—The amendment made 

22 by paragraph (1) shall apply with respect to contract 

23 years beginning on or after March 1, 2010. 


tjames on DSKG8SOYB1PROD with BILLS
90 

•S 2964 IS

1 SEC. 205. PROHIBITION ON PAYMENTS TO INSTITUTIONS 

2 OR ENTITIES LOCATED OUTSIDE OF THE 

3 UNITED STATES. 

4 Section 1902(a) of the Social Security Act (42 U.S.C. 

5 1396b(a)), as amended by section 203, is amended by in6 serting after paragraph (76) the following new paragraph: 

7 ‘‘(77) provide that the State shall not provide 

8 any payments for items or services provided under 

9 the State plan or under a waiver to any financial in10 stitution or entity located outside of the United 

11 States.’’. 

12 SEC. 206. OVERPAYMENTS. 

13 (a) EXTENSION OF PERIOD FOR COLLECTION OF

14 OVERPAYMENTS DUE TO FRAUD.— 

15 (1) IN GENERAL.—Section 1903(d)(2) of the 

16 Social Security Act (42 U.S.C. 1396b(d)(2)) is 

17 amended— 

18 (A) in subparagraph (C)— 

19 (i) in the first sentence, by striking 

20 ‘‘60 days’’ and inserting ‘‘1 year’’; and 

21 (ii) in the second sentence, by striking 

22 ‘‘60 days’’ and inserting ‘‘1-year period’’; 

23 and 

24 (B) in subparagraph (D)— 

25 (i) in inserting ‘‘(i)’’ after ‘‘(D)’’; and 


tjames on DSKG8SOYB1PROD with BILLS
91 

•S 2964 IS

1 (ii) by adding at the end the fol2 lowing: 

3 ‘‘(ii) In any case where the State is unable to recover 

4 a debt which represents an overpayment (or any portion 

5 thereof) made to a person or other entity due to fraud 

6 within 1 year of discovery because there is not a final de7 termination of the amount of the overpayment under an 

8 administrative or judicial process (as applicable), includ9 ing as a result of a judgment being under appeal, no ad10 justment shall be made in the Federal payment to such 

11 State on account of such overpayment (or portion thereof) 

12 before the date that is 30 days after the date on which 

13 a final judgment (including, if applicable, a final deter14 mination on an appeal) is made.’’. 

15 (2) EFFECTIVE DATE.—The amendments made 

16 by this subsection take effect on the date of enact17 ment of this Act and apply to overpayments discov18 ered on or after that date. 

19 (b) CORRECTIVE ACTION.—The Secretary shall pro20 mulgate regulations that require States to correct Feder21 ally identified claims overpayments, of an ongoing or re22 curring nature, with new Medicaid Management Informa23 tion System (MMIS) edits, audits, or other appropriate 

24 corrective action. 


tjames on DSKG8SOYB1PROD with BILLS
92 

•S 2964 IS

1 SEC. 207. MANDATORY STATE USE OF NATIONAL CORRECT 

2 CODING INITIATIVE. 

3 Section 1903(r) of the Social Security Act (42 U.S.C. 

4 1396b(r)) is amended— 

5 (1) in paragraph (1)(B)— 

6 (A) in clause (ii), by striking ‘‘and’’ at the 

7 end; 

8 (B) in clause (iii), by adding ‘‘and’’ after 

9 the semi-colon; and 

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

11 clause: 

12 ‘‘(iv) effective for claims filed on or 

13 after October 1, 2010, incorporate compat14 ible methodologies of the National Correct 

15 Coding Initiative administered by the Sec16 retary (or any successor initiative to pro17 mote correct coding and to control im18 proper coding leading to inappropriate pay19 ment) and such other methodologies of 

20 that Initiative (or such other national cor21 rect coding methodologies) as the Sec22 retary identifies in accordance with para23 graph (4);’’; and 

24 (2) by adding at the end the following new 

25 paragraph: 


tjames on DSKG8SOYB1PROD with BILLS
93 

•S 2964 IS

1 ‘‘(4) For purposes of paragraph (1)(B)(iv), the Sec2 retary shall do the following: 

3 ‘‘(A) Not later than September 1, 2010: 

4 ‘‘(i) Identify those methodologies of the 

5 National Correct Coding Initiative administered 

6 by the Secretary (or any successor initiative to 

7 promote correct coding and to control improper 

8 coding leading to inappropriate payment) which 

9 are compatible to claims filed under this title. 

10 ‘‘(ii) Identify those methodologies of such 

11 Initiative (or such other national correct coding 

12 methodologies) that should be incorporated into 

13 claims filed under this title with respect to 

14 items or services for which States provide med15 ical assistance under this title and no national 

16 correct coding methodologies have been estab17 lished under such Initiative with respect to title 

18 XVIII. 

19 ‘‘(iii) Notify States of— 

20 ‘‘(I) the methodologies identified 

21 under subparagraphs (A) and (B) (and of 

22 any other national correct coding meth23 odologies identified under subparagraph 

24 (B)); and 


tjames on DSKG8SOYB1PROD with BILLS
94 

•S 2964 IS

1 ‘‘(II) how States are to incorporate 

2 such methodologies into claims filed under 

3 this title. 

4 ‘‘(B) Not later than March 1, 2011, submit a 

5 report to Congress that includes the notice to States 

6 under clause (iii) of subparagraph (A) and an anal7 ysis supporting the identification of the methodolo8 gies made under clauses (i) and (ii) of subparagraph 

9 (A).’’. 

10 SEC. 208. PAYMENT FOR ILLEGAL UNAPPROVED DRUGS. 

11 (a) FINDINGS.—Congress finds that each year, the 

12 Medicaid program under title XIX of the Social Security 

13 Act (42 U.S.C. 1396 et seq.) pays millions of dollars in 

14 reimbursement for covered outpatient drugs that are not 

15 approved by the Food and Drug Administration under a 

16 new drug application under section 505(b) of the Federal 

17 Food, Drug, and Cosmetic Act (21 U.S.C. 355(b)) or an 

18 abbreviated new drug application under section 505(j) of 

19 such Act, or that such drug is not subject such section 

20 505 or section 512 due to the application of section 201(p) 

21 of such Act (21 U.S.C. 321(p)). 

22 (b) LISTING OF DRUGS AND DEVICES.—Section 510 

23 of the Food, Drug and Cosmetic Act (21 U.S.C. 360) is 

24 amended— 

25 (1) in subsection (j)(1)(B)— 


tjames on DSKG8SOYB1PROD with BILLS
95 

•S 2964 IS

1 (A) in clause (i), by inserting ‘‘in the case 

2 of a drug, the authority under this Act that 

3 does not require such drug to be subject to sec4 tion 505 and section 512,’’ after ‘‘labeling for 

5 such drug or device,’’; and 

6 (B) in clause (ii), by inserting ‘‘, in the 

7 case of a drug, the authority under this Act 

8 that does not require such drug to be subject to 

9 section 505 and section 512,’’ after ‘‘for such 

10 drug or device’’; and 

11 (2) in subsection (f)— 

12 (A) by striking ‘‘(f) The Secretary’’ and in13 serting the following: 

14 ‘‘(f) INSPECTION BY PUBLIC OF REGISTRATION.— 

15 ‘‘(1) IN GENERAL.—The Secretary’’; and 

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

17 ‘‘(2) LIST OF DRUGS THAT ARE NOT APPROVED

18 UNDER SECTION 505 OR 512.—Not later than Janu19 ary 1, 2011, the Secretary shall make available to 

20 the public on the Internet website of the Food and 

21 Drug Administration a list that includes, for each 

22 drug described in subsection (j)(1)(B)— 

23 ‘‘(A) the drug; 

24 ‘‘(B) the person who listed such drug; and 


tjames on DSKG8SOYB1PROD with BILLS
96 

•S 2964 IS

1 ‘‘(C) the authority under this Act that 

2 does not require such drug to be subject to sec3 tion 505 and section 512, as provided by such 

4 person in such list.’’. 

5 (c) PAYMENT FOR COVERED OUTPATIENT DRUGS.— 

6 Section 1927 of the Social Security Act (42 U.S.C. 1396r– 

7 8) is amended by inserting at the end the following: 

8 ‘‘(l) CONDITION.—Beginning January 1, 2011, no 

9 State shall make any payment under this section for any 

10 covered outpatient drug unless such State first verifies 

11 with the Food and Drug Administration that such covered 

12 outpatient drug has been approved by the Food and Drug 

13 Administration under a new drug application under sec14 tion 505(b) of the Federal Food, Drug, and Cosmetic Act 

15 (21 U.S.C. 355(b)) or an abbreviated new drug application 

16 under section 505(j) of such Act, or that such drug is not 

17 subject such section 505 or section 512 due to the applica18 tion of section 201(p) of such Act (21 U.S.C. 321(p)). The 

19 Secretary shall have the authority to proscribe regulations 

20 to create an information sharing protocol to allow States 

21 to verify that a covered outpatient drug has been approved 

22 by the Food and Drug Administration.’’. 

23 SEC. 209. GENERAL EFFECTIVE DATE. 

24 (a) IN GENERAL.—Except as otherwise provided in 

25 this subtitle, this subtitle and the amendments made by 


tjames on DSKG8SOYB1PROD with BILLS
97 

•S 2964 IS

1 this subtitle take effect on January 1, 2011, without re2 gard to whether final regulations to carry out such amend3 ments and subtitle have been promulgated by that date. 

4 (b) DELAY IF STATE LEGISLATION REQUIRED.—In 

5 the case of a State plan for medical assistance under title 

6 XIX of the Social Security Act or a child health plan 

7 under title XXI of such Act which the Secretary of Health 

8 and Human Services determines requires State legislation 

9 (other than legislation appropriating funds) in order for 

10 the plan to meet the additional requirement imposed by 

11 the amendments made by this subtitle, the State plan or 

12 child health plan shall not be regarded as failing to comply 

13 with the requirements of such title solely on the basis of 

14 its failure to meet this additional requirement before the 

15 first day of the first calendar quarter beginning after the 

16 close of the first regular session of the State legislature 

17 that begins after the date of the enactment of this Act. 

18 For purposes of the previous sentence, in the case of a 

19 State that has a 2-year legislative session, each year of 

20 such session shall be deemed to be a separate regular ses21 sion of the State legislature. 


tjames on DSKG8SOYB1PROD with BILLS
98 

•S 2964 IS

1 TITLE III—ADDITIONAL 

2 PROVISIONS 

3 SEC. 301. REQUIRING INDIVIDUALS OR ENTITIES THAT 

4 PARTICIPATE IN OR CONDUCT ACTIVITIES 

5 UNDER FEDERAL HEALTH CARE PROGRAMS 

6 TO COMPLY WITH CERTAIN CONGRESSIONAL 

7 REQUESTS. 

8 (a) IN GENERAL.—Section 1128G of the Social Secu9 rity Act, as added by section 102(a) and amended by sec10 tion 111, is amended by adding at the end the following 

11 new subsection: 

12 ‘‘(g) COMPLIANCE WITH CERTAIN REQUESTS BY IN13 DIVIDUALS AND ENTITIES THAT PARTICIPATE IN OR

14 CONDUCT ACTIVITIES UNDER FEDERAL HEALTH CARE

15 PROGRAMS.— 

16 ‘‘(1) IN GENERAL.—Any individual or entity 

17 that participates in or conducts activities under a 

18 Federal health care program (as defined in section 

19 1128B(f)) shall, as a condition of such participation 

20 or such conduct, comply (at a time and in a manner 

21 specified by the Chairman or ranking member) with 

22 any request submitted by the Chairman or the rank23 ing member of a relevant committee of Congress to 

24 the individual or entity for the following: 

25 ‘‘(A) Documents. 


tjames on DSKG8SOYB1PROD with BILLS
99 

•S 2964 IS

1 ‘‘(B) Information. 

2 ‘‘(C) Interviews. 

3 ‘‘(2) RELEVANT COMMITTEE OF CONGRESS DE4 FINED.—In this subsection, the term ‘relevant com5 mittee of Congress’ means the Committees on Ways 

6 and Means and Energy and Commerce of the House 

7 of Representatives and the Committee on Finance of 

8 the Senate.’’. 

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

10 this section shall take effect on the date that is 2 years 

11 after the date of enactment of this Act. 

12 SEC. 302. AMENDMENTS TO THE FALSE CLAIMS ACT. 

13 Section 3730(h) of title 31, United States Code, is 

14 amended— 

15 (1) in paragraph (1), by striking ‘‘or agent on 

16 behalf of the employee, contractor, or agent or asso17 ciated others in furtherance of other efforts to stop 

18 1 or more violations of this subchapter’’ and insert19 ing ‘‘agent or associated others in furtherance of an 

20 action under this section or other efforts to stop 1 

21 or more violations of this subchapter’’; and 

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

23 ‘‘(3) LIMITATION ON BRINGING CIVIL AC24 TION.—A civil action under this subsection may not 


tjames on DSKG8SOYB1PROD with BILLS
100 

•S 2964 IS

1 be brought more than 2 years after the date when 

2 the retaliation occurred.’’. 

3 SEC. 303. DISMISSAL OF CERTAIN ACTIONS OR CLAIMS 

4 UNDER THE FALSE CLAIMS ACT. 

5 Section 3730(e) of title 31, United States Code, is 

6 amended by striking paragraph (4) and inserting the fol7 lowing: 

8 ‘‘(4)(A) The court shall dismiss an action or 

9 claim under this section, unless opposed by the Gov10 ernment, if substantially the same allegations or 

11 transactions as alleged in the action or claim were 

12 publicly disclosed— 

13 ‘‘(i) in a Federal criminal, civil, or admin14 istrative hearing in which the Government or its 

15 agent is a party; 

16 ‘‘(ii) in a congressional, Government Ac17 countability Office, or other Federal report, 

18 hearing, audit, or investigation; or 

19 ‘‘(iii) from the news media, unless the ac20 tion is brought by the Attorney General or the 

21 person bringing the action is an original source 

22 of the information. 

23 ‘‘(B) For purposes of this paragraph, the term 

24 ‘original source’ means an individual who— 


tjames on DSKG8SOYB1PROD with BILLS
101 

•S 2964 IS

1 ‘‘(i) prior to a public disclosure under sub2 section (e)(4)(a), has voluntarily disclosed to 

3 the Government the information on which alle4 gations or transactions in a claim are based; or 

5 ‘‘(ii) has knowledge that is independent of 

6 and materially adds to the publicly disclosed al7 legations or transactions, and has voluntarily 

8 provided the information to the Government be9 fore filing an action under this section.’’. 

Æ 


tjames on DSKG8SOYB1PROD with BILLS