I 

112TH CONGRESS 

1ST SESSION H. R. 315 

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

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

education, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

JANUARY 18, 2011 

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

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

on Ways and Means, for a period to be subsequently determined by the 

Speaker, in each case for consideration of such provisions as fall within 

the jurisdiction of the committee concerned 

A BILL 

To reduce the amount of paperwork and improve payment 

policies for health care services, to prevent fraud and 

abuse through health care provider education, and for 

other purposes. 

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

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Health Care Paper5 work Reduction and Fraud Prevention Act’’. 


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1 SEC. 2. NATIONAL BIPARTISAN COMMISSION ON BILLING 

2 CODES AND FORMS SIMPLIFICATION. 

3 (a) ESTABLISHMENT.—There is hereby established 

4 the Commission on Health Care Billing Codes and Forms 

5 Simplification (in this section referred to as the ‘‘Commis6 sion’’). 

7 (b) DUTIES.—The Commission shall make rec8 ommendations regarding the following: 

9 (1) STANDARDIZED AND SIMPLIFIED FORMS.— 

10 Standardizing and simplifying credentialing and bill11 ing forms respecting health care claims, that all 

12 Federal Government agencies would use and that 

13 the private sector is able (and is encouraged, but not 

14 required) to use. 

15 (2) REDUCTION IN BILLING CODES.—A signifi16 cant reduction and simplification in the number of 

17 billing codes for health care claims. 

18 (3) REGULATORY AND APPEALS PROCESS RE19 FORM.—Reforms in the regulatory and appeals proc20 esses under the Medicare program under title XVIII 

21 of the Social Security Act in order to ensure that the 

22 Secretary of Health and Human Services provides 

23 appropriate guidance to suppliers and providers of 

24 services (as such terms are defined in subsections 

25 (d) and (u), respectively, of section 1861 of such 

26 Act), including physicians and providers and supVerDate Mar 15 2010 03:07 Jan 19, 2011 Jkt 099200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H315.IH H315

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1 pliers of ambulance services, that are attempting to 

2 properly submit claims under the Medicare program 

3 and to ensure that the Secretary does not target in4 advertent billing errors. 

5 (4) ELECTRONIC FORMS AND PAYMENTS.—Sim6 plifying and updating electronic forms of the Centers 

7 for Medicare & Medicaid Services to ensure sim8 plicity as well as patient privacy. 

9 (c) MEMBERSHIP.— 

10 (1) NUMBER AND APPOINTMENT.—The Com11 mission shall be composed of 17 members, of 

12 whom— 

13 (A) four shall be appointed by the Presi14 dent; 

15 (B) six shall be appointed by the majority 

16 leader of the Senate, in consultation with the 

17 minority leader of the Senate, of whom not 

18 more than 4 shall be of the same political party; 

19 (C) six shall be appointed by the Speaker 

20 of the House of Representatives, in consultation 

21 with the minority leader of the House of Rep22 resentatives, of whom not more than 4 shall be 

23 of the same political party; and 

24 (D) one, who shall serve as Chairman of 

25 the Commission, shall be appointed jointly by 


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1 the President, majority leader of the Senate, 

2 and the Speaker of the House of Representa3 tives. 

4 (2) APPOINTMENT.—Members of the Commis5 sion shall be appointed by not later than 90 days 

6 after the date of the enactment of this Act. 

7 (d) INCORPORATION OF BIPARTISAN COMMISSION

8 PROVISIONS.—The provisions of paragraphs (3) through 

9 (8) of subsection (c) and subsections (d), (e), and (h) of 

10 section 4021 of the Balanced Budget Act of 1997 shall 

11 apply to the Commission under this section in the same 

12 manner as they applied to the National Bipartisan Com13 mission on the Future of Medicare under such section. 

14 (e) REPORT.—Not later than December 31, 2011, the 

15 Commission shall submit to the President and Congress 

16 a report which shall contain a detailed statement of only 

17 those recommendations, findings, and conclusions of the 

18 Commission that receive the approval of at least 11 mem19 bers of the Commission. 

20 (f) TERMINATION.—The Commission shall terminate 

21 30 days after the date of submission of the report required 

22 in subsection (e). 

23 SEC. 3. EDUCATION OF PHYSICIANS AND PROVIDERS CON24 CERNING MEDICARE PROGRAM PAYMENTS. 

25 (a) WRITTEN REQUESTS.— 


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

2 Human Services shall establish a process under 

3 which a physician may request, in writing from a 

4 carrier, assistance in addressing questionable codes 

5 and procedures under the Medicare program under 

6 title XVIII of the Social Security Act and then the 

7 carrier shall respond in writing within 30 business 

8 days with the correct billing or procedural answer. 

9 (2) USE OF WRITTEN STATEMENT.— 

10 (A) IN GENERAL.—Subject to subpara11 graph (B), a written statement under para12 graph (1) may be used as proof against a fu13 ture audit or overpayment under the Medicare 

14 program. 

15 (B) LIMIT ON APPLICATION.—Subpara16 graph (A) shall not apply retroactively and shall 

17 not apply to cases of fraudulent billing. 

18 (b) DEFINITIONS.—For purposes of this section: 

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

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

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

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

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

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


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1 under title XVIII of such Act to administer benefits 

2 under part B of such title. 

3 SEC. 4. POLICY DEVELOPMENT REGARDING E&M GUIDE4 LINES UNDER THE MEDICARE PROGRAM. 

5 (a) IN GENERAL.—The Administrator of the Centers 

6 for Medicare & Medicaid Services may not implement any 

7 new evaluation and management guidelines (in this section 

8 referred to as ‘‘E&M guidelines’’) under the Medicare pro9 gram, unless the Administrator— 

10 (1) has provided for an assessment of the pro11 posed guidelines by physicians; 

12 (2) has established a plan that contains specific 

13 goals, including a schedule, for improving participa14 tion of physicians in the assessment described in 

15 paragraph (1); 

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

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

18 different regions (to be specified by the Secretary) to 

19 test such guidelines; and 

20 (4) finds that the objectives described in sub21 section (c) will be met in the implementation of such 

22 guidelines. 

23 (b) PILOT PROJECTS.— 

24 (1) LENGTH AND CONSULTATION.—Each pilot 

25 project under this subsection shall— 


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1 (A) be of sufficient length to allow for pre2 paratory physician and carrier education, anal3 ysis, and use and assessment of potential E&M 

4 guidelines; and 

5 (B) be conducted, throughout the planning 

6 and operational stages of the project, in con7 sultation with national and State medical soci8 eties. 

9 (2) PEER REVIEW AND RURAL PILOT

10 PROJECTS.—Of the pilot projects conducted under 

11 this subsection— 

12 (A) at least one shall focus on a peer re13 view method by physicians which evaluates 

14 medical record information for statistical outlier 

15 services relative to definitions and guidelines 

16 published in the most recent Current Proce17 dural Terminology book, instead of an approach 

18 using the review of randomly selected medical 

19 records using non-clinical personnel; and 

20 (B) at least one shall be conducted for 

21 services furnished in a rural area. 

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

23 shall examine the effect of the potential E&M guide24 lines on— 


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1 (A) different types of physician practices, 

2 such as large and small groups; and 

3 (B) the costs of compliance, and patient 

4 and physician satisfaction. 

5 (4) REPORT ON HOW MET OBJECTIVES.—Not 

6 later than 6 months after the date of the conclusion 

7 of all of the pilot projects under this subsection, the 

8 Administrator of the Centers for Medicare & Med9 icaid Services shall submit a report to the Commit10 tees on Commerce and Ways and Means of the 

11 House of Representatives, the Committee on Fi12 nance of the Senate, and the Practicing Physicians 

13 Advisory Council, on such pilot projects. Such report 

14 shall include the extent to which the pilot projects 

15 met the objectives specified in subsection (c). 

16 (c) OBJECTIVES FOR E&M GUIDELINES.—The objec17 tives for E&M guidelines specified in this subsection are 

18 as follows (relative to the E&M guidelines and review poli19 cies in effect as of the date of the enactment of this Act): 

20 (1) Enhancing clinically relevant documentation 

21 needed to accurately code and assess coding levels 

22 accurately. 

23 (2) Reducing administrative burdens. 


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1 (3) Decreasing the level of non-clinically perti2 nent and burdensome documentation time and con3 tent in the record. 

4 (4) Increased accuracy by carrier reviewers. 

5 (5) Education of both physicians and reviewers. 

6 (6) Appropriate use of evaluation and manage7 ment codes by physicians and their staffs. 

8 (7) The extent to which the tested evaluation 

9 and management documentation guidelines substan10 tially adhere to the CPT coding rules. 

11 (8) Simplifying electronic billing. 

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

13 section 5: 

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

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

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

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

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

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

20 under title XVIII of such Act to administer benefits 

21 under part B of such title. 

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

23 the Secretary of Health and Human Services. 


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1 (4) MEDICARE PROGRAM.—The term ‘‘Medicare 

2 program’’ means the program under title XVIII of 

3 the Social Security Act. 

4 SEC. 5. OVERPAYMENTS UNDER THE MEDICARE PROGRAM. 

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

6 with a post-payment audit of a physician under the Medi7 care program, the carrier shall provide the physician with 

8 an individualized notice of billing problems, such as a per9 sonal visit or carrier-to-physician telephone conversation 

10 during normal working hours, within 3 months of initi11 ating such audit. The notice should include suggestions 

12 to the physician on how the billing problem may be rem13 edied. 

14 (b) REPAYMENT OF OVERPAYMENTS WITHOUT PEN15 ALTY.—The Secretary of Health and Human Services 

16 shall permit a physician to repay Medicare overpayments 

17 made to such physician without penalty or interest and 

18 without threat of denial of other claims based upon ex19 trapolation, if such repayment is made not later than 3 

20 months after such physician receives notification of such 

21 overpayment and if such overpayment was not determined 

22 by a final adverse action to be the result of fraudulent 

23 billing. If a physician should discover an overpayment be24 fore a carrier notifies the physician of the error, the physi25 cian may reimburse the Medicare program without penalty 


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1 and the Secretary may not audit or target the physician 

2 on the basis of such repayment, unless other evidence of 

3 fraudulent billing exists. 

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

5 If a physician’s Medicare billing error was a first-time 

6 error and the physician has not previously been the subject 

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

8 through extrapolation of such an error to other claims, 

9 unless the physician has submitted a fraudulent claim. 

10 (d) TIMELY NOTICE OF PROBLEM CLAIMS BEFORE

11 USING EXTRAPOLATION.—A carrier may seek reimburse12 ment or penalties against a physician based on extrapo13 lation of a Medicare claim only if the carrier has informed 

14 the physician of potential problems with the claim not 

15 later than one year after the date the claim was submitted 

16 for reimbursement. 

17 (e) SUBMISSION OF ADDITIONAL INFORMATION.—A 

18 physician may submit additional information and docu19 mentation to dispute a carrier’s charges of overpayment 

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

21 administrative law judge. 

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

23 a post-payment audit, a carrier that is conducting a pre24 payment screen on a physician service under the Medicare 

25 program may not delay reimbursements for more than one 


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1 month and as soon as the physician submits a corrected 

2 claim, the carrier shall eliminate application of such a pre3 payment screen. 

Æ 


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