912
(1) The relative values established under section
1848(c) of such Act for services (other than anesthe-
sia services) and, in the case of anesthesia services,
the conversion factor established under section 1848
of such Act for such services.
(2) The amounts determined under section
1848(a)(2)(B)(i)(I) of such Act.
(3) The prevailing charges or fee schedule
amounts to be applied under such part for services
of a health care practitioner (as defined in section
1842(b)(4)(F)(ii)(I) of such Act, as in effect before
the date of the enactment of this Act).
(c) CONFORMING AMENDMENTS.—Section 1848 (42
U.S.C. 1395w–4), as amended by section 13441(c), is
amended—
(1) in subsection (a)(2)(B)(i)(I), by inserting
‘‘and section 13442(b) of the Omnibus Budget Rec-
onciliation Act of 1993’’ after ‘‘(c)(2)(E)(ii)’’ after
‘‘for 1993’’;
(2) in subsection (c)(2)(A)(i), by inserting ‘‘and
section 13442(b) of the Omnibus Budget Reconcili-
ation Act of 1993’’ after ‘‘under subparagraph
(E)(i)’’; and
(3) in subsection (i)(1)(B), by inserting ‘‘and
section 13442(b) of the Omnibus Budget Reconcili-
913
ation Act of 1993’’ after ‘‘under subsection
(c)(2)(E)’’.
(d) EFFECTIVE DATE.—The amendments made by
subsection (a) shall apply to services furnished on or after
January 1, 1994.
SEC. 13443. RETAINING PAYMENT FOR ACTUAL ANESTHE-
SIA TIME.
(a) PHYSICIANS’ SERVICES.—Section 1848(b)(2)(B)
(42 U.S.C. 1395w–4(b)(2)(B)) is amended by adding at
the end the following: ‘‘The Secretary may not modify the
methodology in effect as of January 1, 1992, for determin-
ing the amount of time that may be billed for such services
under this section.’’.
(b) SERVICES OF CERTIFIED REGISTERED NURSE
ANESTHETISTS.—Section 
1833(l)(1)(B) 
(42 
U.S.C.
1395l(l)(1)(B)) is amended by adding at the end the fol-
lowing: ‘‘The Secretary may not modify the methodology
in effect as of January 1, 1992, for determining the
amount of time that may be billed for such services under
this section.’’.
(c) EFFECTIVE DATE.—The amendments made by
this section shall take apply to services furnished on or
after the date of the enactment of this Act.
914
SEC. 13444. GEOGRAPHIC COST OF PRACTICE INDEX RE-
FINEMENTS.
(a) REQUIRING CONSULTATION WITH REPRESENTA-
TIVES OF PHYSICIANS IN REVIEWING GEOGRAPHIC AD-
JUSTMENT FACTORS.—Section 1848(e)(1)(C) (42 U.S.C.
1395w–4(e)(1)(C)) is amended by striking ‘‘shall review’’
and inserting ‘‘shall, in consultation with appropriate rep-
resentatives of physicians, review’’.
(b) USE OF MOST RECENT DATA IN GEOGRAPHIC
ADJUSTMENT.—Section 1848(e)(1) (42 U.S.C. 1395w–
4(e)(1)) is amended by adding at the end the following
new subparagraph:
‘‘(D) USE OF RECENT DATA.—In estab-
lishing indices and index values under this
paragraph, the Secretary shall use the most re-
cent data available relating to practice ex-
penses, malpractice expenses, and physician
work effort in different fee schedule areas.’’.
(c) DEADLINE
FOR INITIAL REVIEW
AND REVI-
SION.—The Secretary of Health and Human Services
shall first review and revise geographic adjustment factors
under section 1848(e)(1)(C) of the Social Security Act by
not later than January 1, 1995. Not later than April 1,
1994, the Secretary shall study and report to report to
the Committee on Finance of the Senate and the Commit-
tee on Ways and Means and the Committee on Energy
915
and Commerce of the House of Representatives on the
construction of the geographic cost of practice index under
section 1848(e)(1)(A)(i) of such Act.
(d) REPORT ON REVIEW PROCESS.—Not later than
1 year after the date of the enactment of this Act, the
Secretary of Health and Human Services shall study and
report to the Committee on Finance of the Senate and
the Committee on Ways and Means and the Committee
on Energy and Commerce of the House of Representatives
on—
(1) the data necessary to review and revise the
indices established under section 1848(e)(1)(A) of
the Social Security Act, including—
(A) the shares allocated to physicians’
work effort, practice expenses (other than mal-
practice expenses), and malpractice expenses;
(B) the weights assigned to the input com-
ponents of such shares; and
(C) the index values assigned to such com-
ponents;
(2) any limitations on the availability of data
necessary to review and revise such indices at least
every three years;
(3) ways of addressing such limitations, with
particular attention to the development of alternative
916
data sources for input components for which current
index values are based on data collected less fre-
quently than every three years; and
(4) the costs of developing more accurate and
timely data.
(e) DEVELOPMENT OF CRITERIA FOR USE IN DE-
TERMINING PAYMENT LOCALITIES.—The Physician Pay-
ment Review Commission shall conduct a study to develop
criteria that would be used to refine the fee schedule areas
that are used within States, in applying geographic adjust-
ment factors for computing payment amounts, under sec-
tion 1848 of the Social Security Act. The Commission
shall include a report on such study in its recommenda-
tions submitted to the Congress under section 1845(b) of
such Act in 1994.
SEC. 13445. EXTRA-BILLING.
(a) ENFORCEMENT AND UNIFORM APPLICATION.—
(1) ENFORCEMENT.—Paragraph (1) of section
1848(g) (42 U.S.C. 1395w–4(g)) is amended to read
as follows:
‘‘(1) LIMITATION ON ACTUAL CHARGES.—
‘‘(A) IN
GENERAL.—In the case of a
nonparticipating physician or nonparticipating
supplier or other person (as defined in section
1842(i)(2)) who does not accept payment on an
917
assignment-related basis for a physician’s serv-
ice furnished with respect to an individual en-
rolled under this part, the following rules apply:
‘‘(i) 
APPLICATION
OF
LIMITING
CHARGE.—No person may bill or collect an
actual charge for the service in excess of
the limiting charge described in paragraph
(2) for such service.
‘‘(ii) NO
LIABILITY
FOR
EXCESS
CHARGES.—No person is liable for pay-
ment of any amounts billed for the service
in excess of such limiting charge.
‘‘(iii) 
CORRECTION
OF
EXCESS
CHARGES.—If such a physician, supplier,
or other person bills, but does not collect,
an actual charge for a service in violation
of clause (i), the physician, supplier, or
other person shall reduce on a timely basis
the actual charge billed for the service to
an amount not to exceed the limiting
charge for the service.
‘‘(iv) REFUND
OF
EXCESS
COLLEC-
TIONS.—If such a physician, supplier, or
other person collects an actual charge for
a service in violation of clause (i), the phy-
918
sician, supplier, or other person shall pro-
vide on a timely basis a refund to the indi-
vidual charged in the amount by which the
amount collected exceeded the limiting
charge for the service. The amount of such
a refund shall be reduced to the extent the
individual has an outstanding balance owed
by the individual to the physician.
‘‘(B) SANCTIONS.—If a physician, supplier,
or other person—
‘‘(i) knowingly and willfully bills or
collects for services in violation of subpara-
graph (A)(i) on a repeated basis, or
‘‘(ii) fails to comply with clause (iii)
or (iv) of subparagraph (A) on a timely
basis,
the Secretary may apply sanctions against the
physician, supplier, or other person in accord-
ance with paragraph (2) of section 1842(j). In
applying this subparagraph, paragraph (4) of
such section applies in the same manner as
such paragraph applies to such section and any
reference in such section to a physician is
deemed also to include a reference to a supplier
or other person under this subparagraph.
919
‘‘(C) TIMELY BASIS.—For purposes of this
paragraph, a correction of a bill for an excess
charge or refund of an amount with respect to
a violation of subparagraph (A)(i) in the case of
a service is considered to be provided ‘on a
timely basis’, if the reduction or refund is made
not later than 30 days after the date the physi-
cian, supplier, or other person is notified by the
carrier under this part of such violation and of
the requirements of subparagraph (A).’’.
(2) UNIFORM APPLICATION OF EXTRA-BILLING
LIMITS TO PHYSICIANS’ SERVICES.—
(A) IN GENERAL.—Section 1848(g)(2)(C)
(42 U.S.C. 1395w–4(g)(2)(C)) is amended by
inserting ‘‘or for nonparticipating suppliers or
other persons’’ after ‘‘nonparticipating physi-
cians’’.
(B) CONFORMING
DEFINITION.—Section
1842(i)(2) (42 U.S.C. 1395u(i)(2)) is amend-
ed—
(i) by striking ‘‘, and the term’’ and
inserting ‘‘; the term’’, and
(ii) by inserting before the period at
the end the following: ‘‘; and the term
‘nonparticipating supplier or other person’
920
means a supplier or other person (exclud-
ing a provider of services) that is not a
participating physician or supplier (as de-
fined in subsection (h)(1))’’.
(b) PRE-PAYMENT SCREENING
OF CLAIMS.—Sub-
paragraph (G) of section 1842(b)(3) (42 U.S.C.
1395u(b)(3)) is amended to read as follows:
‘‘(G) will, for a service that is furnished with
respect to an individual enrolled under this part,
that is not paid on an assignment-related basis, and
that is subject to a limiting charge under section
1848(g)—
‘‘(i) determine, prior to making payment,
whether the amount billed for such service ex-
ceeds the limiting charge applicable under sec-
tion 1848(g)(2);
‘‘(ii) notify the physician, supplier, or other
person periodically (but not less often than once
every 30 days) of determinations that amounts
billed exceeded such applicable limiting charges;
and
‘‘(iii) provide for prompt response to in-
quiries of physicians, suppliers, and other per-
sons concerning the accuracy of such limiting
charges for their services;’’.
921
(c) INFORMATION ON EXTRA-BILLING LIMITS.—
(1) PART OF EXPLANATION OF MEDICARE BEN-
EFITS.—Section 
1842(h)(7) 
(42 
U.S.C.
1395u(h)(7)) is amended—
(A) by striking ‘‘and’’ at the end of sub-
paragraph (B),
(B) in subparagraph (C), by striking ‘‘shall
include’’ and by striking the period at the end
and inserting ‘‘, and’’, and
(C) by adding at the end the following new
subparagraph:
‘‘(D) in the case of services for which the billed
amount exceeds the limiting charge imposed under
section 1848(g), information regarding such applica-
ble limiting charge (including information concern-
ing 
the 
right 
to 
a 
refund 
under 
section
1848(g)(1)(A)(iv)).’’.
(2) REPORT ON CHARGES IN EXCESS OF LIMIT-
ING
CHARGE.—Section 1848(g)(6)(B) (42 U.S.C.
1395w–4(g)(6)(B)) is amended by inserting ‘‘the ex-
tent to which actual charges exceed limiting charges,
the number and types of services involved, and the
average amount of excess charges and’’ after ‘‘report
to the Congress’’.