I
103D CONGRESS
1ST SESSION
H. R. 721
To amend the Social Security Act to extend the ban on physician self-
referrals to all payors and to radiology and diagnostic imaging services,
radiation therapy services, physical therapy services, and durable medical
equipment.
IN THE HOUSE OF REPRESENTATIVES
FEBRUARY 2, 1992
Mr. KASICH (for himself and Mr. SANTORUM) introduced the following bill;
which was referred jointly to the Committee on Ways and Means and En-
ergy and Commerce
A BILL
To amend the Social Security Act to extend the ban on
physician self-referrals to all payors and to radiology
and diagnostic imaging services, radiation therapy serv-
ices, physical therapy services, and durable medical
equipment.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ‘‘Physician Self-Referral
Amendments of 1993’’.
SEC. 2. EXTENSION OF PHYSICIAN SELF-REFERRAL LIMITA-
TIONS TO ALL PAYORS.
Section 1877 of the Social Security Act (42 U.S.C.
1395nn) is amended—
(1) in subsection (a)—
(A) in paragraph (1)(A), by striking ‘‘for
which payment otherwise may be made under
this title’’ and inserting ‘‘for which a charge is
imposed’’, and
(B) in paragraph (1)(B), by striking
‘‘under this title’’;
(2) by amending paragraph (1) of subsection
(g) to read as follows:
‘‘(1) DENIAL OF PAYMENT.—No payment may
be made under this title, under another Federal
health care program, or under a State health care
program (as defined in section 1128(h)) for a des-
ignated health service for which a claim is presented
in violation of subsection (a)(1)(B). No individual,
third party payor, or other entity is liable for pay-
ment for designated health services for which a
claim is presented in violation of such subsection.’’;
and
(3) in subsection (g)(3), by striking ‘‘for which
payment may not be made under paragraph (1)’’
and inserting ‘‘for which such a claim may not be
presented under subsection (a)(1)’’.
SEC. 3. EXTENSION OF PHYSICIAN SELF-REFERRAL LIMITA-
TIONS TO CERTAIN ADDITIONAL SERVICES.
(a) IN GENERAL.—Section 1877 of the Social Secu-
rity Act is further amended—
(1) by striking ‘‘clinical laboratory services’’
and ‘‘CLINICAL LABORATORY SERVICES’’ and insert-
ing ‘‘designated health services’’ and ‘‘DESIGNATED
HEALTH SERVICES’’, respectively, each place either
appears 
in 
subsections 
(a)(1), 
(b)(2)(A)(ii)(I),
(b)(4), (d)(1), (d)(2), and (d)(3), and
(2) by adding at the end the following new sub-
section:
‘‘(i) DESIGNATED HEALTH SERVICES DEFINED.—In
this section, the term ‘designated health services’ means—
‘‘(1) clinical laboratory services,
‘‘(2) physical therapy services,
‘‘(3) radiology and diagnostic imaging services,
‘‘(4) radiation therapy services, and
‘‘(5) the furnishing of durable medical equip-
ment.’’.
(b) CONFORMING AMENDMENTS.—Section 1877 of
such Act is further amended—
(1) in subsection (d)(2), by striking ‘‘labora-
tory’’ and inserting ‘‘entity’’,
(2) in subsection (g)(1), by striking ‘‘clinical
laboratory service’’ and inserting ‘‘designated health
service’’, and
(3) in subsection (h)(7)(B), by striking ‘‘clinical
laboratory service’’ and inserting ‘‘designated health
service’’, and
SEC. 4. CHANGES IN EXCEPTIONS.
(a) HEALTH MAINTENANCE ORGANIZATIONS
AND
MANAGED
CARE
PLANS.—Paragraph (3) of section
1877(b) of the Social Security Act is amended to read as
follows:
‘‘(3) HEALTH
MAINTENANCE
ORGANIZATIONS
AND MANAGED CARE PLANS.—
‘‘(A) HEALTH
MAINTENANCE
ORGANIZA-
TIONS.—In the case of services furnished by a
health maintenance organization to an individ-
ual enrolled with the health maintenance orga-
nization, including services furnished by—
‘‘(i) an eligible organization (as de-
fined in section 1876(b));
‘‘(ii) an organization described in sec-
tion 1833(a)(1)(A);
‘‘(iii) an organization receiving pay-
ments on a prepaid basis under a dem-
onstration project under section 402(a) of
the Social Security Amendments of 1967
or under section 222(a) of the Social Secu-
rity Amendments of 1972; and
‘‘(iv) any other entity designated by
the Secretary as a health maintenance or-
ganization for purposes of this subpara-
graph.
‘‘(B) CERTAIN MANAGED CARE PLANS.—In
the case of services furnished by a managed
care plan (as defined by the Secretary) to an
individual enrolled under the plan if—
‘‘(i) the plan selectively contracts with
physicians and with providers of des-
ignated health services; and
‘‘(ii) under the plan physicians bear a
significant financial risk for the cost of
designated health services furnished upon
referral.’’.
(b) WAIVER
FOR VALUABLE COMMUNITY SERV-
ICES.—Subsection (b)(5) of such section is amended by
adding at the end the following: ‘‘In making such deter-
minations, the Secretary shall specifically consider wheth-
er the provision of necessary, valuable community services
will be jeopardized without such an exception.’’.
(c) EXCEPTION FOR HOSPITALS.—Subparagraph (A)
of subsection (d)(3) of such section is amended to read
as follows:
‘‘(A) at the time the services are furnished,
the hospital has a participation agreement in
effect under section 1866, and’’.
SEC. 5. EFFECTIVE DATES.
The amendments made by this Act shall apply with
respect to a referral by a physician for designated health
services (as described in section 1877(i) of the Social Se-
curity Act)—
(1) made on or after the first day of the first
month beginning at least 2 years after the date of
the enactment of this Act, in the case of a referral
with respect to which a financial relationship (speci-
fied in section 1877(a)(2) of the Social Security Act)
existed as of the date of the enactment of this Act;
or
(2) made on or after the first day of the first
month beginning at least 6 months after the date of
the enactment of this Act, with respect to which
such a financial relationship did not exist as of the
date of the enactment of this Act.