Union Calendar No. 219
105TH CONGRESS
1ST SESSION
H. R. 1836
[Report No. 105–374]
A BILL
To amend chapter 89 of title 5, United States
Code, to improve administration of sanctions
against unfit health care providers under the
Federal Employees Health Benefits Program,
and for other purposes.
NOVEMBER 4, 1997
Reported with an amendment, committed to the Commit-
tee of the Whole House on the State of the Union, and
ordered to be printed
improve administration of sanctions against unfit health
care providers under the Federal Employees Health Ben-
efits Program, and for other purposes.
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 ‘‘Federal Employees
Health Care Protection Act of 1997’’.
SEC. 2. DEBARMENT AND OTHER SANCTIONS.
(a) AMENDMENTS.—Section 8902a of title 5, United
States Code, is amended—
(1) in subsection (a)—
(A) in paragraph (1)—
(i) by striking ‘‘and’’ at the end of sub-
paragraph (B);
(ii) by striking the period at the end of
subparagraph (C) and inserting ‘‘; and’’;
and
(iii) by adding at the end the follow-
ing:
‘‘(D) the term ‘should know’ means that a per-
son, with respect to information, acts in deliberate ig-
norance of, or in reckless disregard of, the truth or
falsity of the information, and no proof of specific in-
tent to defraud is required;’’; and
(B) in paragraph (2)(A), by striking ‘‘sub-
section (b) or (c)’’ and inserting ‘‘subsection (b),
(c), or (d)’’;
(2) in subsection (b)—
(A) by striking ‘‘The Office of Personnel
Management may bar’’ and inserting ‘‘The Of-
fice of Personnel Management shall bar’’; and
(B) by amending paragraph (5) to read as
follows:
‘‘(5) Any provider that is currently debarred,
suspended, or otherwise excluded from any procure-
ment or nonprocurement activity (within the mean-
ing of section 2455 of the Federal Acquisition Stream-
lining Act of 1994).’’;
(3) by redesignating subsections (c) through (i)
as subsections (d) through (j), respectively, and by in-
serting after subsection (b) the following:
‘‘(c) The Office may bar the following providers of
health care services from participating in the program
under this chapter:
‘‘(1) Any provider—
‘‘(A) whose license to provide health care
services or supplies has been revoked, suspended,
restricted, or not renewed, by a State licensing
authority for reasons relating to the provider’s
professional competence, professional perform-
ance, or financial integrity; or
‘‘(B) that surrendered such a license while
a formal disciplinary proceeding was pending
before such an authority, if the proceeding con-
cerned the provider’s professional competence,
professional performance, or financial integrity.
‘‘(2) Any provider that is an entity directly or
indirectly owned, or with a control interest of 5 per-
cent or more held, by an individual who has been
convicted of any offense described in subsection (b),
against whom a civil monetary penalty has been as-
sessed under subsection (d), or who has been debarred
from participation under this chapter.
‘‘(3) Any individual who directly or indirectly
owns or has a control interest in a sanctioned entity
and who knows or should know of the action con-
stituting the basis for the entity’s conviction of any
offense described in subsection (b), assessment with a
civil monetary penalty under subsection (d), or debar-
ment from participation under this chapter.
‘‘(4) Any provider that the Office determines, in
connection with claims presented under this chapter,
has charged for health care services or supplies in an
amount substantially in excess of such provider’s cus-
tomary charge for such services or supplies (unless the
Office finds there is good cause for such charge), or
charged for health care services or supplies which are
substantially in excess of the needs of the covered in-
dividual or which are of a quality that fails to meet
professionally recognized standards for such services
or supplies.
‘‘(5) Any provider that the Office determines has
committed acts described in subsection (d).
Any determination under paragraph (4) relating to whether
a charge for health care services or supplies is substantially
in excess of the needs of the covered individual shall be made
by trained reviewers based on written medical protocols de-
veloped by physicians. In the event such a determination
cannot be made based on such protocols, a physician in an
appropriate specialty shall be consulted.’’;
(4) in subsection (d) (as so redesignated by para-
graph (3)) by amending paragraph (1) to read as fol-
lows:
‘‘(1) in connection with claims presented under
this chapter, that a provider has charged for a health
care service or supply which the provider knows or
should have known involves—
‘‘(A) an item or service not provided as
claimed,
‘‘(B) charges in violation of applicable
charge limitations under section 8904(b), or
‘‘(C) an item or service furnished during a
period in which the provider was debarred from
participation under this chapter pursuant to a
determination by the Office under this section,
other than as permitted under subsection
(g)(2)(B);’’;
(5) in subsection (f) (as so redesignated by para-
graph (3)) by inserting after ‘‘under this section’’ the
first place it appears the following: ‘‘(where such de-
barment is not mandatory)’’;
(6) in subsection (g) (as so redesignated by para-
graph (3))—
(A) by striking ‘‘(g)(1)’’ and all that follows
through the end of paragraph (1) and inserting
the following:
‘‘(g)(1)(A) Except as provided in subparagraph (B),
debarment of a provider under subsection (b) or (c) shall
be effective at such time and upon such reasonable notice
to such provider, and to carriers and covered individuals,
as shall be specified in regulations prescribed by the Office.
Any such provider that is debarred from participation may
request a hearing in accordance with subsection (h)(1).
‘‘(B) Unless the Office determines that the health or
safety of individuals receiving health care services warrants
an earlier effective date, the Office shall not make a deter-
mination adverse to a provider under subsection (c)(5) or
(d) until such provider has been given reasonable notice and
an opportunity for the determination to be made after a
hearing as provided in accordance with subsection (h)(1).’’;
(B) in paragraph (3)—
(i) by inserting ‘‘of debarment’’ after
‘‘notice’’; and
(ii) by adding at the end the following:
‘‘In the case of a debarment under para-
graph (1), (2), (3), or (4) of subsection (b),
the minimum period of debarment shall not
be less than 3 years, except as provided in
paragraph (4)(B)(ii).’’;
(C) in paragraph (4)(B)(i)(I) by striking
‘‘subsection (b) or (c)’’ and inserting ‘‘subsection
(b), (c), or (d)’’; and
(D) by striking paragraph (6);
(7) in subsection (h) (as so redesignated by para-
graph (3)) by striking ‘‘(h)(1)’’ and all that follows
through the end of paragraph (2) and inserting the
following: