834
Title V
Page
Subtitle A—Quality Management and Improvement
Sec. 5001. National Quality Management Program ...............................
835
Sec. 5002. National Quality Management Council .................................
836
Sec. 5003. National measures of quality performance ............................
838
Sec. 5004. Consumer surveys ..................................................................
842
Sec. 5005. Evaluation and reporting of quality performance .................
843
Sec. 5006. Development and dissemination of practice guidelines .........
846
Sec. 5007. Research on health care quality ............................................
849
Sec. 5008. Regional professional foundations .........................................
851
Sec. 5009. National Quality Consortium ................................................
853
Sec. 5010. Eliminating CLIA requirement for certificate of waiver for
simple laboratory examinations and procedures ...........
855
Sec. 5011. Uniform standards for health care institutions ....................
856
Sec. 5012. Role of alliances in quality assurance ...................................
857
Sec. 5013. Role of health plans in quality management .........................
858
Subtitle B—Information Systems, Privacy, and Administrative
Simplification
PART 1—HEALTH INFORMATION SYSTEMS
Sec. 5101. Establishment of health information system .........................
859
Sec. 5102. Additional requirements for health information system .......
863
Sec. 5103. Electronic data network ........................................................
865
Sec. 5104. Unique identifier numbers .....................................................
867
Sec. 5105. Health security cards ............................................................
868
Sec. 5106. Technical assistance in the establishment of health informa-
tion systems ...................................................................
870
PART 2—PRIVACY OF INFORMATION
Sec. 5120. Health information system privacy standards ......................
871
Sec. 5121. Other duties with respect to privacy .....................................
875
Sec. 5122. Comprehensive Health Information Privacy Protection Act
876
Sec. 5123. Definitions .............................................................................
876
PART 3—INTERIM REQUIREMENTS FOR ADMINISTRATIVE SIMPLIFICATION
Sec. 5130. Standard benefit forms .........................................................
878
PART 4—GENERAL PROVISIONS
Sec. 5140. National Privacy and Health Data Advisory Council ...........
883
Sec. 5141. Civil money penalties .............................................................
885
Sec. 5142. Relationship to other laws .....................................................
886
Subtitle C—Remedies and Enforcement
PART 1—REVIEW OF BENEFIT DETERMINATIONS FOR ENROLLED
INDIVIDUALS
SUBPART A—GENERAL RULES
Sec. 5201. Health plan claims procedure ................................................
887
Sec. 5202. Review in regional alliance complaint review offices of griev-
ances based on acts or practices by health plans .........
894
835
Title V
Sec. 5203. Initial proceedings in complaint review offices ......................
897
Sec. 5204. Hearings before hearing officers in complaint review offices
899
Sec. 5205. Review by Federal Health Plan Review Board .....................
905
Sec. 5206. Rules governing benefit claims determinations .....................
909
Sec. 5207. Civil money penalties .............................................................
909
SUBPART B—EARLY RESOLUTION PROGRAMS
Sec. 5211. Establishment of early resolution programs in complaint re-
view offices ....................................................................
911
Sec. 5212. Initiation of participation in mediation proceedings .............
913
Sec. 5213. Mediation proceedings ...........................................................
915
Sec. 5214. Legal effect of participation in mediation proceedings .........
918
Sec. 5215. Enforcement of settlement agreements .................................
919
PART 2—ADDITIONAL REMEDIES AND ENFORCEMENT PROVISIONS
Sec. 5231. Judicial review of Federal action on State systems ..............
920
Sec. 5232. Administrative and judicial review relating to cost contain-
ment ..............................................................................
921
Sec. 5233. Civil enforcement ...................................................................
922
Sec. 5234. Priority of certain bankruptcy claims ...................................
922
Sec. 5235. Private right to enforce State responsibilities .......................
923
Sec. 5236. Private right to enforce Federal responsibilities in operating
a system in a State .......................................................
923
Sec. 5237. Private right to enforce responsibilities of alliances .............
925
Sec. 5238. Discrimination claims ............................................................
926
Sec. 5239. Nondiscrimination in federally assisted programs ................
929
Sec. 5240. Civil action by essential community provider ........................
929
Sec. 5241. Facial constitutional challenges .............................................
930
Sec. 5242. Treatment of plans as parties in civil actions .......................
932
Sec. 5243. General nonpreemption of existing rights and remedies .......
932
Subtitle D—Medical Malpractice
PART 1—LIABILITY REFORM
Sec. 5301. Federal tort reform ...............................................................
933
Sec. 5302. Plan-based alternative dispute resolution mechanisms .........
937
Sec. 5303. Requirement for certificate of merit .....................................
939
Sec. 5304. Limitation on amount of attorney’s contingency fees ...........
942
Sec. 5305. Reduction of awards for recovery from collateral sources ....
943
Sec. 5306. Periodic payment of awards ..................................................
944
PART 2—OTHER PROVISIONS RELATING TO MEDICAL MALPRACTICE
LIABILITY
Sec. 5311. Enterprise liability demonstration project .............................
944
Sec. 5312. Pilot program applying practice guidelines to medical mal-
practice liability actions ................................................
946
Subtitle E—Fraud and Abuse
PART 1—ESTABLISHMENT OF ALL-PAYER HEALTH CARE FRAUD AND ABUSE
CONTROL PROGRAM
Sec. 5401. All-Payer Health Care Fraud and Abuse Control Program
948
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Title V, Subtitle A
Sec. 5402. Establishment of All-Payer Health Care Fraud and Abuse
Control Account ............................................................
951
Sec. 5403. Use of funds by Inspector General ........................................
954
PART 2—APPLICATION OF FRAUD AND ABUSE AUTHORITIES UNDER THE
SOCIAL SECURITY ACT TO ALL PAYERS
Sec. 5411. Exclusion from participation .................................................
956
Sec. 5412. Civil monetary penalties ........................................................
963
Sec. 5413. Limitations on physician self-referral ...................................
968
Sec. 5414. Construction of Social Security Act references .....................
969
PART 3—AMENDMENTS TO ANTI-FRAUD AND ABUSE PROVISIONS UNDER
THE SOCIAL SECURITY ACT
Sec. 5421. Reference to amendments .....................................................
969
PART 4—AMENDMENTS TO CRIMINAL LAW
Sec. 5431. Health care fraud ..................................................................
970
Sec. 5432. Forfeitures for violations of fraud statutes ...........................
971
Sec. 5433. False Statements ...................................................................
972
Sec. 5434. Bribery and graft ..................................................................
973
Sec. 5435. Injunctive relief relating to health care offenses ...................
975
Sec. 5436. Grand jury disclosure ............................................................
975
Sec. 5437. Theft or embezzlement ..........................................................
976
Sec. 5438. Misuse of health security card or unique identifier ..............
977
PART 5—AMENDMENTS TO CIVIL FALSE CLAIMS ACT
Sec. 5441. Amendments to Civil False Claims Act ................................
978
Subtitle F—McCarran-Ferguson Reform
Sec. 5501. Repeal of exemption for health insurance .............................
979
Subtitle A—Quality Management
and Improvement
SEC. 5001. NATIONAL QUALITY MANAGEMENT PROGRAM.
Not later than 1 year after the date of the enactment
of this Act, the National Health Board shall establish and
oversee a performance-based program of quality manage-
ment and improvement designed to enhance the quality,
appropriateness, and effectiveness of health care services
and access to such services. The program shall be known
as the National Quality Management Program and shall
837
Title V, Subtitle A
be administered by the National Quality Management
Council established under section 5002.
SEC. 5002. NATIONAL QUALITY MANAGEMENT COUNCIL.
(a) ESTABLISHMENT.—There is established a council
to be known as the National Quality Management Council.
(b) DUTIES.—The Council shall—
(1) administer the National Quality Manage-
ment Program;
(2) perform any other duty specified as a duty
of the Council in this subtitle; and
(3) advise the National Health Board with re-
spect its duties under this subtitle.
(c) NUMBER AND APPOINTMENT.—The Council shall
be composed of 15 members appointed by the President.
The Council shall consist of members who are broadly rep-
resentative of the population of the United States and
shall include—
(1) individuals representing the interests of gov-
ernmental and corporate purchasers of health care;
(2) individuals representing the interests of
health plans;
(3) individuals representing the interests of
States;
838
Title V, Subtitle A
(4) individuals representing the interests of
health care providers and academic health centers
(as defined in section 3101(c)); and
(5) individuals distinguished in the fields of
public health, health care quality, and related fields
of health services research.
(d) TERMS.—
(1) IN GENERAL.—Except as provided in para-
graph (2), members of the Council shall serve for a
term of 3 years.
(2) STAGGERED ROTATION.—Of the members
first appointed to the Council under subsection (c),
the President shall appoint 5 members to serve for
a term of 3 years, 5 members to serve for a term
of 2 years, and 5 members to serve for a term of
1 year.
(3) SERVICE BEYOND TERM.—A member of the
Council may continue to serve after the expiration of
the term of the member until a successor is ap-
pointed.
(e) VACANCIES.—If a member of the Council does not
serve the full term applicable under subsection (d), the in-
dividual appointed to fill the resulting vacancy shall be ap-
pointed for the remainder of the term of the predecessor
of the individual.