I 
111TH CONGRESS 
1ST SESSION H. R. 4222 
To provide for the establishment of the Office of Deputy Secretary for 
Health Care Fraud Prevention. 
IN THE HOUSE OF REPRESENTATIVES 
DECEMBER 8, 2009 
Ms. GINNY BROWN-WAITE of Florida (for herself, Mrs. EMERSON, Mr. 
SOUDER, Mr. ROONEY, Mr. BUCHANAN, Mr. ROSKAM, Mr. LINCOLN 
DIAZ-BALART of Florida, Mr. PUTNAM, Mr. MARIO DIAZ-BALART of 
Florida, and Mr. MACK) introduced the following bill; which was referred 
to the Committee on Energy and Commerce 
A BILL 
To provide for the establishment of the Office of Deputy 
Secretary for Health Care Fraud Prevention. 
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 ‘‘Prevent Health Care 
Fraud Act of 2009’’. 
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SEC. 2. ESTABLISHMENT OF OFFICE OF DEPUTY SEC-
RETARY FOR HEALTH CARE FRAUD PREVEN-
TION IN THE DEPARTMENT OF HEALTH AND 
HUMAN SERVICES; APPOINTMENT AND POW-
ERS OF DEPUTY SECRETARY. 
(a) IN GENERAL.—There is hereby established in the 
Department of Health and Human Services the Office of 
the Deputy Secretary for Health Care Fraud Prevention 
(referred to in this section as the ‘‘Office’’). 
(b) DUTIES OF THE OFFICE.—The Office shall— 
(1) direct the appropriate implementation with-
in the Department of Health and Human Services of 
health care fraud prevention and detection rec-
ommendations made by Federal Government and 
private sector antifraud and oversight entities; 
(2) routinely consult with the Office of the In-
spector General for the Department of Health and 
Human Services, the Attorney General, and private 
sector health care antifraud entities to identify 
emerging health care fraud issues requiring imme-
diate action by the Office; 
(3) through a contract entered into with an en-
tity that has experience in designing and imple-
menting antifraud systems in the financial sector, 
provide for the design, development, and operation 
of a predictive model antifraud system (in accord-
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ance with subsection (d)) to analyze health care 
claims data in real-time to identify high risk claims 
activity, develop appropriate rules, processes, and 
procedures and investigative research approaches, in 
coordination with the Office of the Inspector General 
for the Department of Health and Human Services, 
based on the risk level assigned to claims activity, 
and develop a comprehensive antifraud database for 
health care activities carried out or managed by 
Federal health agencies; 
(4) promulgate and enforce regulations relating 
to the reporting of data claims to the health care 
antifraud system developed under paragraph (3) by 
all Federal health agencies; 
(5) establish thresholds, in consultation with 
the Office of the Inspector General of the Depart-
ment of Health and Human Services and the De-
partment of Justice— 
(A) for the amount and extent of claims 
verified and designated as fraudulent, wasteful, 
or abusive through the fraud prevention system 
developed under paragraph (3) for excluding 
providers or suppliers from participation in 
Federal health programs; and 
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(B) for the referral of claims identified 
through the health care fraud prevention sys-
tem developed under paragraph (3) to law en-
forcement entities (such as the Office of the In-
spector General, Medicaid Fraud Control Units, 
and the Department of Justice); and 
(6) share antifraud information and best prac-
tices with Federal health agencies, health insurance 
issuers, health care providers, antifraud organiza-
tions, antifraud databases, and Federal, State, and 
local law enforcement and regulatory agencies. 
(c) DEPUTY SECRETARY FOR HEALTH CARE FRAUD 
PREVENTION.— 
(1) ESTABLISHMENT.—There is established 
within the Department of Health and Human Serv-
ices the position of Deputy Secretary for Health 
Care Fraud Prevention (referred to in this section as 
the ‘‘Deputy Secretary’’). The Deputy Secretary 
shall serve as the head of the Office, shall act as the 
chief health care fraud prevention and detection offi-
cer of the United States, and shall consider and di-
rect the appropriate implementation of recommenda-
tions to prevent and detect health care fraud, waste, 
and abuse activities and initiatives within the De-
partment. 
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(2) APPOINTMENT.—The Deputy Secretary 
shall be appointed by the President, by and with the 
advice and consent of the Senate, and serve for a 
term of 5 years, unless removed prior to the end of 
such term for cause by the President. 
(3) POWERS.—Subject to oversight by the Sec-
retary, the Deputy Secretary shall exercise all pow-
ers necessary to carry out this section, including the 
hiring of staff, entering into contracts, and the dele-
gation of responsibilities to any employee of the De-
partment of Health and Human Services or the Of-
fice appropriately designated for such responsibility. 
(4) DUTIES.— 
(A) IN GENERAL.—The Deputy Secretary 
shall— 
(i) establish and manage the operation 
of the predictive modeling system devel-
oped under subsection (b)(3) to analyze 
Federal health claims in real-time to iden-
tify high risk claims activity and refer 
risky claims for appropriate verification 
and investigative research; 
(ii) consider and order the appropriate 
implementation of fraud prevention and 
detection activities, such as those rec-
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ommended by the Office of the Inspector 
General of the Department of Health and 
Human Services, the Government Account-
ability Office, MedPac, and private sector 
health care antifraud entities; 
(iii) not later than 6 months after the 
date on which he or she is initially ap-
pointed, submit to Congress an implemen-
tation plan for the health care fraud pre-
vention systems under subsection (d); and 
(iv) submit annual performance re-
ports to the Secretary and Congress that, 
at minimum, shall provide an estimate of 
the return on investment with respect to 
the system, for all recommendations made 
to the Deputy Secretary under this section, 
a description of whether such recommenda-
tions are implemented or not implemented, 
and contain other relevant performance 
metrics. 
(B) ANALYSIS AND RECOMMENDATIONS.— 
The Deputy Secretary shall provide required 
strategies and treatments for claims identified 
as high risk (including a system of designations 
for claims, such as ‘‘approve’’, ‘‘decline’’, ‘‘re-
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search’’, and ‘‘educate and pay’’) to the Centers 
for Medicare & Medicaid Services, other Fed-
eral and State entities responsible for verifying 
whether claims identified as high risk are pay-
able, should be automatically denied, or require 
further research and investigation. 
(C) LIMITATION.—The Deputy Secretary 
shall not have any criminal or civil enforcement 
authority otherwise delegated to the Office of 
Inspector General of the Department of Health 
and Human Services or the Attorney General. 
(5) REGULATIONS.—The Deputy Secretary 
shall promulgate and enforce such rules, regulations, 
orders, and interpretations as the Deputy Secretary 
determines to be necessary to carry out the purposes 
of this section. Such authority shall be exercised as 
provided under section 553 of title 5, United States 
Code. 
(d) HEALTH CARE FRAUD PREVENTION SYSTEM.— 
(1) IN GENERAL.—The fraud prevention system 
established under subsection (b)(3) shall be designed 
as follows: 
(A) IN GENERAL.—The fraud prevention 
system shall— 
(i) be holistic; 
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(ii) be able to view all provider and 
patient activities across all Federal health 
program payers; 
(iii) be able to integrate into the exist-
ing health care claims flow with minimal 
effort, time, and cost; 
(iv) be modeled after systems used in 
the Financial Services industry; and 
(v) utilize integrated real-time trans-
action risk scoring and referral strategy 
capabilities to identify claims that are sta-
tistically unusual. 
(B) MODULARIZED ARCHITECTURE.—The 
fraud prevention system shall be designed from 
an end-to-end modularized perspective to allow 
for ease of integration into multiple points 
along a health care claim flow (pre- or post-ad-
judication), which shall— 
(i) utilize a single entity to host, sup-
port, manage, and maintain software-based 
services, predictive models, and solutions 
from a central location for the customers 
who access the fraud prevention system; 
(ii) allow access through a secure pri-
vate data connection rather than the in-
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