I 
111TH CONGRESS 
1ST SESSION H. R. 4390 
To amend title XI of the Social Security Act to provide for enhanced program 
and provider protections under the Medicare, Medicaid, and Children’s 
Health Insurance programs. 
IN THE HOUSE OF REPRESENTATIVES 
DECEMBER 16, 2009 
Mr. MURPHY of New York introduced the following bill; which was referred 
to the Committee on Energy and Commerce, and in addition to the Com-
mittee on Ways and Means, for a period to be subsequently determined 
by the Speaker, in each case for consideration of such provisions as fall 
within the jurisdiction of the committee concerned 
A BILL 
To amend title XI of the Social Security Act to provide 
for enhanced program and provider protections under 
the Medicare, Medicaid, and Children’s Health Insurance 
programs. 
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 ‘‘Medicare and Medicaid 
Fraud Prevention and Control Act of 2009’’. 
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SEC. 2. ENHANCED CMS PROGRAM PROTECTION AUTHOR-
ITY. 
(a) IN GENERAL.—Title XI of the Social Security Act 
(42 U.S.C. 1301 et seq.) is amended by inserting after 
section 1128F the following new section: 
‘‘SEC. 1128G. ENHANCED PROGRAM AND PROVIDER PRO-
TECTIONS IN THE MEDICARE, MEDICAID, AND 
CHIP PROGRAMS. 
‘‘(a) CERTAIN AUTHORIZED SCREENING, ENHANCED 
OVERSIGHT PERIODS, ENROLLMENT MORATORIA, AND 
PERIODIC VALIDATIONS.— 
‘‘(1) AUTHORIZATION.— 
‘‘(A) IN
GENERAL.—In which the Sec-
retary has determined that there is a significant 
risk of fraudulent activity (as determined by the 
Secretary based on relevant complaints, reports, 
referrals by law enforcement or other sources, 
data analysis, trending information, or claims 
submissions by providers of services and sup-
pliers) with respect to a category of provider of 
services or supplier of items or services, which 
may be a category within a geographic area, 
under title XVIII, XIX, or XXI, the Secretary 
may impose, subject to subparagraph (B), with 
respect to a program under title XVIII, XIX, or 
XXI, the Secretary impose any of the following 
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requirements with respect to a provider of serv-
ices or a supplier (whether such provider or 
supplier is initially enrolling in the program or 
is renewing such enrollment): 
‘‘(i) Screening under paragraph (2). 
‘‘(ii) 
Enhanced 
oversight 
periods 
under paragraph (3). 
‘‘(iii) Enrollment moratoria under 
paragraph (4). 
‘‘(iv) Periodic validations of authoriza-
tions under paragraph (5). 
‘‘(B) STATE REQUIREMENT.—In applying 
this subsection for purposes of title XIX and 
XXI, the Secretary may require a State to 
carry out the provisions of this subsection (and 
subsection (b)) as a requirement of the State 
plan under title XIX or the child health plan 
under title XXI. Actions taken and determina-
tions made under this subsection and subsection 
(b) shall not be subject to review by a judicial 
tribunal. 
‘‘(2) SCREENING.—For purposes of paragraph 
(1), the Secretary shall establish procedures under 
which screening is conducted with respect to pro-
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viders of services and suppliers described in such 
paragraph. Such screening may include at least— 
‘‘(A) licensing board checks; 
‘‘(B) screening against the list of individ-
uals and entities excluded from the program 
under title XVIII, XIX, or XXI; 
‘‘(C) the excluded provider list system; 
‘‘(D) background checks; 
‘‘(E) unannounced pre-enrollment or other 
site visits; and 
‘‘(F) heightened disclosure of affiliations. 
‘‘(3) ENHANCED
OVERSIGHT
PERIOD.—For 
purposes of paragraph (1), the Secretary shall estab-
lish procedures to provide for a period of not less 
than 30 days and not more than 365 days during 
which providers of services and suppliers described 
in such paragraph, as the Secretary determines ap-
propriate, would be subject to enhanced oversight, 
such as required or unannounced (or required and 
unannounced) site visits or inspections, prepayment 
review, enhanced review of claims, and such other 
actions as specified by the Secretary, under the pro-
grams under titles XVIII, XIX, and XXI. Under 
such procedures, the Secretary may extend such pe-
riod for more than 365 days if the Secretary deter-
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mines that after the initial period such additional 
period of oversight is necessary. 
‘‘(4) ENHANCED OVERSIGHT FOR CLAIMS OF 
DME SUPPLIERS.—If the Secretary determines under 
paragraph (1) that there is a significant risk of 
fraudulent activity among suppliers of durable med-
ical equipment, in the case of a supplier of durable 
medical equipment who is within a category or geo-
graphic area under title XVIII identified pursuant to 
such determination, whether at the time of initial 
enrollment under such title or otherwise, the Sec-
retary shall, notwithstanding section 1842(c)(2), 
withhold payment under such title with respect to 
durable medical equipment furnished by such sup-
plier during a period specified by the Secretary. 
‘‘(5) PERIODIC REVIEW OF PHYSICIAN AUTHOR-
IZATIONS.—For purposes of paragraph (1), the Sec-
retary shall establish a program under which, in 
cases in which the Secretary (or an administrative 
contractor) determines under a program described in 
paragraph (1) that there may have been a pattern 
of excessive prescribing or authorization of items or 
services by a physician or other health care profes-
sional— 
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‘‘(A) the Secretary (or contractor) submits 
to the physician or professional on a quarterly 
basis a list of the claims submitted under the 
program based on a prescription or authoriza-
tion by the physician or professional; and 
‘‘(B) if the physician or professional does 
not validate by the end of the 90-day period be-
ginning on the date of receipt of the list the le-
gitimacy of the previously identified claims for 
items and services prescribed or authorized by 
the physician or professional, claims relating to 
such items and services prescribed or author-
ized by such physician or professional for subse-
quent periods shall be denied until such valida-
tion is made. 
‘‘(6) MORATORIUM ON ENROLLMENT OF PRO-
VIDERS
AND
SUPPLIERS.—For purposes of para-
graph (1), the Secretary, based upon a finding of a 
risk of serious ongoing fraud within a program 
under title XVIII, XIX, or XXI, may impose a mor-
atorium on the enrollment of providers of services 
and suppliers within a category of providers of serv-
ices and suppliers (including a category within a spe-
cific geographic area) under such title. Such a mora-
torium may only be imposed if the Secretary makes 
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a determination that the moratorium would not ad-
versely impact access of individuals to care under 
such program. 
‘‘(7) CLARIFICATION.—Nothing in this sub-
section shall be interpreted to preclude or limit the 
ability of a State to engage in provider screening or 
enhanced provider oversight activities beyond those 
required by the Secretary. 
‘‘(b) PROBATIONARY PERIOD TO DETERMINE LEGIT-
IMACY OF NEW PROVIDERS AND SUPPLIERS.—The Sec-
retary shall establish procedures (without regard to sec-
tion 1874A(h)) under which at the time a provider or sup-
plier is first approved for participation in the program 
under title XVIII, XIX, or XXI, there shall be a proba-
tionary period of heightened review (specified by the Sec-
retary, but in no case longer than 1 year) under which— 
‘‘(1) the Secretary (or an administrative con-
tractor) shall review a random or other appropriate 
sample of claims to determine the legitimacy of the 
operations of the provider or supplier; 
‘‘(2) the Secretary (or such contractor) shall 
validate the legitimacy of physician prescriptions or 
other authorizations for the items and services fur-
nished by such provider or supplier; and 
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‘‘(3) if the Secretary, on the basis of such a re-
view of such claims or such validation, makes a pre-
liminary finding that a significant or dispropor-
tionate number of such claims are not legitimate (as 
determined by the Secretary), the Secretary may 
suspend or terminate the participation of the pro-
vider or supplier with notice to the provider or sup-
plier. 
The provisions of subsections (c) through (g) of section 
1128 shall apply to a suspension or termination under 
paragraph (3) in the same manner as such provisions 
apply to an exclusion under subsection (a) or (b) of such 
section. In the case of a physician or other professional 
that fails to cooperate with the Secretary (or a contractor) 
in the validation of prescriptions or authorizations de-
scribed in paragraph (2), the Secretary may impose a civil 
monetary penalty of not to exceed $10,000 with respect 
to the validation of items and services furnished by any 
particular provider or supplier. The provisions of section 
1128A (other than subsections (a) and (b)) shall apply 
to a civil money penalty under the previous sentence in 
the same manner as such provisions apply to a penalty 
or proceeding under section 1128A(a).’’. 
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