I
106TH CONGRESS
2D SESSION
H. R. 5094
To reduce the amount of paperwork and improve payment policies for health
care services, to prevent fraud and abuse through health care provider
education, and for other purposes.
IN THE HOUSE OF REPRESENTATIVES
JULY 27, 2000
Mr. THORNBERRY introduced the following bill; which was referred to the
Committee on Commerce, and in addition to the Committee 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 jurisdic-
tion of the committee concerned
A BILL
To reduce the amount of paperwork and improve payment
policies for health care services, to prevent fraud and
abuse through health care provider education, 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 ‘‘Health Care Fraud
Prevention and Paperwork Reduction Act of 2000’’.
SEC. 2. FEDERAL COMMISSION ON BILLING CODES AND
FORMS SIMPLIFICATION.
(a) ESTABLISHMENT.—There is hereby established
the Commission on Billing Codes and Forms Simplifica-
tion (in this section referred to as the ‘‘Commission’’).
(b) DUTIES.—The Commission shall make rec-
ommendations regarding the following:
(1) 
STANDARDIZED
FORMS.—Standardizing
credentialing and billing forms respecting health
care claims, that all Federal Government agencies
would use and that the private sector is able (and
is encouraged, but not required) to use.
(2) REDUCTION IN BILLING CODES.—A signifi-
cant reduction and simplification in the number of
billing codes.
(c) MEMBERSHIP.—
(1) NUMBER AND APPOINTMENT.—The Com-
mission shall be composed of such members as the
Comptroller General of the United States shall ap-
point.
(2) QUALIFICATIONS.—The membership of the
Commission shall include individuals who are mem-
bers of the medical community.
(d) INCORPORATION OF MEDPAC PROVISIONS.—The
provisions of paragraphs (3) through (6) of subsection (c)
and subsections (d) through (f) of section 1805 of the So-
cial Security Act (42 U.S.C. 1395b–6) shall apply to the
Commission in the same manner as they apply to the
Medicare Payment Advisory Commission.
(e) REPORTS.—The Commission shall submit to Con-
gress and the President such periodic reports on its rec-
ommendations as it deems appropriate.
SEC. 3. EDUCATION OF PHYSICIANS AND PROVIDERS CON-
CERNING MEDICARE PROGRAM PAYMENTS.
(a) WRITTEN REQUESTS.—
(1) IN GENERAL.—The Secretary of Health and
Human Services shall establish a process under
which a physician may request, in writing from a
carrier, assistance in addressing questionable codes
and procedures under the medicare program under
title XVIII of the Social Security Act and then the
carrier shall respond in writing within 30 business
days respond with the correct billing or procedural
answer.
(2) USE OF WRITTEN STATEMENT.—
(A) IN
GENERAL.—Subject to subpara-
graph (B), a written statement under para-
graph (1) may be used as proof against a fu-
ture audit or overpayment under the medicare
program.
(B) LIMIT
ON
APPLICATION.—Subpara-
graph (A) shall not apply retroactively and shall
not apply to cases of fraudulent billing.
(b) RESTORATION OF TOLL-FREE HOTLINE.—
(1) IN
GENERAL.—The Administrator of the
Health Care Financing Administration shall restore
the toll-free telephone hotline so that physicians may
call for information and questions about the medi-
care program.
(2) AUTHORIZATION
OF
APPROPRIATIONS.—
There are authorized to be appropriated such sums
as may be necessary to carry out paragraph (1).
(c) DEFINITIONS.—For purposes of this section:
(1) PHYSICIAN.—The term ‘‘physician’’ has the
meaning given such term in section 1861(r) of the
Social Security Act (42 U.S.C. 1395x(r)).
(2) CARRIER.—The term ‘‘carrier’’ means a
carrier (as defined in section 1842(f) of the Social
Security Act (42 U.S.C. 1395u(f))) with a contract
under title XVIII of such Act to administer benefits
under part B of such title.
SEC. 4. POLICY DEVELOPMENT REGARDING E&M GUIDE-
LINES UNDER THE MEDICARE PROGRAM.
(a) IN GENERAL.—HCFA may not implement any
new evaluation and management guidelines (in this section
referred to as ‘‘E&M guidelines’’) under the medicare pro-
gram, unless HCFA—
(1) has provided for an assessment of the pro-
posed guidelines by physicians;
(2) has established a plan that contains specific
goals, including a schedule, for improving participa-
tion of physicians;
(3) has carried out a minimum of 4 pilot
projects consistent with subsection (b) in at least 4
different HCFA regions (to be specified by the Sec-
retary) to test such guidelines; and
(4) finds that the objectives described in sub-
section (c) will be met in the implementation of such
guidelines.
(b) PILOT PROJECTS.—
(1) LENGTH AND CONSULTATION.—Each pilot
project under this subsection shall—
(A) be of sufficient length to allow for pre-
paratory physician and carrier education, anal-
ysis, and use and assessment of potential E&M
guidelines; and
(B) be conducted, throughout the planning
and operational stages of the project, in con-
sultation with national and State medical soci-
eties.
(2) 
PEER
REVIEW
AND
RURAL
PILOT
PROJECTS.—Of the pilot projects conducted under
this subsection—
(A) at least one shall focus on a peer re-
view method by physicians which evaluates
medical record information for statistical outlier
services relative to definitions and guidelines
published in the CPT book, instead of an ap-
proach using the review of randomly selected
medical records using non-clinical personnel;
and
(B) at least one shall be conducted for
services furnished in a rural area.
(3) STUDY
OF
IMPACT.—Each pilot project
shall examine the effect of the E&M guidelines on—
(A) different types of physician practices,
such as large and small groups; and
(B) the costs of compliance, and patient
and physician satisfaction.
(4) REPORT
ON
HOW
MET
OBJECTIVES.—
HCFA shall submit a report to the Committees on
Commerce and Ways and Means of the House of
Representatives, the Committee on Finance of the
Senate, and the Practicing Physicians Advisory
Council, six months after the conclusion of the pilot
projects. Such report shall include the extent to
which the pilot projects met the objectives specified
in subsection (c).
(c) OBJECTIVES FOR E&M GUIDELINES.—The objec-
tives for E&M guidelines specified in this subsection are
as follows (relative to the E&M guidelines and review poli-
cies in effect as of the date of the enactment of this Act):
(1) Enhancing clinically relevant documentation
needed to accurately code and assess coding levels
accurately.
(2) Reducing administrative burdens.
(3) Decreasing the level of non-clinically perti-
nent and burdensome documentation time and con-
tent in the record.
(4) Increased accuracy by carrier reviewers.
(5) Education of both physicians and reviewers.
(6) Appropriate use of E&M codes by physi-
cians and their staffs.
(7) The extent to which the tested E&M docu-
mentation guidelines substantially adhere to the
CPT coding rules.
(d) DEFINITIONS.—For purposes of this section and
sections 5 and 6:
(1) PHYSICIAN.—The term ‘‘physician’’ has the
meaning given such term in section 1861(r) of the
Social Security Act (42 U.S.C. 1395x(r)).
(2) CARRIER.—The term ‘‘carrier’’ means a
carrier (as defined in section 1842(f) of the Social
Security Act (42 U.S.C. 1395u(f))) with a contract
under title XVIII of such Act to administer benefits
under part B of such title.
(3) SECRETARY.—The term ‘‘Secretary’’ means
the Secretary of Health and Human Services.
(4) HCFA.—The term ‘‘HCFA’’ means the
Health Care Financing Administration.
(5) MEDICARE PROGRAM.—The term ‘‘medicare
program’’ means the program under title XVIII of
the Social Security Act.
SEC. 5. OVERPAYMENTS UNDER THE MEDICARE PROGRAM.
(a) INDIVIDUALIZED NOTICE.—If a carrier proceeds
with a post-payment audit of a physician under the medi-
care program, the carrier shall provide the physician with
an individualized notice of billing problems, such as a per-
sonal visit or carrier-to-physician telephone conversation
during normal working hours, within 3 months of initi-
ating such audit. The notice should include suggestions
to the physician on how the billing problem may be rem-
edied.
(b) REPAYMENT OF OVERPAYMENTS WITHOUT PEN-
ALTY.—The Secretary shall permit physicians to repay
medicare overpayments within 3 months without penalty
or interest and without threat of denial of other claims
based upon extrapolation. If a physician should discover
an overpayment before a carrier notifies the physician of
the error, the physician may reimburse the medicare pro-
gram without penalty and the Secretary may not audit or
target the physician on the basis of such repayment, un-
less other evidence of fraudulent billing exists.
(c) TREATMENT OF FIRST-TIME BILLING ERRORS.—
If a physician’s medicare billing error was a first-time
error and the physician has not previously been the subject
of a post-payment audit, the carrier may not assess a fine
through extrapolation of such an error to other claims,
unless the physician has submitted a fraudulent claim.
(d) TIMELY NOTICE OF PROBLEM CLAIMS BEFORE
USING EXTRAPOLATION.—A carrier may seek reimburse-
ment or penalties against a physician based on extrapo-
lation of a medicare claim only if the carrier has informed
the physician of potential problems with the claim within
one year after the date the claim was submitted for reim-
bursement.
(e) SUBMISSION OF ADDITIONAL INFORMATION.—A
physician may submit additional information and docu-