Title: Fighting Medicare Fraud Act of 2018
Policy area: Health

Summary:
Fighting Medicare Fraud Act of 2018
This bill expands the authority of the Centers for Medicare & Medicaid Services (CMS) to exclude from participation in federal health programs certain affiliates of a sanctioned entity. (A "sanctioned entity" is one that has been convicted of one of several specified crimes or excluded from participation under either Medicare or a state health care program.)
In addition, the bill requires Medicare Advantage organizations to report instances of fraud or abuse to the CMS within 60 days.

[Congressional Bills 115th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5757 Introduced in House (IH)]

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115th CONGRESS
  2d Session
                                H. R. 5757

 To amend title XI of the Social Security Act to expand the permissive 
 exclusion from Federal health programs to include certain individuals 
with prior interest in sanctioned entities and entities affiliated with 
              sanctioned entities, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                              May 10, 2018

  Ms. Frankel of Florida (for herself and Mr. Keating) introduced the 
   following bill; which was referred to the Committee on Energy and 
  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 jurisdiction of the 
                          committee concerned

_______________________________________________________________________

                                 A BILL


 
 To amend title XI of the Social Security Act to expand the permissive 
 exclusion from Federal health programs to include certain individuals 
with prior interest in sanctioned entities and entities affiliated with 
              sanctioned entities, and for other purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Fighting Medicare Fraud Act of 
2018''.

SEC. 2. PERMISSIVE EXCLUSION FROM FEDERAL HEALTH PROGRAMS EXPANDED TO 
              CERTAIN INDIVIDUALS WITH PRIOR INTEREST IN SANCTIONED 
              ENTITIES AND ENTITIES AFFILIATED WITH SANCTIONED 
              ENTITIES.

    Paragraph (15) of section 1128(b) of the Social Security Act (42 
U.S.C. 1320a-7(b)) is amended to read as follows:
            ``(15) Individuals and entities affiliated with a 
        sanctioned entity.--(A) Any of the following:
                    ``(i) Any individual who--
                            ``(I) is a person with an ownership or 
                        control interest in a sanctioned entity or an 
                        affiliated entity of such sanctioned entity (or 
                        was a person with such an ownership or control 
                        interest at the time of any of the conduct that 
                        formed a basis for the conviction or exclusion 
                        described in subparagraph (B)); and
                            ``(II) knows or should have known (as 
                        defined in section 1128A(i)(7)) (or knew or 
                        should have known) of such conduct.
                    ``(ii) Any individual who is an officer or managing 
                employee (as defined in section 1126(b)) of a 
                sanctioned entity or affiliated entity of such 
                sanctioned entity (or was such an officer or managing 
                employee at the time of any of the conduct that formed 
                a basis for the conviction or exclusion described in 
                subparagraph (B)).
                    ``(iii) Any affiliated entity of a sanctioned 
                entity.
            ``(B) For purposes of this paragraph, the term `sanctioned 
        entity' means an entity--
                    ``(i) that has been convicted of any offense 
                described in subsection (a) of this section or in 
                paragraph (1), (2), or (3) of this subsection; or
                    ``(ii) that has been excluded from participation 
                under a program under title XVIII or under a State 
                health care program.
            ``(C) For purposes of subparagraph (A), the term 
        `affiliated entity' means, with respect to a sanctioned entity, 
        an entity that is (or was at the time of any of the conduct 
        that formed the basis for the conviction or exclusion described 
        in subparagraph (B)) affiliated with such sanctioned entity, 
        and includes an entity--
                    ``(i) that is a person with an ownership or control 
                interest in such sanctioned entity (or was such a 
                person with respect to such sanctioned entity at the 
                time of any conduct that formed the basis for the 
                conviction described in subparagraph (B));
                    ``(ii) with respect to which a sanctioned entity is 
                a person with an ownership or control interest in such 
                entity (or was such a person with respect to such 
                entity at the time of any conduct that formed the basis 
                for the conviction described in subparagraph (B));
                    ``(iii) with respect to which a person with an 
                ownership or control interest in such entity also has 
                such an interest in such sanctioned entity; and
                    ``(iv) with respect to which a person who is an 
                officer or managing employee (as defined in section 
                1126(b)) of such entity also is such an officer or 
                managing employee of such sanctioned entity.
            ``(D) For purposes of this paragraph, the term `person with 
        an ownership or control interest' has the meaning given such 
        term in section 1124(a)(3).''.

SEC. 3. REPORTS ON INCIDENCES OF FRAUD AND ABUSE UNDER MEDICARE PARTS C 
              AND D.

    (a) In General.--Section 1857(d) of the Social Security Act (42 
U.S.C. 1395w-27(d)) is amended by adding at the end the following new 
paragraph:
            ``(7) Report on incidences of fraud and abuse.--
                    ``(A) In general.--A contract under this section 
                with an MA organization offering an MA plan shall 
                provide that such MA organization report to the 
                Secretary (or to any person or organization designated 
                by the Secretary for such purpose) any instances of 
                fraud or abuse related to the payment or delivery of 
                health benefits under such contract not later than 60 
                days after such organization identifies such instance.
                    ``(B) Guidance.--Not later than 90 days after the 
                date of the enactment of this paragraph, the Secretary, 
                in consultation with the Inspector General of the 
                Department of Health and Human Services and the 
                Attorney General, shall issue to MA organizations (and 
                PDP sponsors) guidance for defining the terms `fraud' 
                and `abuse' for purposes of subparagraph (A).''.
    (b) Conforming Amendment to Part D.--Section 1860D-12(b)(3)(C) of 
the Social Security Act (42 U.S.C. 1395w-112(b)(3)(C)) is amended by 
inserting before the period at the end the following: ``, except in 
applying paragraph (7) of such section any reference to an MA 
organization, with respect to an MA plan, shall be deemed a reference 
to a PDP sponsor or MA organization, with respect to a prescription 
drug plan or MA-PD plan''.
    (c) Effective Date.--The amendments made by subsections (a) and (b) 
shall apply with respect to plan years beginning on or after the date 
of the enactment of this Act.
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