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SECTION 1. SHORT TITLE.

This Act may be cited as the ''Health Care Claims Guidance Act''.

SEC. 2. RULES FOR ACTIONS UNDER FALSE CLAIMS PROVISIONS BASED ON CLAIMS
SUBMITTED UNDER CERTAIN HEALTH CARE PROGRAMS.

(a) In General.--Subchapter III of chapter 37 of title 31, United
States Code, is amended by adding at the end the following:
''Sec. 3734. Rules for certain actions based on health care claims
''(a) In General.--In the case of any action that is brought under
this subchapter based on a claim submitted with respect to a federally
funded health care program, the preceding provisions of this subchapter
shall apply only to the extent that such provisions are consistent with
the provisions of this section.
''(b) Actions if Amount of Damages Are Material Amount.--
Notwithstanding the preceding sections of this subchapter, no action
may be brought under this subchapter based on a claim that is submitted
under a federally funded health care program unless the amount of
damages alleged to have been sustained by the United States Government
with respect to such claim is a material amount.
''(c) Actions for Claims Submitted in Reliance on Official
Guidance.--Notwithstanding the preceding sections of this subchapter,
no action may be brought under this subchapter based on a claim
submitted--
''(1) in reliance on (and correctly using) erroneous
information supplied by a Federal agency (or an agent thereof)
about matters of fact at issue; or
''(2) in reliance on (and correctly applying) written
statements of Federal policy which affects such claim provided
by a Federal agency (or an agent thereof).
''(d) Action for Claims Submitted by Persons in Substantial
Compliance With Model Compliance Plan.--Notwithstanding the preceding
sections of this subchapter, no action may be brought under this
subchapter based on a claim submitted by a person that is in
substantial compliance with a model compliance plan issued by the
Secretary of Health and Human Services (in consultation with the
Secretary of Defense).
''(e) Standard of Proof.--In any action brought under this
subchapter with respect to a claim submitted to a federally funded
health care program, section 3731(c) shall be applied by substituting
'clear and convincing evidence' for 'a preponderance of the evidence'.
''(f) Rule of Construction.--Nothing in this section shall be
construed as limiting the authority of the Government of the United
States to recoup or otherwise recover damages with respect to a claim
submitted to a federally funded health care program under provisions of
law other than this subchapter.
''(g) Definitions; Related Rules.--For purposes of this section--
''(1) the term 'claim' means a claim (as defined in section
3729(c)) made with respect to a federally funded health care
program;
''(2) the term 'damages' means the amount of any
overpayment made by the United States Government with respect
to a claim;
''(3) the term 'federally funded health care program' means
a program that provides health benefits, whether directly,
through the purchase of insurance, or otherwise, that is
established under--
''(A) title XVIII, XIX, or XXI of the Social
Security Act, or
''(B) title 10, United States Code;
''(4) the amount of damages alleged to have been sustained
by the United States Government with respect to a claim
submitted by (or on behalf of) a person shall be treated as a
'material amount' only if such amount exceeds a proportion
(specified in regulations promulgated by the Secretary of
Health and Human Services in consultation with the Secretary of
Defense) of the total of the amounts for which claims were
submitted by (or on behalf of) such person--
''(A) to the same federally funded health care
program, and
''(B) for the same calendar year,
as the claim upon which an action under this subchapter is
based;
''(5) the regulations specifying the proportion referred to
in paragraph (4) shall be based on the definition of the term
'material' used by the American Institute of Certified Public
Accountants as of the date of the enactment of this section;
and
''(6) in determining whether an amount of damages is a
'material amount' under paragraph (4), with respect to a
person--
''(A) the amount of damages for more than 1 claim
may be aggregated only if the acts or omissions
resulting in such damages were part of a pattern of
related acts or omissions by such person, and
''(B) if damages for more than 1 claim are
aggregated in accordance with subparagraph (A), the
proportion referred to in such paragraph shall be
determined by comparing the amount of such aggregate
damages to the total of the amounts for which claims
were submitted by (or on behalf of) such person to the
same federally funded health care program for each of
the calendar years for which any claim upon which such
aggregate damages were based was submitted.''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to actions brought under subchapter III of chapter 37 of title
31, United States Code, with respect to claims submitted before, on,
and after the date of the enactment of this Act.
Output:
Health Care Claims Guidance Act - Amends Federal law relating to claims against the U. S. Government to prohibit any action under such provisions based on a claim submitted: (1) under a federally funded health care program unless the amount of damages alleged is a material amount; (2) in reliance on erroneous information supplied by a Federal agency or in reliance on written statements of Federal policy which affects such claim provided by a Federal agency; or (3) by a person that is in substantial compliance with a model compliance plan issued by the Secretary of Health and Human Services (in consultation with the Secretary of Defense). Requires that the Government prove an allegation of a false health care claim by clear and convincing evidence. Defines, for the amendments made by this Act, "federally funded health care program" to mean a program that provides health benefits, directly or otherwise, established under Social Security Act titles XVIII (Medicare), XIX (Medicaid), or XXI (Children's Health Insurance) or provisions of Federal law relating to the armed forces.