[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[S. 2964 Introduced in Senate (IS)]
111th CONGRESS
2d Session
S. 2964
To amend titles XVIII, XIX, and XXI of the Social Security Act to
prevent fraud, waste, and abuse under Medicare, Medicaid, and CHIP, and
for other purposes.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
January 28, 2010
Mr. Grassley introduced the following bill; which was read twice and
referred to the Committee on Finance
_______________________________________________________________________
A BILL
To amend titles XVIII, XIX, and XXI of the Social Security Act to
prevent fraud, waste, and abuse under Medicare, Medicaid, and CHIP, 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; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Strengthening
Program Integrity and Accountability in Health Care Act''.
(b) Table of Contents.--The table of contents of this title is as
follows:
Sec. 1. Short title; table of contents.
TITLE I--MEDICARE, MEDICAID, AND CHIP
Sec. 101. Provider screening and other enrollment requirements under
Medicare, Medicaid, and CHIP.
Sec. 102. Enhanced Medicare and Medicaid program integrity provisions.
Sec. 103. Elimination of duplication between the Healthcare Integrity
and Protection Data Bank and the National
Practitioner Data Bank.
Sec. 104. Maximum period for submission of Medicare claims reduced to
not more than 12 months.
Sec. 105. Physicians who order items or services required to be
Medicare enrolled physicians or eligible
professionals.
Sec. 106. Requirement for physicians to provide documentation on
referrals to programs at high risk of waste
and abuse.
Sec. 107. Face to face encounter with patient required before
physicians may certify eligibility for home
health services or durable medical
equipment under Medicare.
Sec. 108. Enhanced penalties.
Sec. 109. Medicare self-referral disclosure protocol.
Sec. 110. Expansion of the Recovery Audit Contractor (RAC) program.
Sec. 111. Requirements for the transmission of management implication
reports by the HHS OIG.
Sec. 112. Medical ID theft information sharing program and
clearinghouse.
TITLE II--ADDITIONAL MEDICAID PROVISIONS
Sec. 201. Termination of provider participation under Medicaid if
terminated under Medicare or other State
plan.
Sec. 202. Medicaid exclusion from participation relating to certain
ownership, control, and management
affiliations.
Sec. 203. Billing agents, clearinghouses, or other alternate payees
required to register under Medicaid.
Sec. 204. Requirement to report expanded set of data elements under
MMIS to detect fraud and abuse.
Sec. 205. Prohibition on payments to institutions or entities located
outside of the United States.
Sec. 206. Overpayments.
Sec. 207. Mandatory State use of national correct coding initiative.
Sec. 208. Payment for illegal unapproved drugs.
Sec. 209. General effective date.
TITLE III--ADDITIONAL PROVISIONS
Sec. 301. Requiring individuals or entities that participate in or
conduct activities under Federal health
care programs to comply with certain
Congressional requests.
Sec. 302. Amendments to the False Claims Act.
Sec. 303. Dismissal of certain actions or claims under the False Claims
Act.
TITLE I--MEDICARE, MEDICAID, AND CHIP
SEC. 101. PROVIDER SCREENING AND OTHER ENROLLMENT REQUIREMENTS UNDER
MEDICARE, MEDICAID, AND CHIP.
(a) Medicare.--Section 1866(j) of the Social Security Act (42
U.S.C. 1395cc(j)) is amended--
(1) in paragraph (1)(A), by adding at the end the
following: ``Such process shall include screening of providers
and suppliers in accordance with paragraph (2), a provisional
period of enhanced oversight in accordance with paragraph (3),
disclosure requirements in accordance with paragraph (4), the
imposition of temporary enrollment moratoria in accordance with
paragraph (5), and the establishment of compliance programs in
accordance with paragraph (6).'';
(2) by redesignating paragraph (2) as paragraph (7); and
(3) by inserting after paragraph (1) the following:
``(2) Provider screening.--
``(A) Procedures.--Not later than 180 days after
the date of enactment of this paragraph, the Secretary,
in consultation with the Inspector General of the
Department of Health and Human Services, shall
establish procedures under which screening is conducted
with respect to providers of medical or other items or
services and suppliers under the program under this
title, the Medicaid program under title XIX, and the
CHIP program under title XXI.
``(B) Level of screening.--The Secretary shall
determine the level of screening conducted under this
paragraph according to the risk of fraud, waste, and
abuse, as determined by the Secretary, with respect to
the category of provider of medical or other items or
services or supplier. Such screening--
``(i) shall include a licensure check,
which may include such checks across States;
and
``(ii) may, as the Secretary determines
appropriate based on the risk of fraud, waste,
and abuse described in the preceding sentence,
include--
``(I) a criminal background check;
``(II) fingerprinting;
``(III) unscheduled and unannounced
site visits, including preenrollment
site visits;
``(IV) database checks (including
such checks across States); and
``(V) such other screening as the
Secretary determines appropriate.
``(C) Application fees.--
``(i) Institutional providers.--Except as
provided in clause (ii), the Secretary shall
impose a fee on each institutional provider of
medical or other items or services or supplier
(such as a hospital or skilled nursing
facility) with respect to which screening is
conducted under this paragraph in an amount
equal to--
``(I) for 2011, $500; and
``(II) for 2012 and each subsequent
year, the amount determined under this
clause for the preceding year, adjusted
by the percentage change in the
consumer price index for all urban
consumers (all items; United States
city average) for the 12-month period
ending with June of the previous year.
``(ii) Hardship exception; waiver for
certain medicaid providers.--The Secretary may,
on a case-by-case basis, exempt a provider of
medical or other items or services or supplier
from the imposition of an application fee under
this subparagraph if the Secretary determines
that the imposition of the application fee
would result in a hardship. The Secretary may
waive the application fee under this
subparagraph for providers enrolled in a State
Medicaid program for whom the State
demonstrates that imposition of the fee would
impede beneficiary access to care.
``(iii) Use of funds.--Amounts collected as
a result of the imposition of a fee under this
subparagraph shall be used by the Secretary for
program integrity efforts, including to cover
the costs of conducting screening under this
paragraph and to carry out this subsection and
section 1128J.
``(D) Application and enforcement.--
``(i) New providers of services and
suppliers.--The screening under this paragraph
shall apply, in the case of a provider of
medical or other items or services or supplier
who is not enrolled in the program under this
title, title XIX, or title XXI as of the date
of enactment of this paragraph, on or after the
date that is 1 year after such date of
enactment.
``(ii) Current providers of services and
suppliers.--The screening under this paragraph
shall apply, in the case of a provider of
medical or other items or services or supplier
who is enrolled in the program under this
title, title XIX, or title XXI as of such date
of enactment, on or after the date that is 2
years after such date of enactment.
``(iii) Revalidation of enrollment.--
Effective beginning on the date that is 180
days after such date of enactment, the
screening under this paragraph shall apply with
respect to the revalidation of enrollment of a
provider of medical or other items or services
or supplier in the program under this title,
title XIX, or title XXI.
``(iv) Limitation on enrollment and
revalidation of enrollment.--In no case may a
provider of medical or other items or services
or supplier who has not been screened under
this paragraph be initially enrolled or
reenrolled in the program under this title,
title XIX, or title XXI on or after the date
that is 3 years after such date of enactment.
``(E) Expedited rulemaking.--The Secretary may
promulgate an interim final rule to carry out this
paragraph.
``(3) Provisional period of enhanced oversight for new
providers of services and suppliers.--
``(A) In general.--The Secretary shall establish
procedures to provide for a provisional period of not
less than 30 days and not more than 1 year during which
new providers of medical or other items or services and
suppliers, as the Secretary determines appropriate,
including categories of providers or suppliers, would
be subject to enhanced oversight, such as prepayment
review and payment caps, under the program under this
title, the Medicaid program under title XIX, and the
CHIP program under title XXI.
``(B) Implementation.--The Secretary may establish
by program instruction or otherwise the procedures
under this paragraph.
``(4) Increased disclosure requirements.--
``(A) Disclosure.--A provider of medical or other
items or services or supplier who submits an
application for enrollment or revalidation of
enrollment in the program under this title, title XIX,
or title XXI on or after the date that is 1 year after
the date of enactment of this paragraph shall disclose
(in a form and manner and at such time as determined by
the Secretary) any current or previous affiliation
(directly or indirectly) with a provider of medical or
other items or services or supplier that has
uncollected debt, has been or is subject to a payment
suspension under a Federal health care program (as
defined in section 1128B(f)), has been excluded from
participation under the program under this title, the
Medicaid program under title XIX, or the CHIP program
under title XXI, or has had its billing privileges
denied or revoked.
``(B) Authority to deny enrollment.--If the
Secretary determines that such previous affiliation
poses an undue risk of fraud, waste, or abuse, the
Secretary may deny such application. Such a denial
shall be subject to appeal in accordance with paragraph
(7).
``(5) Authority to adjust payments of providers of services
and suppliers with the same tax identification number for past-
due obligations.--
``(A) In general.--Notwithstanding any other
provision of this title, in the case of an applicable
provider of services or supplier, the Secretary may
make any necessary adjustments to payments to the
applicable provider of services or supplier under the
program under this title in order to satisfy any past-
due obligations described in subparagraph (B)(ii) of an
obligated provider of services or supplier.
``(B) Definitions.--In this paragraph:
``(i) In general.--The term `applicable
provider of services or supplier' means a
provider of services or supplier that has the
same taxpayer identification number assigned
under section 6109 of the Internal Revenue Code
of 1986 as is assigned to the obligated
provider of services or supplier under such
section, regardless of whether the applicable
provider of services or supplier is assigned a
different billing number or national provider
identification number under the program under
this title than is assigned to the obligated
provider of services or supplier.
``(ii) Obligated provider of services or
supplier.--The term `obligated provider of
services or supplier' means a provider of
services or supplier that owes a past-due
obligation under the program under this title
(as determined by the Secretary).
``(6) Temporary moratorium on enrollment of new
providers.--
``(A) In general.--The Secretary may impose a
temporary moratorium on the enrollment of new providers
of services and suppliers, including categories of
providers of services and suppliers, in the program
under this title, under the Medicaid program under
title XIX, or under the CHIP program under title XXI if
the Secretary determines such moratorium is necessary
to prevent or combat fraud, waste, or abuse under
either such program.
``(B) Limitation on review.--There shall be no
judicial review under section 1869, section 1878, or
otherwise, of a temporary moratorium imposed under
subparagraph (A).
``(7) Compliance programs.--
``(A) In general.--On or after the date of
implementation determined by the Secretary under
subparagraph (C), a provider of medical or other items
or services or supplier within a particular industry
sector or category shall, as a condition of enrollment
in the program under this title, title XIX, or title
XXI, establish a compliance program that contains the
core elements established under subparagraph (B) with
respect to that provider or supplier and industry or
category.
``(B) Establishment of core elements.--The
Secretary, in consultation with the Inspector General
of the Department of Health and Human Services, shall
establish core elements for a compliance program under
subparagraph (A) for providers or suppliers within a
particular industry or category.
``(C) Timeline for implementation.--The Secretary
shall determine the timeline for the establishment of
the core elements under subparagraph (B) and the date
of the implementation of subparagraph (A) for providers
or suppliers within a particular industry or category.
The Secretary shall, in determining such date of
implementation, consider the extent to which the
adoption of compliance programs by a provider of
medical or other items or services or supplier is
widespread in a particular industry sector or with
respect to a particular provider or supplier
category.''.
(b) Medicaid.--
(1) State plan amendment.--Section 1902(a) of the Social
Security Act (42 U.S.C. 1396a(a)) is amended--
(A) in subsection (a)--
(i) by striking ``and'' at the end of
paragraph (72);
(ii) by striking the period at the end of
paragraph (73) and inserting a semicolon; and
(iii) by inserting after paragraph (73) the
following:
``(74) provide that the State shall comply with provider
and supplier screening, oversight, and reporting requirements
in accordance with subsection (ii);''; and
(B) by adding at the end the following:
``(ii) Provider and Supplier Screening, Oversight, and Reporting
Requirements.--For purposes of subsection (a)(74), the requirements of
this subsection are the following:
``(1) Screening.--The State complies with the process for
screening providers and suppliers under this title, as
established by the Secretary under section 1886(j)(2).
``(2) Provisional period of enhanced oversight for new
providers and suppliers.--The State complies with procedures to
provide for a provisional period of enhanced oversight for new
providers and suppliers under this title, as established by the
Secretary under section 1886(j)(3).
``(3) Disclosure requirements.--The State requires
providers and suppliers under the State plan or under a waiver
of the plan to comply with the disclosure requirements
established by the Secretary under section 1886(j)(4).
``(4) Temporary moratorium on enrollment of new providers
or suppliers.--
``(A) Temporary moratorium imposed by the
secretary.--
``(i) In general.--Subject to clause (ii),
the State complies with any temporary
moratorium on the enrollment of new providers
or suppliers imposed by the Secretary under
section 1886(j)(6).
``(ii) Exception.--A State shall not be
required to comply with a temporary moratorium
described in clause (i) if the State determines
that the imposition of such temporary
moratorium would adversely impact
beneficiaries' access to medical assistance.
``(B) Moratorium on enrollment of providers and
suppliers.--At the option of the State, the State
imposes, for purposes of entering into participation
agreements with providers or suppliers under the State
plan or under a waiver of the plan, periods of
enrollment moratoria, or numerical caps or other
limits, for providers or suppliers identified by the
Secretary as being at high-risk for fraud, waste, or
abuse as necessary to combat fraud, waste, or abuse,
but only if the State determines that the imposition of
any such period, cap, or other limits would not
adversely impact beneficiaries' access to medical
assistance.
``(5) Compliance programs.--The State requires providers
and suppliers under the State plan or under a waiver of the
plan to establish, in accordance with the requirements of
section 1866(j)(7), a compliance program that contains the core
elements established under subparagraph (B) of that section
1866(j)(7) for providers or suppliers within a particular
industry or category.
``(6) Reporting of adverse provider actions.--The State
complies with the national system for reporting criminal and
civil convictions, sanctions, negative licensure actions, and
other adverse provider actions to the Secretary, through the
Administrator of the Centers for Medicare & Medicaid Services,
in accordance with regulations of the Secretary.
``(7) Enrollment and npi of ordering or referring
providers.--The State requires--
``(A) all ordering or referring physicians or other
professionals to be enrolled under the State plan or
under a waiver of the plan as a participating provider;
and
``(B) the national provider identifier of any
ordering or referring physician or other professional
to be specified on any claim for payment that is based
on an order or referral of the physician or other
professional.
``(8) Other state oversight.--Nothing in this subsection
shall be interpreted to preclude or limit the ability of a
State to engage in provider and supplier screening or enhanced
provider and supplier oversight activities beyond those
required by the Secretary.''.
(2) Disclosure of medicare terminated providers and
suppliers to states.--The Administrator of the Centers for
Medicare & Medicaid Services shall establish a process for
making available to the each State agency with responsibility
for administering a State Medicaid plan (or a waiver of such
plan) under title XIX of the Social Security Act or a child
health plan under title XXI the name, national provider
identifier, and other identifying information for any provider
of medical or other items or services or supplier under the
Medicare program under title XVIII or under the CHIP program
under title XXI that is terminated from participation under
that program within 30 days of the termination (and, with
respect to all such providers or suppliers who are terminated
from the Medicare program on the date of enactment of this Act,
within 90 days of such date).
(3) Conforming amendment.--Section 1902(a)(23) of the
Social Security Act (42 U.S.C. 1396a), is amended by inserting
before the semicolon at the end the following: ``or by a
provider or supplier to which a moratorium under subsection
(ii)(4) is applied during the period of such moratorium''.
(c) CHIP.--Section 2107(e)(1) of the Social Security Act (42 U.S.C.
1397gg(e)(1)) is amended--
(1) by redesignating subparagraphs (D) through (L) as
subparagraphs (E) through (M), respectively; and
(2) by inserting after subparagraph (C), the following:
``(D) Subsections (a)(74) and (ii) of section 1902
(relating to provider and supplier screening,
oversight, and reporting requirements).''.
SEC. 102. ENHANCED MEDICARE AND MEDICAID PROGRAM INTEGRITY PROVISIONS.
(a) In General.--Part A of 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. MEDICARE AND MEDICAID PROGRAM INTEGRITY PROVISIONS.
``(a) Data Matching.--
``(1) Integrated data repository.--
``(A) Inclusion of certain data.--
``(i) In general.--The Integrated Data
Repository of the Centers for Medicare &
Medicaid Services shall include, at a minimum,
claims and payment data from the following:
``(I) The programs under titles
XVIII and XIX (including parts A, B, C,
and D of title XVIII).
``(II) The program under title XXI.
``(III) Health-related programs
administered by the Secretary of
Veterans Affairs.
``(IV) Health-related programs
administered by the Secretary of
Defense.
``(V) The program of old-age,
survivors, and disability insurance
benefits established under title II.
``(VI) The Indian Health Service
and the Contract Health Service
program.
``(ii) Priority for inclusion of certain
data.--Inclusion of the data described in
subclause (I) of such clause in the Integrated
Data Repository shall be a priority. Data
described in subclauses (II) through (VI) of
such clause shall be included in the Integrated
Data Repository as appropriate.
``(B) Data sharing and matching.--
``(i) In general.--The Secretary shall
enter into agreements with the individuals
described in clause (ii) under which such
individuals share and match data in the system
of records of the respective agencies of such
individuals with data in the system of records
of the Department of Health and Human Services
for the purpose of identifying potential fraud,
waste, and abuse under the programs under
titles XVIII and XIX.
``(ii) Individuals described.--The
following individuals are described in this
clause:
``(I) The Commissioner of Social
Security.
``(II) The Secretary of Veterans
Affairs.
``(III) The Secretary of Defense.
``(IV) The Director of the Indian
Health Service.
``(iii) Definition of system of records.--
For purposes of this paragraph, the term
`system of records' has the meaning given such
term in section 552a(a)(5) of title 5, United
States Code.
``(2) Access to claims and payment databases.--For purposes
of conducting law enforcement and oversight activities and to
the extent consistent with applicable information, privacy,
security, and disclosure laws, including the regulations
promulgated under the Health Insurance Portability and
Accountability Act of 1996 and section 552a of title 5, United
States Code, and subject to any information systems security
requirements under such laws or otherwise required by the
Secretary, the Inspector General of the Department of Health
and Human Services and the Attorney General shall have access
to claims and payment data of the Department of Health and
Human Services and its contractors related to titles XVIII,
XIX, and XXI.
``(b) OIG Authority To Obtain Information.--
``(1) In general.--Notwithstanding and in addition to any
other provision of law, the Inspector General of the Department
of Health and Human Services may, for purposes of protecting
the integrity of the programs under titles XVIII and XIX,
obtain information from any individual (including a beneficiary
provided all applicable privacy protections are followed) or
entity that--
``(A) is a provider of medical or other items or
services, supplier, grant recipient, contractor, or
subcontractor; or
``(B) directly or indirectly provides, orders,
manufactures, distributes, arranges for, prescribes,
supplies, or receives medical or other items or
services payable by any Federal health care program (as
defined in section 1128B(f)) regardless of how the item
or service is paid for, or to whom such payment is
made.
``(2) Inclusion of certain information.--Information which
the Inspector General may obtain under paragraph (1) includes
any supporting documentation necessary to validate claims for
payment or payments under title XVIII or XIX, including a
prescribing physician's medical records for an individual who
is prescribed an item or service which is covered under part B
of title XVIII, a covered part D drug (as defined in section
1860D-2(e)) for which payment is made under an MA-PD plan under
part C of such title, or a prescription drug plan under part D
of such title, and any records necessary for evaluation of the
economy, efficiency, and effectiveness of the programs under
titles XVIII and XIX.
``(c) Administrative Remedy for Knowing Participation by
Beneficiary in Health Care Fraud Scheme.--
``(1) In general.--In addition to any other applicable
remedies, if an applicable individual has knowingly
participated in a Federal health care fraud offense or a
conspiracy to commit a Federal health care fraud offense, the
Secretary shall impose an appropriate administrative penalty
commensurate with the offense or conspiracy.
``(2) Applicable individual.--For purposes of paragraph
(1), the term `applicable individual' means an individual--
``(A) entitled to, or enrolled for, benefits under
part A of title XVIII or enrolled under part B of such
title;
``(B) eligible for medical assistance under a State
plan under title XIX or under a waiver of such plan; or
``(C) eligible for child health assistance under a
child health plan under title XXI.
``(d) Reporting and Returning of Overpayments.--
``(1) In general.--If a person has received an overpayment,
the person shall--
``(A) report and return the overpayment to the
Secretary, the State, an intermediary, a carrier, or a
contractor, as appropriate, at the correct address; and
``(B) notify the Secretary, State, intermediary,
carrier, or contractor to whom the overpayment was
returned in writing of the reason for the overpayment.
``(2) Deadline for reporting and returning overpayments.--
An overpayment must be reported and returned under paragraph
(1) by the later of--
``(A) the date which is 60 days after the date on
which the overpayment was identified; or
``(B) the date any corresponding cost report is
due, if applicable.
``(3) Enforcement.--Any overpayment retained by a person
after the deadline for reporting and returning the overpayment
under paragraph (2) is an obligation (as defined in section
3729(b)(3) of title 31, United States Code) for purposes of
section 3729 of such title.
``(4) Definitions.--In this subsection:
``(A) Knowing and knowingly.--The terms `knowing'
and `knowingly' have the meaning given those terms in
section 3729(b) of title 31, United States Code.
``(B) Overpayment.--The term `overpayment' means
any funds that a person receives or retains under title
XVIII or XIX to which the person, after applicable
reconciliation, is not entitled under such title.
``(C) Person.--
``(i) In general.--The term `person' means
a provider of services, supplier, Medicaid
managed care organization (as defined in
section 1903(m)(1)(A)), Medicare Advantage
organization (as defined in section
1859(a)(1)), or PDP sponsor (as defined in
section 1860D-41(a)(13)).
``(ii) Exclusion.--Such term does not
include a beneficiary.
``(e) Inclusion of National Provider Identifier on All Applications
and Claims.--The Secretary shall promulgate a regulation that requires,
not later than January 1, 2011, all providers of medical or other items
or services and suppliers under the programs under titles XVIII and XIX
that qualify for a national provider identifier to include their
national provider identifier on all applications to enroll in such
programs and on all claims for payment submitted under such
programs.''.
(b) Access to Data.--
(1) Medicare part d.--Section 1860D-15(f)(2) of the Social
Security Act (42 U.S.C. 1395w-116(f)(2)) is amended by striking
``may be used by'' and all that follows through the period at
the end and inserting ``may be used--
``(A) by officers, employees, and contractors of
the Department of Health and Human Services for the
purposes of, and to the extent necessary in--
``(i) carrying out this section; and
``(ii) conducting oversight, evaluation,
and enforcement under this title; and
``(B) by the Attorney General and the Comptroller
General of the United States for the purposes of, and
to the extent necessary in, carrying out health
oversight activities.''.
(2) Data matching.--Section 552a(a)(8)(B) of title 5,
United States Code, is amended--
(A) in clause (vii), by striking ``or'' at the end;
(B) in clause (viii), by inserting ``or'' after the
semicolon; and
(C) by adding at the end the following new clause:
``(ix) matches performed by the Secretary
of Health and Human Services or the Inspector
General of the Department of Health and Human
Services with respect to potential fraud,
waste, and abuse, including matches of a system
of records with non-Federal records;''.
(3) Matching agreements with the commissioner of social
security.--Section 205(r) of the Social Security Act (42 U.S.C.
405(r)) is amended by adding at the end the following new
paragraph:
``(9)(A) The Commissioner of Social Security shall, upon
the request of the Secretary or the Inspector General of the
Department of Health and Human Services--
``(i) enter into an agreement with the Secretary or
such Inspector General for the purpose of matching data
in the system of records of the Social Security
Administration and the system of records of the
Department of Health and Human Services; and
``(ii) include in such agreement safeguards to
assure the maintenance of the confidentiality of any
information disclosed.
``(B) For purposes of this paragraph, the term `system of
records' has the meaning given such term in section 552a(a)(5)
of title 5, United States Code.''.
(c) Withholding of Federal Matching Payments for States That Fail
To Report Enrollee Encounter Data in the Medicaid Statistical
Information System.--Section 1903(i) of the Social Security Act (42
U.S.C. 1396b(i)) is amended--
(1) in paragraph (23), by striking ``or'' at the end;
(2) in paragraph (24), by striking the period at the end
and inserting ``; or''; and
(3) by adding at the end the following new paragraph:.
``(25) with respect to any amounts expended for medical
assistance for individuals for whom the State does not report
enrollee encounter data (as defined by the Secretary) to the
Medicaid Statistical Information System (MSIS) in a timely
manner (as determined by the Secretary).''.
(d) Permissive Exclusions and Civil Monetary Penalties.--
(1) Permissive exclusions.--Section 1128(b) of the Social
Security Act (42 U.S.C. 1320a-7(b)) is amended--
(A) by striking clauses (i) and (ii) of paragraph
(15)(A) and inserting the following:
``(i) who has or had a direct or indirect
ownership or control interest in the sanctioned
entity and who knew or should have known (as
defined in section 1128A(i)(7)) of the action
constituting the basis for the conviction or
exclusion described in subparagraph (B); or
``(ii) who is or was an officer or managing
employee (as defined in section 1126(b)) of
such an entity at the time of the action
constituting the basis for the conviction or
exclusion so described.''; and
(B) by adding at the end the following new
paragraph:
``(16) Making false statements or misrepresentation of
material facts.--Any individual or entity that knowingly makes
or causes to be made any false statement, omission, or
misrepresentation of a material fact in any application,
agreement, bid, or contract to participate or enroll as a
provider of services or supplier under a Federal health care
program (as defined in section 1128B(f)), including Medicare
Advantage organizations under part C of title XVIII,
prescription drug plan sponsors under part D of title XVIII,
Medicaid managed care organizations under title XIX, and
entities that apply to participate as providers of services or
suppliers in such managed care organizations and such plans.''.
(2) Civil monetary penalties.--
(A) In general.--Section 1128A(a) of the Social
Security Act (42 U.S.C. 1320a-7a(a)) is amended--
(i) in paragraph (1)(D), by striking ``was
excluded'' and all that follows through the
period at the end and inserting ``was excluded
from the Federal health care program (as
defined in section 1128B(f)) under which the
claim was made pursuant to Federal law.'';
(ii) in paragraph (6), by striking ``or''
at the end;
(iii) by inserting after paragraph (7), the
following new paragraphs:
``(8) orders or prescribes a medical or other item or
service during a period in which the person was excluded from a
Federal health care program (as so defined), in the case where
the person knows or should know that a claim for such medical
or other item or service will be made under such a program;
``(9) knowingly makes or causes to be made any false
statement, omission, or misrepresentation of a material fact in
any application, bid, or contract to participate or enroll as a
provider of services or a supplier under a Federal health care
program (as so defined), including Medicare Advantage
organizations under part C of title XVIII, prescription drug
plan sponsors under part D of title XVIII, Medicaid managed
care organizations under title XIX, and entities that apply to
participate as providers of services or suppliers in such
managed care organizations and such plans;
``(10) knows of an overpayment (as defined in paragraph (4)
of section 1128G(d)) and does not report and return the
overpayment in accordance with such section;'';
(iv) in the first sentence--
(I) by striking the ``or'' after
``prohibited relationship occurs;'';
and
(II) by striking ``act)'' and
inserting ``act; or in cases under
paragraph (9), $50,000 for each false
statement or misrepresentation of a
material fact)''; and
(v) in the second sentence, by striking
``purpose)'' and inserting ``purpose; or in
cases under paragraph (9), an assessment of not
more than 3 times the total amount claimed for
each item or service for which payment was made
based upon the application containing the false
statement or misrepresentation of a material
fact)''.
(B) Clarification of treatment of certain
charitable and other innocuous programs.--Section
1128A(i)(6) of the Social Security Act (42 U.S.C.
1320a-7a(i)(6)) is amended--
(i) in subparagraph (C), by striking ``or''
at the end;
(ii) in subparagraph (D), as redesignated
by section 4331(e) of the Balanced Budget Act
of 1997 (Public Law 105-33), by striking the
period at the end and inserting a semicolon;
(iii) by redesignating subparagraph (D), as
added by section 4523(c) of such Act, as
subparagraph (E) and striking the period at the
end and inserting ``; or''; and
(iv) by adding at the end the following new
subparagraphs:
``(F) any other remuneration which promotes access
to care and poses a low risk of harm to patients and
Federal health care programs (as defined in section
1128B(f) and designated by the Secretary under
regulations);
``(G) the offer or transfer of items or services
for free or less than fair market value by a person,
if--
``(i) the items or services consist of
coupons, rebates, or other rewards from a
retailer;
``(ii) the items or services are offered or
transferred on equal terms available to the
general public, regardless of health insurance
status; and
``(iii) the offer or transfer of the items
or services is not tied to the provision of
other items or services reimbursed in whole or
in part by the program under title XVIII or a
State health care program (as defined in
section 1128(h));
``(H) the offer or transfer of items or services
for free or less than fair market value by a person,
if--
``(i) the items or services are not offered
as part of any advertisement or solicitation;
``(ii) the items or services are not tied
to the provision of other services reimbursed
in whole or in part by the program under title
XVIII or a State health care program (as so
defined);
``(iii) there is a reasonable connection
between the items or services and the medical
care of the individual; and
``(iv) the person provides the items or
services after determining in good faith that
the individual is in financial need; or
``(I) effective on a date specified by the
Secretary (but not earlier than January 1, 2011), the
waiver by a PDP sponsor of a prescription drug plan
under part D of title XVIII or an MA organization
offering an MA-PD plan under part C of such title of
any copayment for the first fill of a covered part D
drug (as defined in section 1860D-2(e)) that is a
generic drug for individuals enrolled in the
prescription drug plan or MA-PD plan, respectively.''.
(e) Testimonial Subpoena Authority in Exclusion-Only Cases.--
Section 1128(f) of the Social Security Act (42 U.S.C. 1320a-7(f)) is
amended by adding at the end the following new paragraph:
``(4) The provisions of subsections (d) and (e) of section
205 shall apply with respect to this section to the same extent
as they are applicable with respect to title II. The Secretary
may delegate the authority granted by section 205(d) (as made
applicable to this section) to the Inspector General of the
Department of Health and Human Services for purposes of any
investigation under this section.''.
(f) Revising the Intent Requirement for Health Care Fraud.--Section
1128B of the Social Security Act (42 U.S.C. 1320a-7b) is amended by
adding at the end the following new subsection:
``(g) With respect to violations of this section, a person need not
have actual knowledge of this section or specific intent to commit a
violation of this section.''.
(g) Surety Bond Requirements.--
(1) Durable medical equipment.--Section 1834(a)(16)(B) of
the Social Security Act (42 U.S.C. 1395m(a)(16)(B)) is amended
by inserting ``that the Secretary determines is commensurate
with the volume of the billing of the supplier'' before the
period at the end.
(2) Home health agencies.--Section 1861(o)(7)(C) of the
Social Security Act (42 U.S.C. 1395x(o)(7)(C)) is amended by
inserting ``that the Secretary determines is commensurate with
the volume of the billing of the home health agency'' before
the semicolon at the end.
(3) Requirements for certain other providers of services
and suppliers.--Section 1862 of the Social Security Act (42
U.S.C. 1395y) is amended by adding at the end the following new
subsection:
``(n) Requirement of a Surety Bond for Certain Providers of
Services and Suppliers.--
``(1) In general.--The Secretary may require a provider of
services or supplier described in paragraph (2) to provide the
Secretary on a continuing basis with a surety bond in a form
specified by the Secretary in an amount (not less than $50,000)
that the Secretary determines is commensurate with the volume
of the billing of the provider of services or supplier. The
Secretary may waive the requirement of a bond under the
preceding sentence in the case of a provider of services or
supplier that provides a comparable surety bond under State
law.
``(2) Provider of services or supplier described.--A
provider of services or supplier described in this paragraph is
a provider of services or supplier the Secretary determines
appropriate based on the level of risk involved with respect to
the provider of services or supplier, and consistent with the
surety bond requirements under sections 1834(a)(16)(B) and
1861(o)(7)(C).''.
(h) Suspension of Medicare and Medicaid Payments Pending
Investigation of Credible Allegations of Fraud.--
(1) Medicare.--Section 1862 of the Social Security Act (42
U.S.C. 1395y), as amended by subsection (g)(3), is amended by
adding at the end the following new subsection:
``(o) Suspension Authority.--
``(1) In general.--The Secretary shall suspend payment to a
provider of services or supplier under this title pending an
investigation of credible allegations of fraud against the
provider of services or supplier, unless the Secretary finds
good cause not to suspend such payment.
``(2) Consultation.--The Secretary shall consult with the
Inspector General of the Department of Health and Human
Services in determining whether there is a credible allegation
of fraud against a provider of services or supplier.
``(3) Promulgation of regulations.--The Secretary shall
promulgate regulations to carry out this subsection and section
1903(i)(2)(C).''.
(2) Medicaid.--Section 1903(i)(2) of such Act (42 U.S.C.
1396b(i)(2)) is amended--
(A) in subparagraph (A), by striking ``or'' at the
end; and
(B) by inserting after subparagraph (B), the
following:
``(C) by any individual or entity to whom the State
has failed to suspend payments under the plan during
any period when there is pending an investigation of a
credible allegation of fraud against the individual or
entity, as determined by the State in accordance with
regulations promulgated by the Secretary for purposes
of section 1862(o) and this subparagraph, unless the
State determines in accordance with such regulations
there is good cause not to suspend such payments; or''.
(i) Extension of Number of Days in Which Medicare Claims Are
Required To Be Paid in Order to Prevent or Combat Fraud, Waste, or
Abuse.--
(1) Part a claims.--Section 1816(c)(2) of the Social
Security Act (42 U.S.C. 1395h(c)(2)) is amended--
(A) in subparagraph (B)(ii)(V), by striking ``with
respect'' and inserting ``subject to subparagraph (D),
with respect''; and
(B) by adding at the end the following new
subparagraph:
``(D)(i) Upon a determination by the Secretary that
there is a likelihood of fraud, waste, or abuse
involving a particular category of providers of
services or suppliers, categories of providers of
services or suppliers in a certain geographic area, or
individual providers of services or suppliers, the
Secretary shall extend the number of calendar days
described in subparagraph (B)(ii)(V) to--
``(I) up to 365 calendar days with respect
to claims submitted by--
``(aa) categories of providers of
services or suppliers; or
``(bb) categories of providers of
services or suppliers in a certain
geographic area; or
``(II) such time that the Secretary
determines is necessary to ensure that the
claims with respect to individual providers of
services or suppliers are clean claims.
``(ii) During the extended period of time under
subclauses (I) and (II) of clause (ii), the Secretary
shall engage in heightened scrutiny of claims, such as
prepayment review and other methods the Secretary
determines to be appropriate.
``(iii) Not later than 90 days after the date of
enactment of this subparagraph and not less than
annually thereafter, the Inspector General of the
Department of Health and Human Services shall submit to
the Secretary a report containing recommendations with
respect to the application of this subparagraph and
section 1842(c)(2)(D). Not later than 60 days after
receiving such a report, the Secretary shall submit to
the Inspector General a written response to the
recommendations contained in the report.
``(iv) There shall be no administrative or judicial
review under section 1869, section 1878, or otherwise
of the implementation of this subparagraph by the
Secretary.''.
(2) Part b claims.--Section 1842(c)(2) of the Social
Security Act (42 U.S.C. 1395u(c)(2)) is amended--
(A) in subparagraph (B)(ii)(V), by striking ``with
respect'' and inserting ``subject to subparagraph (D),
with respect''; and
(B) by adding at the end the following new
subparagraph:
``(D)(i) Upon a determination by the Secretary that
there is a likelihood of fraud, waste, or abuse
involving a particular category of providers of
services or suppliers, categories of providers of
services or suppliers in a certain geographic area, or
individual providers of services or suppliers, the
Secretary shall extend the number of calendar days
described in subparagraph (B)(ii)(V) to--
``(I) up to 365 calendar days with respect
to claims submitted by--
``(aa) categories of providers of
services or suppliers; or
``(bb) categories of providers of
services or suppliers in a certain
geographic area; or
``(II) such time that the Secretary
determines is necessary to ensure that the
claims with respect to individual providers of
services or suppliers are clean claims.
``(ii) During the extended period of time under
subclauses (I) and (II) of clause (ii), the Secretary
shall engage in heightened scrutiny of claims, such as
prepayment review and other methods the Secretary
determines to be appropriate.
``(iii) There shall be no administrative or
judicial review under section 1869, section 1878, or
otherwise of the implementation of this subparagraph by
the Secretary.''.
(3) Effective date.--
(A) In general.--The amendments made by this
subsection shall take effect on the day that is 6
months after the date of the enactment of this Act.
(B) Expediting implementation.--The Secretary shall
promulgate regulations to carry out the amendments made
by this subsection which may be effective and final
immediately on an interim basis as of the date of
publication of the interim final regulation. If the
Secretary provides for an interim final regulation, the
Secretary shall provide for a period of public comment
on such regulation after the date of publication. The
Secretary may change or revise such regulation after
completion of the period of public comment.
(j) Increased Funding To Fight Fraud and Abuse.--
(1) In general.--Section 1817(k) of the Social Security Act
(42 U.S.C. 1395i(k)) is amended--
(A) by adding at the end the following new
paragraph:
``(7) Additional funding.--In addition to the funds
otherwise appropriated to the Account from the Trust Fund under
paragraphs (3) and (4) and for purposes described in paragraphs
(3)(C) and (4)(A), there are hereby appropriated an additional
$10,000,000 to such Account from such Trust Fund for each of
fiscal years 2011 through 2020. The funds appropriated under
this paragraph shall be allocated in the same proportion as the
total funding appropriated with respect to paragraphs (3)(A)
and (4)(A) was allocated with respect to fiscal year 2010, and
shall be available without further appropriation until
expended.''; and
(B) in paragraph (4)(A), by inserting ``until
expended'' after ``appropriation''.
(2) Indexing of amounts appropriated.--
(A) Departments of health and human services and
justice.--Section 1817(k)(3)(A)(i) of the Social
Security Act (42 U.S.C. 1395i(k)(3)(A)(i)) is amended--
(i) in subclause (III), by inserting
``and'' at the end;
(ii) in subclause (IV)--
(I) by striking ``for each of
fiscal years 2007, 2008, 2009, and
2010'' and inserting ``for each fiscal
year after fiscal year 2006''; and
(II) by striking ``; and'' and
inserting a period; and
(iii) by striking subclause (V).
(B) Office of the inspector general of the
department of health and human services.--Section
1817(k)(3)(A)(ii) of such Act (42 U.S.C.
1395i(k)(3)(A)(ii)) is amended--
(i) in subclause (VIII), by inserting
``and'' at the end;
(ii) in subclause (IX)--
(I) by striking ``for each of
fiscal years 2008, 2009, and 2010'' and
inserting ``for each fiscal year after
fiscal year 2007''; and
(II) by striking ``; and'' and
inserting a period; and
(iii) by striking subclause (X).
(C) Federal bureau of investigation.--Section
1817(k)(3)(B) of the Social Security Act (42 U.S.C.
1395i(k)(3)(B)) is amended--
(i) in clause (vii), by inserting ``and''
at the end;
(ii) in clause (viii)--
(I) by striking ``for each of
fiscal years 2007, 2008, 2009, and
2010'' and inserting ``for each fiscal
year after fiscal year 2006''; and
(II) by striking ``; and'' and
inserting a period; and
(iii) by striking clause (ix).
(D) Medicare integrity program.--Section
1817(k)(4)(C) of the Social Security Act (42 U.S.C.
1395i(k)(4)(C)) is amended by adding at the end the
following new clause:
``(ii) For each fiscal year after 2010, by
the percentage increase in the consumer price
index for all urban consumers (all items;
United States city average) over the previous
year.''.
(k) Medicare Integrity Program and Medicaid Integrity Program.--
(1) Medicare integrity program.--
(A) Requirement to provide performance
statistics.--Section 1893(c) of the Social Security Act
(42 U.S.C. 1395ddd(c)) is amended--
(i) in paragraph (3), by striking ``and''
at the end;
(ii) by redesignating paragraph (4) as
paragraph (5); and
(iii) by inserting after paragraph (3) the
following new paragraph:
``(4) the entity agrees to provide the Secretary and the
Inspector General of the Department of Health and Human
Services with such performance statistics (including the number
and amount of overpayments recovered, the number of fraud
referrals, and the return on investment of such activities by
the entity) as the Secretary or the Inspector General may
request; and''.
(B) Evaluations and annual report.--Section 1893 of
the Social Security Act (42 U.S.C. 1395ddd) is amended
by adding at the end the following new subsection:
``(i) Evaluations and Annual Report.--
``(1) Evaluations.--The Secretary shall conduct evaluations
of eligible entities which the Secretary contracts with under
the Program not less frequently than every 3 years.
``(2) Annual report.--Not later than 180 days after the end
of each fiscal year (beginning with fiscal year 2011), the
Secretary shall submit a report to Congress which identifies--
``(A) the use of funds, including funds transferred
from the Federal Hospital Insurance Trust Fund under
section 1817 and the Federal Supplementary Insurance
Trust Fund under section 1841, to carry out this
section; and
``(B) the effectiveness of the use of such
funds.''.
(C) Flexibility in pursuing fraud and abuse.--
Section 1893(a) of the Social Security Act (42 U.S.C.
1395ddd(a)) is amended by inserting ``, or otherwise,''
after ``entities''.
(2) Medicaid integrity program.--
(A) Requirement to provide performance
statistics.--Section 1936(c)(2) of the Social Security
Act (42 U.S.C. 1396u-6(c)(2)) is amended--
(i) by redesignating subparagraph (D) as
subparagraph (E); and
(ii) by inserting after subparagraph (C)
the following new subparagraph:
``(D) The entity agrees to provide the Secretary
and the Inspector General of the Department of Health
and Human Services with such performance statistics
(including the number and amount of overpayments
recovered, the number of fraud referrals, and the
return on investment of such activities by the entity)
as the Secretary or the Inspector General may
request.''.
(B) Evaluations and annual report.--Section 1936(e)
of the Social Security Act (42 U.S.C. 1396u-7(e)) is
amended--
(i) by redesignating paragraph (4) as
paragraph (5); and
(ii) by inserting after paragraph (3) the
following new paragraph:
``(4) Evaluations.--The Secretary shall conduct evaluations
of eligible entities which the Secretary contracts with under
the Program not less frequently than every 3 years.''.
(l) Expanded Application of Hardship Waivers for Exclusions.--
Section 1128(c)(3)(B) of the Social Security Act (42 U.S.C. 1320a-
7(c)(3)(B)) is amended by striking ``individuals entitled to benefits
under part A of title XVIII or enrolled under part B of such title, or
both'' and inserting ``beneficiaries (as defined in section
1128A(i)(5)) of that program''.
SEC. 103. ELIMINATION OF DUPLICATION BETWEEN THE HEALTHCARE INTEGRITY
AND PROTECTION DATA BANK AND THE NATIONAL PRACTITIONER
DATA BANK.
(a) Information Reported by Federal Agencies and Health Plans.--
Section 1128E of the Social Security Act (42 U.S.C. 1320a-7e) is
amended--
(1) by striking subsection (a) and inserting the following:
``(a) In General.--The Secretary shall maintain a national health
care fraud and abuse data collection program under this section for the
reporting of certain final adverse actions (not including settlements
in which no findings of liability have been made) against health care
providers, suppliers, or practitioners as required by subsection (b),
with access as set forth in subsection (d), and shall furnish the
information collected under this section to the National Practitioner
Data Bank established pursuant to the Health Care Quality Improvement
Act of 1986 (42 U.S.C. 11101 et seq.).'';
(2) by striking subsection (d) and inserting the following:
``(d) Access to Reported Information.--
``(1) Availability.--The information collected under this
section shall be available from the National Practitioner Data
Bank to the agencies, authorities, and officials which are
provided under section 1921(b) information reported under
section 1921(a).
``(2) Fees for disclosure.--The Secretary may establish or
approve reasonable fees for the disclosure of information under
this section. The amount of such a fee may not exceed the costs
of processing the requests for disclosure and of providing such
information. Such fees shall be available to the Secretary to
cover such costs.'';
(3) by striking subsection (f) and inserting the following:
``(f) Appropriate Coordination.--In implementing this section, the
Secretary shall provide for the maximum appropriate coordination with
part B of the Health Care Quality Improvement Act of 1986 (42 U.S.C.
11131 et seq.) and section 1921.''; and
(4) in subsection (g)--
(A) in paragraph (1)(A)--
(i) in clause (iii)--
(I) by striking ``or State'' each
place it appears;
(II) by redesignating subclauses
(II) and (III) as subclauses (III) and
(IV), respectively; and
(III) by inserting after subclause
(I) the following new subclause:
``(II) any dismissal or closure of
the proceedings by reason of the
provider, supplier, or practitioner
surrendering their license or leaving
the State or jurisdiction''; and
(ii) by striking clause (iv) and inserting
the following:
``(iv) Exclusion from participation in a
Federal health care program (as defined in
section 1128B(f)).'';
(B) in paragraph (3)--
(i) by striking subparagraphs (D) and (E);
and
(ii) by redesignating subparagraph (F) as
subparagraph (D); and
(C) in subparagraph (D) (as so redesignated), by
striking ``or State''.
(b) Information Reported by State Law or Fraud Enforcement
Agencies.--Section 1921 of the Social Security Act (42 U.S.C. 1396r-2)
is amended--
(1) in subsection (a)--
(A) in paragraph (1)--
(i) by striking ``system.--The State'' and
all that follows through the semicolon and
inserting system.--
``(A) Licensing or certification actions.--The
State must have in effect a system of reporting the
following information with respect to formal
proceedings (as defined by the Secretary in
regulations) concluded against a health care
practitioner or entity by a State licensing or
certification agency:'';
(ii) by redesignating subparagraphs (A)
through (D) as clauses (i) through (iv),
respectively, and indenting appropriately;
(iii) in subparagraph (A)(iii) (as so
redesignated)--
(I) by striking ``the license of''
and inserting ``license or the right to
apply for, or renew, a license by'';
and
(II) by inserting
``nonrenewability,'' after ``voluntary
surrender,''; and
(iv) by adding at the end the following new
subparagraph:
``(B) Other final adverse actions.--The State must
have in effect a system of reporting information with
respect to any final adverse action (not including
settlements in which no findings of liability have been
made) taken against a health care provider, supplier,
or practitioner by a State law or fraud enforcement
agency.''; and
(B) in paragraph (2), by striking ``the authority
described in paragraph (1)'' and inserting ``a State
licensing or certification agency or State law or fraud
enforcement agency'';
(2) in subsection (b)--
(A) by striking paragraph (2) and inserting the
following:
``(2) to State licensing or certification agencies and
Federal agencies responsible for the licensing and
certification of health care providers, suppliers, and licensed
health care practitioners;'';
(B) in each of paragraphs (4) and (6), by inserting
``, but only with respect to information provided
pursuant to subsection (a)(1)(A)'' before the comma at
the end;
(C) by striking paragraph (5) and inserting the
following:
``(5) to State law or fraud enforcement agencies,'';
(D) by redesignating paragraphs (7) and (8) as
paragraphs (8) and (9), respectively; and
(E) by inserting after paragraph (6) the following
new paragraph:
``(7) to health plans (as defined in section 1128C(c));'';
(3) by redesignating subsection (d) as subsection (h), and
by inserting after subsection (c) the following new
subsections:
``(d) Disclosure and Correction of Information.--
``(1) Disclosure.--With respect to information reported
pursuant to subsection (a)(1), the Secretary shall--
``(A) provide for disclosure of the information,
upon request, to the health care practitioner who, or
the entity that, is the subject of the information
reported; and
``(B) establish procedures for the case where the
health care practitioner or entity disputes the
accuracy of the information reported.
``(2) Corrections.--Each State licensing or certification
agency and State law or fraud enforcement agency shall report
corrections of information already reported about any formal
proceeding or final adverse action described in subsection (a),
in such form and manner as the Secretary prescribes by
regulation.
``(e) Fees for Disclosure.--The Secretary may establish or approve
reasonable fees for the disclosure of information under this section.
The amount of such a fee may not exceed the costs of processing the
requests for disclosure and of providing such information. Such fees
shall be available to the Secretary to cover such costs.
``(f) Protection From Liability for Reporting.--No person or
entity, including any agency designated by the Secretary in subsection
(b), shall be held liable in any civil action with respect to any
reporting of information as required under this section, without
knowledge of the falsity of the information contained in the report.
``(g) References.--For purposes of this section:
``(1) State licensing or certification agency.--The term
`State licensing or certification agency' includes any
authority of a State (or of a political subdivision thereof)
responsible for the licensing of health care practitioners (or
any peer review organization or private accreditation entity
reviewing the services provided by health care practitioners)
or entities.
``(2) State law or fraud enforcement agency.--The term
`State law or fraud enforcement agency' includes--
``(A) a State law enforcement agency; and
``(B) a State Medicaid fraud control unit (as
defined in section 1903(q)).
``(3) Final adverse action.--
``(A) In general.--Subject to subparagraph (B), the
term `final adverse action' includes--
``(i) civil judgments against a health care
provider, supplier, or practitioner in State
court related to the delivery of a health care
item or service;
``(ii) State criminal convictions related
to the delivery of a health care item or
service;
``(iii) exclusion from participation in
State health care programs (as defined in
section 1128(h));
``(iv) any licensing or certification
action described in subsection (a)(1)(A) taken
against a supplier by a State licensing or
certification agency; and
``(v) any other adjudicated actions or
decisions that the Secretary shall establish by
regulation.
``(B) Exception.--Such term does not include any
action with respect to a malpractice claim.''; and
(4) in subsection (h), as so redesignated, by striking
``The Secretary'' and all that follows through the period at
the end and inserting ``In implementing this section, the
Secretary shall provide for the maximum appropriate
coordination with part B of the Health Care Quality Improvement
Act of 1986 (42 U.S.C. 11131 et seq.) and section 1128E.''.
(c) Conforming Amendment.--Section 1128C(a)(1) of the Social
Security Act (42 U.S.C. 1320a-7c(a)(1)) is amended--
(1) in subparagraph (C), by adding ``and'' after the comma
at the end;
(2) in subparagraph (D), by striking ``, and'' and
inserting a period; and
(3) by striking subparagraph (E).
(d) Transition Process; Effective Date.--
(1) In general.--Effective on the date of enactment of this
Act, the Secretary of Health and Human Services (in this
section referred to as the ``Secretary'') shall implement a
transition process under which, by not later than the end of
the transition period described in paragraph (5), the Secretary
shall cease operating the Healthcare Integrity and Protection
Data Bank established under section 1128E of the Social
Security Act (as in effect before the effective date specified
in paragraph (6)) and shall transfer all data collected in the
Healthcare Integrity and Protection Data Bank to the National
Practitioner Data Bank established pursuant to the Health Care
Quality Improvement Act of 1986 (42 U.S.C. 11101 et seq.).
During such transition process, the Secretary shall have in
effect appropriate procedures to ensure that data collection
and access to the Healthcare Integrity and Protection Data Bank
and the National Practitioner Data Bank are not disrupted.
(2) Regulations.--The Secretary shall promulgate
regulations to carry out the amendments made by subsections (a)
and (b).
(3) Funding.--
(A) Availability of fees.--Fees collected pursuant
to section 1128E(d)(2) of the Social Security Act prior
to the effective date specified in paragraph (6) for
the disclosure of information in the Healthcare
Integrity and Protection Data Bank shall be available
to the Secretary, without fiscal year limitation, for
payment of costs related to the transition process
described in paragraph (1). Any such fees remaining
after the transition period is complete shall be
available to the Secretary, without fiscal year
limitation, for payment of the costs of operating the
National Practitioner Data Bank.
(B) Availability of additional funds.--In addition
to the fees described in subparagraph (A), any funds
available to the Secretary or to the Inspector General
of the Department of Health and Human Services for a
purpose related to combating health care fraud, waste,
or abuse shall be available to the extent necessary for
operating the Healthcare Integrity and Protection Data
Bank during the transition period, including systems
testing and other activities necessary to ensure that
information formerly reported to the Healthcare
Integrity and Protection Data Bank will be accessible
through the National Practitioner Data Bank after the
end of such transition period.
(4) Special provision for access to the national
practitioner data bank by the department of veterans affairs.--
(A) In general.--Notwithstanding any other
provision of law, during the 1-year period that begins
on the effective date specified in paragraph (6), the
information described in subparagraph (B) shall be
available from the National Practitioner Data Bank to
the Secretary of Veterans Affairs without charge.
(B) Information described.--For purposes of
subparagraph (A), the information described in this
subparagraph is the information that would, but for the
amendments made by this section, have been available to
the Secretary of Veterans Affairs from the Healthcare
Integrity and Protection Data Bank.
(5) Transition period defined.--For purposes of this
subsection, the term ``transition period'' means the period
that begins on the date of enactment of this Act and ends on
the later of--
(A) the date that is 1 year after such date of
enactment; or
(B) the effective date of the regulations
promulgated under paragraph (2).
(6) Effective date.--The amendments made by subsections
(a), (b), and (c) shall take effect on the first day after the
final day of the transition period.
SEC. 104. MAXIMUM PERIOD FOR SUBMISSION OF MEDICARE CLAIMS REDUCED TO
NOT MORE THAN 12 MONTHS.
(a) Reducing Maximum Period for Submission.--
(1) Part a.--Section 1814(a) of the Social Security Act (42
U.S.C. 1395f(a)(1)) is amended--
(A) in paragraph (1), by striking ``period of 3
calendar years'' and all that follows through the
semicolon and inserting ``period ending 1 calendar year
after the date of service;''; and
(B) by adding at the end the following new
sentence: ``In applying paragraph (1), the Secretary
may specify exceptions to the 1 calendar year period
specified in such paragraph.''
(2) Part b.--
(A) Section 1842(b)(3) of such Act (42 U.S.C.
1395u(b)(3)(B)) is amended--
(i) in subparagraph (B), in the flush
language following clause (ii), by striking
``close of the calendar year following the year
in which such service is furnished (deeming any
service furnished in the last 3 months of any
calendar year to have been furnished in the
succeeding calendar year)'' and inserting
``period ending 1 calendar year after the date
of service''; and
(ii) by adding at the end the following new
sentence: ``In applying subparagraph (B), the
Secretary may specify exceptions to the 1
calendar year period specified in such
subparagraph.''
(B) Section 1835(a) of such Act (42 U.S.C.
1395n(a)) is amended--
(i) in paragraph (1), by striking ``period
of 3 calendar years'' and all that follows
through the semicolon and inserting ``period
ending 1 calendar year after the date of
service;''; and
(ii) by adding at the end the following new
sentence: ``In applying paragraph (1), the
Secretary may specify exceptions to the 1
calendar year period specified in such
paragraph.''
(b) Effective Date.--
(1) In general.--The amendments made by subsection (a)
shall apply to services furnished on or after March 1, 2010.
(2) Services furnished before march 2010.--In the case of
services furnished before March 1, 2010, a bill or request for
payment under section 1814(a)(1), 1842(b)(3)(B), or 1835(a)
shall be filed not later that December 31, 2010.
SEC. 105. PHYSICIANS WHO ORDER ITEMS OR SERVICES REQUIRED TO BE
MEDICARE ENROLLED PHYSICIANS OR ELIGIBLE PROFESSIONALS.
(a) DME.--Section 1834(a)(11)(B) of the Social Security Act (42
U.S.C. 1395m(a)(11)(B)) is amended by striking ``physician'' and
inserting ``physician enrolled under section 1866(j) or an eligible
professional under section 1848(k)(3)(B) that is enrolled under section
1866(j)''.
(b) Home Health Services.--
(1) Part a.--Section 1814(a)(2) of such Act (42 U.S.C.
1395(a)(2)) is amended in the matter preceding subparagraph (A)
by inserting ``in the case of services described in
subparagraph (C), a physician enrolled under section 1866(j) or
an eligible professional under section 1848(k)(3)(B),'' before
``or, in the case of services''.
(2) Part b.--Section 1835(a)(2) of such Act (42 U.S.C.
1395n(a)(2)) is amended in the matter preceding subparagraph
(A) by inserting ``, or in the case of services described in
subparagraph (A), a physician enrolled under section 1866(j) or
an eligible professional under section 1848(k)(3)(B),'' after
``a physician''.
(c) Application to Other Items or Services.--The Secretary may
extend the requirement applied by the amendments made by subsections
(a) and (b) to durable medical equipment and home health services
(relating to requiring certifications and written orders to be made by
enrolled physicians and health professions) to all other categories of
items or services under title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.), including covered part D drugs as defined in
section 1860D-2(e) of such Act (42 U.S.C. 1395w-102), that are ordered,
prescribed, or referred by a physician enrolled under section 1866(j)
of such Act (42 U.S.C. 1395cc(j)) or an eligible professional under
section 1848(k)(3)(B) of such Act (42 U.S.C. 1395w-4(k)(3)(B)).
(d) Effective Date.--The amendments made by this section shall
apply to written orders and certifications made on or after July 1,
2010.
SEC. 106. REQUIREMENT FOR PHYSICIANS TO PROVIDE DOCUMENTATION ON
REFERRALS TO PROGRAMS AT HIGH RISK OF WASTE AND ABUSE.
(a) Physicians and Other Suppliers.--Section 1842(h) of the Social
Security Act (42 U.S.C. 1395u(h)) is amended by adding at the end the
following new paragraph:
``(9) The Secretary may revoke enrollment, for a period of not more
than one year for each act, for a physician or supplier under section
1866(j) if such physician or supplier fails to maintain and, upon
request of the Secretary, provide access to documentation relating to
written orders or requests for payment for durable medical equipment,
certifications for home health services, or referrals for other items
or services written or ordered by such physician or supplier under this
title, as specified by the Secretary.''.
(b) Providers of Services.--Section 1866(a)(1) of such Act (42
U.S.C. 1395cc) is further amended--
(1) in subparagraph (U), by striking at the end ``and'';
(2) in subparagraph (V), by striking the period at the end
and adding ``; and''; and
(3) by adding at the end the following new subparagraph:
``(W) maintain and, upon request of the Secretary,
provide access to documentation relating to written
orders or requests for payment for durable medical
equipment, certifications for home health services, or
referrals for other items or services written or
ordered by the provider under this title, as specified
by the Secretary.''.
(c) OIG Permissive Exclusion Authority.--Section 1128(b)(11) of the
Social Security Act (42 U.S.C. 1320a-7(b)(11)) is amended by inserting
``, ordering, referring for furnishing, or certifying the need for''
after ``furnishing''.
(d) Effective Date.--The amendments made by this section shall
apply to orders, certifications, and referrals made on or after March
1, 2010.
SEC. 107. FACE TO FACE ENCOUNTER WITH PATIENT REQUIRED BEFORE
PHYSICIANS MAY CERTIFY ELIGIBILITY FOR HOME HEALTH
SERVICES OR DURABLE MEDICAL EQUIPMENT UNDER MEDICARE.
(a) Condition of Payment for Home Health Services.--
(1) Part a.--Section 1814(a)(2)(C) of such Act is amended--
(A) by striking ``and such services'' and inserting
``such services''; and
(B) by inserting after ``care of a physician'' the
following: ``, and, in the case of a certification made
by a physician after March 1, 2010, prior to making
such certification the physician must document that the
physician himself or herself has had a face-to-face
encounter (including through use of telehealth, subject
to the requirements in section 1834(m), and other than
with respect to encounters that are incident to
services involved) with the individual within a
reasonable timeframe as determined by the Secretary''.
(2) Part b.--Section 1835(a)(2)(A) of the Social Security
Act is amended--
(A) by striking ``and'' before ``(iii)''; and
(B) by inserting after ``care of a physician'' the
following: ``, and (iv) in the case of a certification
after March 1, 2010, prior to making such certification
the physician must document that the physician has had
a face-to-face encounter (including through use of
telehealth and other than with respect to encounters
that are incident to services involved) with the
individual during the 6-month period preceding such
certification, or other reasonable timeframe as
determined by the Secretary''.
(b) Condition of Payment for Durable Medical Equipment.--Section
1834(a)(11)(B) of the Social Security Act (42 U.S.C. 1395m(a)(11)(B))
is amended--
(1) by striking ``Order.--The Secretary'' and inserting
``Order.--
``(i) In general.--The Secretary''; and
(2) by adding at the end the following new clause:
``(ii) Requirement for face to face
encounter.--The Secretary shall require that
such an order be written pursuant to the
physician documenting that a physician, a
physician assistant, a nurse practitioner, or a
clinical nurse specialist (as those terms are
defined in section 1861(aa)(5)) has had a face-
to-face encounter (including through use of
telehealth under subsection (m) and other than
with respect to encounters that are incident to
services involved) with the individual involved
during the 6-month period preceding such
written order, or other reasonable timeframe as
determined by the Secretary.''.
(c) Application to Other Areas Under Medicare.--The Secretary may
apply the face-to-face encounter requirement described in the
amendments made by subsections (a) and (b) to other items and services
for which payment is provided under title XVIII of the Social Security
Act based upon a finding that such an decision would reduce the risk of
waste, fraud, or abuse.
(d) Application to Medicaid.--The requirements pursuant to the
amendments made by subsections (a) and (b) shall apply in the case of
physicians making certifications for home health services under title
XIX of the Social Security Act in the same manner and to the same
extent as such requirements apply in the case of physicians making such
certifications under title XVIII of such Act.
SEC. 108. ENHANCED PENALTIES.
(a) Civil Monetary Penalties for False Statements or Delaying
Inspections.--Section 1128A(a) of the Social Security Act (42 U.S.C.
1320a-7a(a)), as amended by section 102(d)(2)(A), is amended--
(1) by inserting after paragraph (10) the following new
paragraphs:
``(11) knowingly makes, uses, or causes to be made or used,
a false record or statement material to a false or fraudulent
claim for payment for items and services furnished under a
Federal health care program; or
``(12) fails to grant timely access, upon reasonable
request (as defined by the Secretary in regulations), to the
Inspector General of the Department of Health and Human
Services, for the purpose of audits, investigations,
evaluations, or other statutory functions of the Inspector
General of the Department of Health and Human Services;''; and
(2) in the first sentence (as so amended)--
(A) by striking ``or in cases under paragraph (9)''
and inserting ``in cases under paragraph (9)''; and
(B) by striking ``a material fact)'' and inserting
``a material fact, in cases under paragraph (11),
$50,000 for each false record or statement, or in cases
under paragraph (12), $15,000 for each day of the
failure described in such paragraph)''.
(b) Medicare Advantage and Part D Plans.--
(1) Ensuring timely inspections relating to contracts with
ma organizations.--Section 1857(d)(2) of such Act (42 U.S.C.
1395w-27(d)(2)) is amended--
(A) in subparagraph (A), by inserting ``timely''
before ``inspect''; and
(B) in subparagraph (B), by inserting ``timely''
before ``audit and inspect''.
(2) Marketing violations.--Section 1857(g)(1) of the Social
Security Act (42 U.S.C. 1395w-27(g)(1)) is amended--
(A) in subparagraph (F), by striking ``or'' at the
end;
(B) by inserting after subparagraph (G) the
following new subparagraphs:
``(H) except as provided under subparagraph (C) or
(D) of section 1860D-1(b)(1), enrolls an individual in
any plan under this part without the prior consent of
the individual or the designee of the individual;
``(I) transfers an individual enrolled under this
part from one plan to another without the prior consent
of the individual or the designee of the individual or
solely for the purpose of earning a commission;
``(J) fails to comply with marketing restrictions
described in subsections (h) and (j) of section 1851 or
applicable implementing regulations or guidance; or
``(K) employs or contracts with any individual or
entity who engages in the conduct described in
subparagraphs (A) through (J) of this paragraph;''; and
(C) by adding at the end the following new
sentence: ``The Secretary may provide, in addition to
any other remedies authorized by law, for any of the
remedies described in paragraph (2), if the Secretary
determines that any employee or agent of such
organization, or any provider or supplier who contracts
with such organization, has engaged in any conduct
described in subparagraphs (A) through (K) of this
paragraph.''.
(3) Provision of false information.--Section 1857(g)(2)(A)
of the Social Security Act (42 U.S.C. 1395w-27(g)(2)(A)) is
amended by inserting ``except with respect to a determination
under subparagraph (E), an assessment of not more than the
amount claimed by such plan or plan sponsor based upon the
misrepresentation or falsified information involved,'' after
``for each such determination,''.
(c) Obstruction of Program Audits.--Section 1128(b)(2) of the
Social Security Act (42 U.S.C. 1320a-7(b)(2)) is amended--
(1) in the heading, by inserting ``or audit'' after
``investigation''; and
(2) by striking ``investigation into'' and all that follows
through the period and inserting ``investigation or audit
related to--
``(i) any offense described in paragraph
(1) or in subsection (a); or
``(ii) the use of funds received, directly
or indirectly, from any Federal health care
program (as defined in section 1128B(f)).''.
(d) Effective Date.--
(1) In general.--Except as provided in paragraph (2), the
amendments made by this section shall apply to acts committed
on or after January 1, 2010.
(2) Exception.--The amendments made by subsection (b)(1)
take effect on the date of enactment of this Act.
SEC. 109. MEDICARE SELF-REFERRAL DISCLOSURE PROTOCOL.
(a) Development of Self-Referral Disclosure Protocol.--
(1) In general.--The Secretary of Health and Human
Services, in cooperation with the Inspector General of the
Department of Health and Human Services, shall establish, not
later than 6 months after the date of the enactment of this
Act, a protocol to enable health care providers of services and
suppliers to disclose an actual or potential violation of
section 1877 of the Social Security Act (42 U.S.C. 1395nn)
pursuant to a self-referral disclosure protocol (in this
section referred to as an ``SRDP''). The SRDP shall include
direction to health care providers of services and suppliers
on--
(A) a specific person, official, or office to whom
such disclosures shall be made; and
(B) instruction on the implication of the SRDP on
corporate integrity agreements and corporate compliance
agreements.
(2) Publication on internet website of srdp information.--
The Secretary of Health and Human Services shall post
information on the public Internet website of the Centers for
Medicare & Medicaid Services to inform relevant stakeholders of
how to disclose actual or potential violations pursuant to an
SRDP.
(3) Relation to advisory opinions.--The SRDP shall be
separate from the advisory opinion process set forth in
regulations implementing section 1877(g) of the Social Security
Act.
(b) Reduction in Amounts Owed.--The Secretary of Health and Human
Services is authorized to reduce the amount due and owing for all
violations under section 1877 of the Social Security Act to an amount
less than that specified in subsection (g) of such section. In
establishing such amount for a violation, the Secretary may consider
the following factors:
(1) The nature and extent of the improper or illegal
practice.
(2) The timeliness of such self-disclosure.
(3) The cooperation in providing additional information
related to the disclosure.
(4) Such other factors as the Secretary considers
appropriate.
(c) Report.--Not later than 18 months after the date on which the
SRDP protocol is established under subsection (a)(1), the Secretary
shall submit to Congress a report on the implementation of this
section. Such report shall include--
(1) the number of health care providers of services and
suppliers making disclosures pursuant to the SRDP;
(2) the amounts collected pursuant to the SRDP;
(3) the types of violations reported under the SRDP; and
(4) such other information as may be necessary to evaluate
the impact of this section.
SEC. 110. EXPANSION OF THE RECOVERY AUDIT CONTRACTOR (RAC) PROGRAM.
(a) Expansion to Medicaid.--
(1) State plan amendment.--Section 1902(a)(42) of the
Social Security Act (42 U.S.C. 1396a(a)(42)) is amended--
(A) by striking ``that the records'' and inserting
``that--
``(A) the records'';
(B) by inserting ``and'' after the semicolon; and
(C) by adding at the end the following:
``(B) not later than December 31, 2010, the State
shall--
``(i) establish a program under which the
State contracts (consistent with State law and
in the same manner as the Secretary enters into
contracts with recovery audit contractors under
section 1893(h), subject to such exceptions or
requirements as the Secretary may require for
purposes of this title or a particular State)
with 1 or more recovery audit contractors for
the purpose of identifying underpayments and
overpayments and recouping overpayments under
the State plan and under any waiver of the
State plan with respect to all services for
which payment is made to any entity under such
plan or waiver; and
``(ii) provide assurances satisfactory to
the Secretary that--
``(I) under such contracts, payment
shall be made to such a contractor only
from amounts recovered;
``(II) from such amounts recovered,
payment--
``(aa) shall be made on a
contingent basis for collecting
overpayments; and
``(bb) may be made in such
amounts as the State may
specify for identifying
underpayments;
``(III) the State has an adequate
process for entities to appeal any
adverse determination made by such
contractors; and
``(IV) such program is carried out
in accordance with such requirements as
the Secretary shall specify,
including--
``(aa) for purposes of
section 1903(a)(7), that
amounts expended by the State
to carry out the program shall
be considered amounts expended
as necessary for the proper and
efficient administration of the
State plan or a waiver of the
plan;
``(bb) that section 1903(d)
shall apply to amounts
recovered under the program;
and
``(cc) that the State and
any such contractors under
contract with the State shall
coordinate such recovery audit
efforts with other contractors
or entities performing audits
of entities receiving payments
under the State plan or waiver
in the State, including efforts
with Federal and State law
enforcement with respect to the
Department of Justice,
including the Federal Bureau of
Investigations, the Inspector
General of the Department of
Health and Human Services, and
the State Medicaid fraud
control unit; and''.
(2) Coordination; regulations.--
(A) In general.--The Secretary of Health and Human
Services, acting through the Administrator of the
Centers for Medicare & Medicaid Services, shall
coordinate the expansion of the Recovery Audit
Contractor program to Medicaid with States,
particularly with respect to each State that enters
into a contract with a recovery audit contractor for
purposes of the State's Medicaid program prior to
December 31, 2010.
(B) Regulations.--The Secretary of Health and Human
Services shall promulgate regulations to carry out this
subsection and the amendments made by this subsection,
including with respect to conditions of Federal
financial participation, as specified by the Secretary.
(b) Expansion to Medicare Parts C and D.--Section 1893(h) of the
Social Security Act (42 U.S.C. 1395ddd(h)) is amended--
(1) in paragraph (1), in the matter preceding subparagraph
(A), by striking ``part A or B'' and inserting ``this title'';
(2) in paragraph (2), by striking ``parts A and B'' and
inserting ``this title'';
(3) in paragraph (3), by inserting ``(not later than
December 31, 2010, in the case of contracts relating to
payments made under part C or D)'' after ``2010'';
(4) in paragraph (4), in the matter preceding subparagraph
(A), by striking ``part A or B'' and inserting ``this title'';
and
(5) by adding at the end the following:
``(9) Special rules relating to parts c and d.--The
Secretary shall enter into contracts under paragraph (1) to
require recovery audit contractors to--
``(A) ensure that each MA plan under part C has an
anti- fraud plan in effect and to review the
effectiveness of each such anti-fraud plan;
``(B) ensure that each prescription drug plan under
part D has an anti- fraud plan in effect and to review
the effectiveness of each such anti-fraud plan;
``(C) examine claims for reinsurance payments under
section 1860D-15(b) to determine whether prescription
drug plans submitting such claims incurred costs in
excess of the allowable reinsurance costs permitted
under paragraph (2) of that section; and
``(D) review estimates submitted by prescription
drug plans by private plans with respect to the
enrollment of high cost beneficiaries (as defined by
the Secretary) and to compare such estimates with the
numbers of such beneficiaries actually enrolled by such
plans.''.
(c) Annual Report.--The Secretary of Health and Human Services,
acting through the Administrator of the Centers for Medicare & Medicaid
Services, shall submit an annual report to Congress concerning the
effectiveness of the Recovery Audit Contractor program under Medicaid
and Medicare and shall include such reports recommendations for
expanding or improving the program.
SEC. 111. REQUIREMENTS FOR THE TRANSMISSION OF MANAGEMENT IMPLICATION
REPORTS BY THE HHS OIG.
Section 1128G of the Social Security Act, as added by section
102(a), is amended by adding at the end the following new subsection:
``(f) Transmission of Management Implication Reports by the HHS
OIG.--
``(1) Congressional notification.--Not later than 30 days
after the transmission by the Inspector General of the
Department of Health and Human Services to another agency of
the Department of Health and Human Services of a management
implication report, the Inspector General shall notify the
relevant committees of Congress of such transmission.
``(2) Secretarial response.--The Secretary shall respond to
a management implication report transmitted under paragraph (1)
not later than 90 days after such transmission.
``(3) Relevant committees of congress defined.--In this
subsection, the term `relevant committees of Congress' means
the Committees on Ways and Means and Energy and Commerce of the
House of Representatives and the Committee on Finance of the
Senate.''.
SEC. 112. MEDICAL ID THEFT INFORMATION SHARING PROGRAM AND
CLEARINGHOUSE.
(a) Establishment.--Not later than 24 months after the date of
enactment of this Act, the Secretary of Health and Human Services (in
this section referred to as the ``Secretary''), acting through the
Administrator of the Centers for Medicare & Medicaid Services and in
coordination with the Chairman of the Federal Trade Commission, shall
establish an information sharing program regarding beneficiary medical
ID theft under the programs under titles XVIII, XIX, and XXI of the
Social Security Act (in this section referred to as the ``program'').
(b) Contents of Program.--The program shall include--
(1) the establishment of methods to identify and detect
relevant warning signs of medical ID theft;
(2) the establishment of appropriate responses to such
warning signs that would mitigate and prevent beneficiary
medical ID theft; and
(3) the development of a detailed plan to update the
program as appropriate, taking into consideration such warning
signs and appropriate responses.
(c) Establishment of Clearinghouse.--The Secretary, in coordination
with the Chairman of the Federal Trade Commission, shall establish a
clearinghouse at the Centers for Medicare & Medicaid Services that
collects reports of ID theft against beneficiaries under the programs
under titles XVIII, XIX, and XXI of the Social Security Act from the
Federal Trade Commission and other sources determined appropriate by
the Secretary. Such clearinghouse shall be used to fight medical ID
theft against beneficiaries and to prevent the improper payment of
claims under such programs.
TITLE II--ADDITIONAL MEDICAID PROVISIONS
SEC. 201. TERMINATION OF PROVIDER PARTICIPATION UNDER MEDICAID IF
TERMINATED UNDER MEDICARE OR OTHER STATE PLAN.
Section 1902(a)(39) of the Social Security Act (42 U.S.C. 42 U.S.C.
1396a(a)) is amended by inserting after ``1128A,'' the following:
``terminate the participation of any individual or entity in such
program if (subject to such exceptions as are permitted with respect to
exclusion under sections 1128(c)(3)(B) and 1128(d)(3)(B)) participation
of such individual or entity is terminated under title XVIII or any
other State plan under this title,''.
SEC. 202. MEDICAID EXCLUSION FROM PARTICIPATION RELATING TO CERTAIN
OWNERSHIP, CONTROL, AND MANAGEMENT AFFILIATIONS.
Section 1902(a) of the Social Security Act (42 U.S.C. 1396a(a)), as
amended by section 101(b), is amended by inserting after paragraph (74)
the following:
``(75) provide that the State agency described in paragraph
(9) exclude, with respect to a period, any individual or entity
from participation in the program under the State plan if such
individual or entity owns, controls, or manages an entity that
(or if such entity is owned, controlled, or managed by an
individual or entity that)--
``(A) has unpaid overpayments (as defined by the
Secretary) under this title during such period
determined by the Secretary or the State agency to be
delinquent;
``(B) is suspended or excluded from participation
under or whose participation is terminated under this
title during such period; or
``(C) is affiliated with an individual or entity
that has been suspended or excluded from participation
under this title or whose participation is terminated
under this title during such period;''.
SEC. 203. BILLING AGENTS, CLEARINGHOUSES, OR OTHER ALTERNATE PAYEES
REQUIRED TO REGISTER UNDER MEDICAID.
(a) In General.--Section 1902(a) of the Social Security Act (42
U.S.C. 42 U.S.C. 1396a(a)), as amended by section 202(a), is amended by
inserting after paragraph (75) the following:
``(76) provide that any agent, clearinghouse, or other
alternate payee (as defined by the Secretary) that submits
claims on behalf of a health care provider must register with
the State and the Secretary in a form and manner specified by
the Secretary; and''.
SEC. 204. REQUIREMENT TO REPORT EXPANDED SET OF DATA ELEMENTS UNDER
MMIS TO DETECT FRAUD AND ABUSE.
(a) In General.--Section 1903(r)(1)(F) of the Social Security Act
(42 U.S.C. 1396b(r)(1)(F)) is amended by inserting after ``necessary''
the following: ``and including, for data submitted to the Secretary on
or after March 1, 2010, data elements from the automated data system
that the Secretary determines to be necessary for program integrity,
program oversight, and administration, at such frequency as the
Secretary shall determine''.
(b) Managed Care Organizations.--
(1) In general.--Section 1903(m)(2)(A)(xi) of the Social
Security Act (42 U.S.C. 1396b(m)(2)(A)(xi)) is amended by
inserting ``and for the provision of such data to the State at
a frequency and level of detail to be specified by the
Secretary'' after ``patients''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply with respect to contract years beginning on or
after March 1, 2010.
SEC. 205. PROHIBITION ON PAYMENTS TO INSTITUTIONS OR ENTITIES LOCATED
OUTSIDE OF THE UNITED STATES.
Section 1902(a) of the Social Security Act (42 U.S.C. 1396b(a)), as
amended by section 203, is amended by inserting after paragraph (76)
the following new paragraph:
``(77) provide that the State shall not provide any
payments for items or services provided under the State plan or
under a waiver to any financial institution or entity located
outside of the United States.''.
SEC. 206. OVERPAYMENTS.
(a) Extension of Period for Collection of Overpayments Due to
Fraud.--
(1) In general.--Section 1903(d)(2) of the Social Security
Act (42 U.S.C. 1396b(d)(2)) is amended--
(A) in subparagraph (C)--
(i) in the first sentence, by striking ``60
days'' and inserting ``1 year''; and
(ii) in the second sentence, by striking
``60 days'' and inserting ``1-year period'';
and
(B) in subparagraph (D)--
(i) in inserting ``(i)'' after ``(D)''; and
(ii) by adding at the end the following:
``(ii) In any case where the State is unable to recover a debt
which represents an overpayment (or any portion thereof) made to a
person or other entity due to fraud within 1 year of discovery because
there is not a final determination of the amount of the overpayment
under an administrative or judicial process (as applicable), including
as a result of a judgment being under appeal, no adjustment shall be
made in the Federal payment to such State on account of such
overpayment (or portion thereof) before the date that is 30 days after
the date on which a final judgment (including, if applicable, a final
determination on an appeal) is made.''.
(2) Effective date.--The amendments made by this subsection
take effect on the date of enactment of this Act and apply to
overpayments discovered on or after that date.
(b) Corrective Action.--The Secretary shall promulgate regulations
that require States to correct Federally identified claims
overpayments, of an ongoing or recurring nature, with new Medicaid
Management Information System (MMIS) edits, audits, or other
appropriate corrective action.
SEC. 207. MANDATORY STATE USE OF NATIONAL CORRECT CODING INITIATIVE.
Section 1903(r) of the Social Security Act (42 U.S.C. 1396b(r)) is
amended--
(1) in paragraph (1)(B)--
(A) in clause (ii), by striking ``and'' at the end;
(B) in clause (iii), by adding ``and'' after the
semi-colon; and
(C) by adding at the end the following new clause:
``(iv) effective for claims filed on or
after October 1, 2010, incorporate compatible
methodologies of the National Correct Coding
Initiative administered by the Secretary (or
any successor initiative to promote correct
coding and to control improper coding leading
to inappropriate payment) and such other
methodologies of that Initiative (or such other
national correct coding methodologies) as the
Secretary identifies in accordance with
paragraph (4);''; and
(2) by adding at the end the following new paragraph:
``(4) For purposes of paragraph (1)(B)(iv), the Secretary shall do
the following:
``(A) Not later than September 1, 2010:
``(i) Identify those methodologies of the National
Correct Coding Initiative administered by the Secretary
(or any successor initiative to promote correct coding
and to control improper coding leading to inappropriate
payment) which are compatible to claims filed under
this title.
``(ii) Identify those methodologies of such
Initiative (or such other national correct coding
methodologies) that should be incorporated into claims
filed under this title with respect to items or
services for which States provide medical assistance
under this title and no national correct coding
methodologies have been established under such
Initiative with respect to title XVIII.
``(iii) Notify States of--
``(I) the methodologies identified under
subparagraphs (A) and (B) (and of any other
national correct coding methodologies
identified under subparagraph (B)); and
``(II) how States are to incorporate such
methodologies into claims filed under this
title.
``(B) Not later than March 1, 2011, submit a report to
Congress that includes the notice to States under clause (iii)
of subparagraph (A) and an analysis supporting the
identification of the methodologies made under clauses (i) and
(ii) of subparagraph (A).''.
SEC. 208. PAYMENT FOR ILLEGAL UNAPPROVED DRUGS.
(a) Findings.--Congress finds that each year, the Medicaid program
under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.)
pays millions of dollars in reimbursement for covered outpatient drugs
that are not approved by the Food and Drug Administration under a new
drug application under section 505(b) of the Federal Food, Drug, and
Cosmetic Act (21 U.S.C. 355(b)) or an abbreviated new drug application
under section 505(j) of such Act, or that such drug is not subject such
section 505 or section 512 due to the application of section 201(p) of
such Act (21 U.S.C. 321(p)).
(b) Listing of Drugs and Devices.--Section 510 of the Food, Drug
and Cosmetic Act (21 U.S.C. 360) is amended--
(1) in subsection (j)(1)(B)--
(A) in clause (i), by inserting ``in the case of a
drug, the authority under this Act that does not
require such drug to be subject to section 505 and
section 512,'' after ``labeling for such drug or
device,''; and
(B) in clause (ii), by inserting ``, in the case of
a drug, the authority under this Act that does not
require such drug to be subject to section 505 and
section 512,'' after ``for such drug or device''; and
(2) in subsection (f)--
(A) by striking ``(f) The Secretary'' and inserting
the following:
``(f) Inspection by Public of Registration.--
``(1) In general.--The Secretary''; and
(B) by adding at the end the following:
``(2) List of drugs that are not approved under section 505
or 512.--Not later than January 1, 2011, the Secretary shall
make available to the public on the Internet website of the
Food and Drug Administration a list that includes, for each
drug described in subsection (j)(1)(B)--
``(A) the drug;
``(B) the person who listed such drug; and
``(C) the authority under this Act that does not
require such drug to be subject to section 505 and
section 512, as provided by such person in such
list.''.
(c) Payment for Covered Outpatient Drugs.--Section 1927 of the
Social Security Act (42 U.S.C. 1396r-8) is amended by inserting at the
end the following:
``(l) Condition.--Beginning January 1, 2011, no State shall make
any payment under this section for any covered outpatient drug unless
such State first verifies with the Food and Drug Administration that
such covered outpatient drug has been approved by the Food and Drug
Administration under a new drug application under section 505(b) of the
Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355(b)) or an
abbreviated new drug application under section 505(j) of such Act, or
that such drug is not subject such section 505 or section 512 due to
the application of section 201(p) of such Act (21 U.S.C. 321(p)). The
Secretary shall have the authority to proscribe regulations to create
an information sharing protocol to allow States to verify that a
covered outpatient drug has been approved by the Food and Drug
Administration.''.
SEC. 209. GENERAL EFFECTIVE DATE.
(a) In General.--Except as otherwise provided in this subtitle,
this subtitle and the amendments made by this subtitle take effect on
January 1, 2011, without regard to whether final regulations to carry
out such amendments and subtitle have been promulgated by that date.
(b) Delay if State Legislation Required.--In the case of a State
plan for medical assistance under title XIX of the Social Security Act
or a child health plan under title XXI of such Act which the Secretary
of Health and Human Services determines requires State legislation
(other than legislation appropriating funds) in order for the plan to
meet the additional requirement imposed by the amendments made by this
subtitle, the State plan or child health plan shall not be regarded as
failing to comply with the requirements of such title solely on the
basis of its failure to meet this additional requirement before the
first day of the first calendar quarter beginning after the close of
the first regular session of the State legislature that begins after
the date of the enactment of this Act. For purposes of the previous
sentence, in the case of a State that has a 2-year legislative session,
each year of such session shall be deemed to be a separate regular
session of the State legislature.
TITLE III--ADDITIONAL PROVISIONS
SEC. 301. REQUIRING INDIVIDUALS OR ENTITIES THAT PARTICIPATE IN OR
CONDUCT ACTIVITIES UNDER FEDERAL HEALTH CARE PROGRAMS TO
COMPLY WITH CERTAIN CONGRESSIONAL REQUESTS.
(a) In General.--Section 1128G of the Social Security Act, as added
by section 102(a) and amended by section 111, is amended by adding at
the end the following new subsection:
``(g) Compliance With Certain Requests by Individuals and Entities
That Participate in or Conduct Activities Under Federal Health Care
Programs.--
``(1) In general.--Any individual or entity that
participates in or conducts activities under a Federal health
care program (as defined in section 1128B(f)) shall, as a
condition of such participation or such conduct, comply (at a
time and in a manner specified by the Chairman or ranking
member) with any request submitted by the Chairman or the
ranking member of a relevant committee of Congress to the
individual or entity for the following:
``(A) Documents.
``(B) Information.
``(C) Interviews.
``(2) Relevant committee of congress defined.--In this
subsection, the term `relevant committee of Congress' means the
Committees on Ways and Means and Energy and Commerce of the
House of Representatives and the Committee on Finance of the
Senate.''.
(b) Effective Date.--The amendments made by this section shall take
effect on the date that is 2 years after the date of enactment of this
Act.
SEC. 302. AMENDMENTS TO THE FALSE CLAIMS ACT.
Section 3730(h) of title 31, United States Code, is amended--
(1) in paragraph (1), by striking ``or agent on behalf of
the employee, contractor, or agent or associated others in
furtherance of other efforts to stop 1 or more violations of
this subchapter'' and inserting ``agent or associated others in
furtherance of an action under this section or other efforts to
stop 1 or more violations of this subchapter''; and
(2) by adding at the end the following:
``(3) Limitation on bringing civil action.--A civil action
under this subsection may not be brought more than 2 years
after the date when the retaliation occurred.''.
SEC. 303. DISMISSAL OF CERTAIN ACTIONS OR CLAIMS UNDER THE FALSE CLAIMS
ACT.
Section 3730(e) of title 31, United States Code, is amended by
striking paragraph (4) and inserting the following:
``(4)(A) The court shall dismiss an action or claim under
this section, unless opposed by the Government, if
substantially the same allegations or transactions as alleged
in the action or claim were publicly disclosed--
``(i) in a Federal criminal, civil, or
administrative hearing in which the Government or its
agent is a party;
``(ii) in a congressional, Government
Accountability Office, or other Federal report,
hearing, audit, or investigation; or
``(iii) from the news media, unless the action is
brought by the Attorney General or the person bringing
the action is an original source of the information.
``(B) For purposes of this paragraph, the term `original
source' means an individual who--
``(i) prior to a public disclosure under subsection
(e)(4)(a), has voluntarily disclosed to the Government
the information on which allegations or transactions in
a claim are based; or
``(ii) has knowledge that is independent of and
materially adds to the publicly disclosed allegations
or transactions, and has voluntarily provided the
information to the Government before filing an action
under this section.''.
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