[Congressional Bills 103th Congress]
[From the U.S. Government Publishing Office]
[H.R. 315 Introduced in House (IH)]

103d CONGRESS
  1st Session
                                H. R. 315

  To limit medicare denials by peer review organizations of medically 
                 necessary inpatient hospital services.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                            January 5, 1993

 Mr. Quillen introduced the following bill; which was referred jointly 
      to the Committees on Ways and Means and Energy and Commerce

_______________________________________________________________________

                                 A BILL


 
  To limit medicare denials by peer review organizations of medically 
                 necessary inpatient hospital services.

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

SECTION 1. LIMITATION ON MEDICARE DENIAL OF MEDICALLY NECESSARY 
              INPATIENT HOSPITAL SERVICES.

    (a) In General.--Notwithstanding any provision of the medicare 
program to the contrary, except as provided in subsection (b), payment 
may not be denied by the Secretary or a PRO under the medicare program 
with respect to inpatient hospital services on the basis that the 
services were not reasonable and medically necessary (or not allowable 
under subsection (a)(1) or (a)(9) of section 1862 of the Social 
Security Act) if a physician has made the certification required under 
section 1814(a)(3) of such Act with respect to the services.
    (b) Exception.--Subsection (a) shall not apply to inpatient 
hospital services ordered by a physician whom the Secretary or PRO has 
determined (after notice and opportunity for a hearing) has a clear 
pattern of certifying as reasonable and medically necessary inpatient 
hospital services that are not reasonable and medically necessary.
    (c) Definitions.--In this section:
            (1) The term ``medicare program'' refers to the programs 
        under title XVIII of the Social Security Act, and includes the 
        peer review program established under part B of title XI of 
        such Act.
            (2) The term ``PRO'' refers to a utilization and quality 
        control peer review organization which has a contract under 
        part B of title XI of the Social Security Act.
            (3) The term ``Secretary'' means the Secretary of Health 
        and Human Services.

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