[Congressional Bills 103th Congress]
[From the U.S. Government Publishing Office]
[S. 514 Introduced in Senate (IS)]

103d CONGRESS
  1st Session
                                 S. 514

 To amend title XVIII of the Social Security Act to improve procedures 
under part B of the medicare program relating to extra-billing limits, 
                        and for other purposes.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                March 5 (legislative day, March 3), 1993

  Mr. Pryor (for himself, Mr. Cohen, Mr. Riegle, Mr. Rockefeller, Mr. 
  Conrad, Mr. Boren, Mr. Grassley, Mr. Durenberger, and Mr. Mitchell) 
introduced the following bill; which was read twice and referred to the 
                          Committee on Finance

_______________________________________________________________________

                                 A BILL


 
 To amend title XVIII of the Social Security Act to improve procedures 
under part B of the medicare program relating to extra-billing limits, 
                        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. REFERENCES TO SOCIAL SECURITY ACT.

    Except as otherwise specifically provided, whenever in this Act an 
amendment is expressed in terms of an amendment to or repeal of a 
section or other provision, the reference shall be considered to be 
made to that section or other provision of the Social Security Act.

SEC. 2. EXTRA-BILLING.

    (a) Application of Extra-Billing Limits.--Paragraph (1) of section 
1848(g) (42 U.S.C. 1395w-4(g)) is amended to read as follows:
            ``(1) Limitation on actual charges.--
                    ``(A) No billing in excess of limiting charges.--A 
                nonparticipating physician who does not accept payment 
                on an assignment-related basis for physicians' services 
                furnished with respect to an individual enrolled under 
                this part may not bill or collect an actual charge in 
                excess of the limiting charge described in paragraph 
                (2) for such services.
                    ``(B) No liability for excess charges.--No person 
                is liable for payment of any amounts billed in excess 
                of the amount permitted under subparagraph (A).
                    ``(C) Refund of excess charges.--If a physician 
                bills or collects an amount that exceeds by at least 
                one dollar the applicable limiting charge for a service 
                furnished to an individual enrolled under this part, 
                the physician shall on a timely basis--
                            ``(i) refund the full amount collected in 
                        excess of the limiting charge,
                            ``(ii) if there is an outstanding balance 
                        owed to the physician for other items and 
                        services and furnished to the individual, 
                        reduce this balance by the amount of the excess 
                        charge and refund any amount in excess of the 
                        outstanding balance, or
                            ``(iii) if the physician has not yet 
                        collected such excess charges, reduce the 
                        actual charge billed for the service to the 
                        amount permitted under subparagraph (A).
                    ``(D) Timeliness of refund.--
                            ``(i) In general.--A refund (or reduction) 
                        under subparagraph (C) is considered to be made 
                        on a timely basis if the full refund (or notice 
                        to the individual of reduced outstanding 
                        balance or reduced charge, as applicable) is 
                        made within 30 days after a carrier notifies 
                        the physician that the limiting charge has been 
                        exceeded.
                            ``(ii) Response to carrier's 
                        determination.--In the case of a physician who, 
                        within 30 days after the carrier notifies the 
                        physician that the limiting charge has been 
                        exceeded, submits to the carrier documentation 
                        supporting application of a different limiting 
                        charge to the service furnished, a refund (or 
                        reduction) under subparagraph (C) is considered 
                        to be made on a timely basis if the full refund 
                        (or notice to the individual of reduced 
                        outstanding balance or reduced charge, as 
                        applicable) is made within 15 days after the 
                        carrier notifies the physician following review 
                        of such documentation that the limiting charge 
                        has been exceeded.
                    ``(E) Sanctions.--If a physician--
                            ``(i) knowingly and willfully bills for 
                        services in violation of subparagraph (A),
                            ``(ii) collects for services in violation 
                        of subparagraph (A) on a repeated basis, or
                            ``(iii) fails to comply with subparagraph 
                        (C),
                the Secretary may apply sanctions against the physician 
                in accordance with section 1842(j)(2) and apply 
                paragraph (4) of section 1842(j) in the same manner as 
                such paragraph applies to such section.''.
    (b) Determinations by Carriers Regarding Applicable Limiting 
Charges for Physician Services.--Section 1842(b)(3) (42 U.S.C. 
1395u(b)(3)) is amended--
            (1) by striking ``and'' at the end of subparagraph (G);
            (2) by striking ``and'' at the end of subparagraph (H); and
            (3) by inserting after subparagraph (H), the following new 
        subparagraph:
            ``(I) will, for claims that are not paid on an assignment-
        related basis--
                    ``(i) determine, prior to making payment, whether 
                the amount billed for physicians' services furnished 
                with respect to an individual enrolled under this part 
                exceeds the limiting charge applicable under section 
                1848(g)(2);
                    ``(ii) notify the physician, supplier, or other 
                person within 30 days of any determination that the 
                amount billed exceeds by at least one dollar the 
                limiting charge applicable under section 1848(g)(2) and 
                provide an opportunity for the physician supplier or 
                other person to respond;
                    ``(iii) notify the physician, supplier, or other 
                person, within 30 days of the receipt of a response, of 
                the carrier's determination with respect to such 
                response regarding whether the limiting charge 
                applicable under section 1848(g)(2) has been exceeded; 
                and
                    ``(iv) include limiting charge information in the 
                explanation of medicare benefits that is sent to an 
                individual enrolled under this part after the 
                submission of an unassigned claim on an individual's 
                behalf which exceeds the limiting charge by at least 
                one dollar; and''.
    (c) Monitoring of Charges in Excess of Limiting Charge.--Section 
1848(g)(6) (42 U.S.C. 1395w-4(g)(6)) is amended in subparagraph (B), by 
striking ``report to the Congress'' and inserting ``report to the 
Congress regarding the charges described in subparagraph (A)(i), 
including the extent to which actual charges exceed limiting charges, 
the number and types of services involved, and the average amount of 
excess charges''.
    (d) Establishment of Medicare Beneficiary Advisory Council.--Title 
XVIII (42 U.S.C. 1395 et seq.) is amended by inserting after section 
1889 the following new section:

``SEC. 1890. MEDICARE BENEFICIARY ADVISORY COUNCIL.

    ``(a) Appointment of Members.--The Secretary shall appoint, based 
on nominations submitted by organizations representing elderly and 
disabled populations, a Medicare Beneficiary Advisory Council 
(hereafter in this section referred to as the `Council') to be composed 
of 15 individuals who are entitled to benefits under part A or who are 
enrolled under part B.
    ``(b) Meetings.--The Council shall meet once during each calendar 
quarter to discuss proposed regulations, carrier manual instructions, 
and any other issues with a direct or indirect impact on delivery, 
cost, quality, or expansion of medicare services. To the extent 
feasible and consistent with statutory deadlines, such consultation 
shall occur before the publication of such proposed changes.
    ``(c) Reimbursement of Expenses.--Members of the Council shall be 
entitled to receive reimbursement of expenses and per diem in lieu of 
subsistence in the same manner as other members of advisory councils 
appointed by the Secretary are provided such reimbursement and per diem 
under this title.''.
    (e) Effective Dates.--
            (1) In general.--Except as provided in paragraph (2), the 
        amendments made by this section shall apply to services 
        furnished on or after January 1, 1994.
            (2) Council.--The amendment made by subsection (e) shall 
        take effect on the date of the enactment of this Act.

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