[Congressional Bills 104th Congress]
[From the U.S. Government Publishing Office]
[S. 1325 Introduced in Senate (IS)]


104th CONGRESS
  1st Session
                                S. 1325

 To amend title XI of the Social Security Act to provide an incentive 
 for the reporting of inaccurate medicare claims for payment, and for 
                            other purposes.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

             October 17 (legislative day, October 10), 1995

  Mr. McCain (for himself and Mr. Kyl) introduced the following bill; 
     which was read twice and referred to the Committee on Finance

_______________________________________________________________________

                                 A BILL


 
 To amend title XI of the Social Security Act to provide an incentive 
 for the reporting of inaccurate medicare claims for payment, and for 
                            other purposes.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Medicare Whistleblower Act of 
1995''.

SEC. 2. PURPOSE.

    The purpose of this Act is to--
            (1) reduce and eliminate fraud and abuse under the medicare 
        program;
            (2) reduce negligent and fraudulent medicare billings by 
        providers;
            (3) provide medicare beneficiaries with incentives to 
        report inappropriate billing practices; and
            (4) provide savings to the medicare trust funds by 
        increasing the recovery of medicare overpayments.

SEC. 3. REQUEST FOR ITEMIZED BILL FOR MEDICARE ITEMS AND SERVICES.

    (a) In General.--Section 1128A of the Social Security Act (42 
U.S.C. 1320a-7a) is amended by adding at the end the following new 
subsection:
    ``(m) Written Request for Itemized Bill.--
            ``(1) In general.--A beneficiary may submit a written 
        request for an itemized bill for medical or other items or 
        services provided to such beneficiary by any person (including 
        an organization, agency, or other entity) that receives payment 
        under title XVIII for providing such items or services to such 
        beneficiary.
            ``(2) 30-day period to receive bill.--
                    ``(A) In general.--Not later than 30 days after the 
                date on which a request under paragraph (1) has been 
                received, a person described in such paragraph shall 
                furnish an itemized bill describing each medical or 
                other item or service provided to the beneficiary 
                requesting the itemized bill.
                    ``(B) Penalty.--Whoever knowingly fails to furnish 
                an itemized bill in accordance with subparagraph (A) 
                shall be subject to a civil fine of not more than $100 
                for each such failure.
            ``(3) Review of itemized bill.--
                    ``(A) In general.--Not later than 90 days after the 
                receipt of an itemized bill furnished under paragraph 
                (1), a beneficiary may submit a written request for a 
                review of the itemized bill to the appropriate fiscal 
                intermediary or carrier with a contract under section 
                1816 or 1842.
                    ``(B) Specific allegations.--A request for a review 
                of the itemized bill shall identify--
                            ``(i) specific medical or other items or 
                        services that the beneficiary believes were not 
                        provided as claimed, or
                            ``(ii) any other billing irregularity 
                        (including duplicate billing).
            ``(4) Findings of fiscal intermediary or carrier.--Each 
        fiscal intermediary or carrier with a contract under section 
        1816 or 1842 shall, with respect to each claim submitted to the 
        fiscal intermediary or carrier under paragraph (3), make one of 
        the following determinations:
                    ``(A) The itemized bill accurately reflects medical 
                or other items or services provided to the beneficiary.
                    ``(B) The itemized bill does not accurately reflect 
                medical or other items or services provided to the 
                beneficiary or contains a billing irregularity but the 
                inaccuracy or irregularity is inadvertent or is the 
                result of a misinterpretation of law.
                    ``(C) The itemized bill negligently describes 
                medical or other items or services not provided to the 
                beneficiary or contains a negligent billing 
                irregularity.
                    ``(D) The itemized bill fraudulently describes 
                medical or other items or services not provided to the 
                beneficiary or contains a fraudulent billing 
                irregularity.
            ``(5) Review of findings of fiscal intermediary or 
        carrier.--
                    ``(A) In general.--If a fiscal intermediary or 
                carrier makes a finding described in subparagraph (B), 
                (C), or (D) of paragraph (4), the fiscal intermediary 
or carrier shall submit to the Secretary a report containing such 
findings and the basis for such findings.
                    ``(B) Determination by secretary.--The Secretary 
                shall determine whether the findings of the fiscal 
                intermediary or carrier submitted under subparagraph 
                (A) are correct.
            ``(6) Recovery of amounts.--The Secretary shall require 
        fiscal intermediaries and carriers to take all appropriate 
        measures to recover amounts inappropriately paid under title 
        XVIII with respect to a bill for which the Secretary makes a 
        determination of correctness under paragraph (5)(B).
            ``(7) Antifraud incentive payments.--
                    ``(A) In general.--If the Secretary makes a 
                determination of correctness under paragraph (5)(B) 
                with respect to a finding described in subparagraph (C) 
                or (D) of paragraph (4), the Secretary shall make an 
                antifraud incentive payment (in an amount determined 
                under subparagraph (B)) to the beneficiary who 
                submitted the request for the itemized bill under 
                paragraph (1) that resulted in such findings.
                    ``(B) Antifraud incentive payment determined.--
                            ``(i) In general.--The amount of the 
                        antifraud incentive payment determined under 
                        this subparagraph is equal to the lesser of--
                                    ``(I) 1 percent of the amount that 
                                the bill negligently or fraudulently 
                                charged for medical or other items or 
                                services; or
                                    ``(II) $10,000.
                            ``(ii) Limitation of amount.--The amount 
                        determined under this subparagraph may not 
                        exceed--
                                    ``(I) in the case of a negligent 
                                bill, the total amounts recovered with 
                                respect to the bill in accordance with 
                                paragraph (6); or
                                    ``(II) in the case of a fraudulent 
                                bill, the sum of the amounts assessed 
                                and collected with respect to the bill 
                                under paragraph (8).
            ``(8) Penalty.--If the Secretary makes a determination of 
        correctness with respect to a finding described in paragraph 
        (4)(D) (relating to fraudulent billing), the provider or other 
        person responsible for providing the beneficiary with the 
        itemized bill that is the subject of such findings, shall be 
        subject, in addition to any other penalties that may be 
        prescribed by law, to a civil money penalty equal to the lesser 
        of--
                    ``(A) 1 percent of the amount that the bill 
                fraudulently charged for medical or other items or 
                services; or
                    ``(B) $10,000.
            ``(9) Prevention of abuse by beneficiaries.--The Secretary 
        shall--
                    ``(A) address abuses of the incentive system 
                established under this subsection; and
                    ``(B) establish appropriate procedures to prevent 
                such abuses.
            ``(10) Requirement that beneficiary discover negligent or 
        fraudulent bill to receive incentive payment.--No incentive 
        payment shall be made under paragraph (7) to a beneficiary if 
        the Secretary or the appropriate fiscal intermediary or carrier 
        identified the bill that was the subject of the beneficiary's 
        request for review under this subsection as being negligent or 
        fraudulent prior to such request.''.
    (b) Payment of Antifraud Incentive to Medicare Beneficiary.--
Section 1128A(f) of the Social Security Act (42 U.S.C. 1320a-7a(f)) is 
amended--
            (1) in paragraph (3), by striking ``(3)'' and inserting 
        ``(4)''; and
            (2) by inserting after paragraph (2) the following:
            ``(3) Any penalty recovered under subsection (m)(8) shall 
        be paid as an antifraud incentive payment to the beneficiary 
        who submitted the request for the itemized bill under 
        subsection (m)(1) that resulted in the imposition of the 
        penalty.''.
    (c) Conforming Amendment.--Subsections (c) and (d) of section 1128A 
of the Social Security Act (42 U.S.C. 1320a-7a) are each amended by 
striking ``(a) or (b)'' each place it appears and inserting ``(a), (b), 
or (m)''.
    (d) Effective Date.--The amendments made by this section shall 
apply with respect to medical or other items or services provided on or 
after January 1, 1996.
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