[Congressional Bills 106th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5094 Introduced in House (IH)]







106th CONGRESS
  2d Session
                                H. R. 5094

  To reduce the amount of paperwork and improve payment policies for 
 health care services, to prevent fraud and abuse through health care 
              provider education, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             July 27, 2000

Mr. Thornberry introduced the following bill; which was referred to the 
  Committee on Commerce, and in addition to the Committee on Ways and 
 Means, for a period to be subsequently determined by the Speaker, in 
   each case for consideration of such provisions as fall within the 
                jurisdiction of the committee concerned

_______________________________________________________________________

                                 A BILL


 
  To reduce the amount of paperwork and improve payment policies for 
 health care services, to prevent fraud and abuse through health care 
              provider education, 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 ``Health Care Fraud Prevention and 
Paperwork Reduction Act of 2000''.

SEC. 2. FEDERAL COMMISSION ON BILLING CODES AND FORMS SIMPLIFICATION.

    (a) Establishment.--There is hereby established the Commission on 
Billing Codes and Forms Simplification (in this section referred to as 
the ``Commission'').
    (b) Duties.--The Commission shall make recommendations regarding 
the following:
            (1) Standardized forms.--Standardizing credentialing and 
        billing forms respecting health care claims, that all Federal 
        Government agencies would use and that the private sector is 
        able (and is encouraged, but not required) to use.
            (2) Reduction in billing codes.--A significant reduction 
        and simplification in the number of billing codes.
    (c) Membership.--
            (1) Number and appointment.--The Commission shall be 
        composed of such members as the Comptroller General of the 
        United States shall appoint.
            (2) Qualifications.--The membership of the Commission shall 
        include individuals who are members of the medical community.
    (d) Incorporation of MedPAC Provisions.--The provisions of 
paragraphs (3) through (6) of subsection (c) and subsections (d) 
through (f) of section 1805 of the Social Security Act (42 U.S.C. 
1395b-6) shall apply to the Commission in the same manner as they apply 
to the Medicare Payment Advisory Commission.
    (e) Reports.--The Commission shall submit to Congress and the 
President such periodic reports on its recommendations as it deems 
appropriate.

SEC. 3. EDUCATION OF PHYSICIANS AND PROVIDERS CONCERNING MEDICARE 
              PROGRAM PAYMENTS.

    (a) Written Requests.--
            (1) In general.--The Secretary of Health and Human Services 
        shall establish a process under which a physician may request, 
        in writing from a carrier, assistance in addressing 
        questionable codes and procedures under the medicare program 
        under title XVIII of the Social Security Act and then the 
        carrier shall respond in writing within 30 business days 
        respond with the correct billing or procedural answer.
            (2) Use of written statement.--
                    (A) In general.--Subject to subparagraph (B), a 
                written statement under paragraph (1) may be used as 
                proof against a future audit or overpayment under the 
                medicare program.
                    (B) Limit on application.--Subparagraph (A) shall 
                not apply retroactively and shall not apply to cases of 
                fraudulent billing.
    (b) Restoration of Toll-Free Hotline.--
            (1) In general.--The Administrator of the Health Care 
        Financing Administration shall restore the toll-free telephone 
        hotline so that physicians may call for information and 
        questions about the medicare program.
            (2) Authorization of appropriations.--There are authorized 
        to be appropriated such sums as may be necessary to carry out 
        paragraph (1).
    (c) Definitions.--For purposes of this section:
            (1) Physician.--The term ``physician'' has the meaning 
        given such term in section 1861(r) of the Social Security Act 
        (42 U.S.C. 1395x(r)).
            (2) Carrier.--The term ``carrier'' means a carrier (as 
        defined in section 1842(f) of the Social Security Act (42 
        U.S.C. 1395u(f))) with a contract under title XVIII of such Act 
        to administer benefits under part B of such title.

SEC. 4. POLICY DEVELOPMENT REGARDING E&M GUIDELINES UNDER THE MEDICARE 
              PROGRAM.

    (a) In General.--HCFA may not implement any new evaluation and 
management guidelines (in this section referred to as ``E&M 
guidelines'') under the medicare program, unless HCFA--
            (1) has provided for an assessment of the proposed 
        guidelines by physicians;
            (2) has established a plan that contains specific goals, 
        including a schedule, for improving participation of 
        physicians;
            (3) has carried out a minimum of 4 pilot projects 
        consistent with subsection (b) in at least 4 different HCFA 
        regions (to be specified by the Secretary) to test such 
        guidelines; and
            (4) finds that the objectives described in subsection (c) 
        will be met in the implementation of such guidelines.
    (b) Pilot Projects.--
            (1) Length and consultation.--Each pilot project under this 
        subsection shall--
                    (A) be of sufficient length to allow for 
                preparatory physician and carrier education, analysis, 
                and use and assessment of potential E&M guidelines; and
                    (B) be conducted, throughout the planning and 
                operational stages of the project, in consultation with 
                national and State medical societies.
            (2) Peer review and rural pilot projects.--Of the pilot 
        projects conducted under this subsection--
                    (A) at least one shall focus on a peer review 
                method by physicians which evaluates medical record 
                information for statistical outlier services relative 
                to definitions and guidelines published in the CPT 
                book, instead of an approach using the review of 
                randomly selected medical records using non-clinical 
                personnel; and
                    (B) at least one shall be conducted for services 
                furnished in a rural area.
            (3) Study of impact.--Each pilot project shall examine the 
        effect of the E&M guidelines on--
                    (A) different types of physician practices, such as 
                large and small groups; and
                    (B) the costs of compliance, and patient and 
                physician satisfaction.
            (4) Report on how met objectives.--HCFA shall submit a 
        report to the Committees on Commerce and Ways and Means of the 
        House of Representatives, the Committee on Finance of the 
        Senate, and the Practicing Physicians Advisory Council, six 
        months after the conclusion of the pilot projects. Such report 
        shall include the extent to which the pilot projects met the 
        objectives specified in subsection (c).
    (c) Objectives for E&M Guidelines.--The objectives for E&M 
guidelines specified in this subsection are as follows (relative to the 
E&M guidelines and review policies in effect as of the date of the 
enactment of this Act):
            (1) Enhancing clinically relevant documentation needed to 
        accurately code and assess coding levels accurately.
            (2) Reducing administrative burdens.
            (3) Decreasing the level of non-clinically pertinent and 
        burdensome documentation time and content in the record.
            (4) Increased accuracy by carrier reviewers.
            (5) Education of both physicians and reviewers.
            (6) Appropriate use of E&M codes by physicians and their 
        staffs.
            (7) The extent to which the tested E&M documentation 
        guidelines substantially adhere to the CPT coding rules.
    (d) Definitions.--For purposes of this section and sections 5 and 
6:
            (1) Physician.--The term ``physician'' has the meaning 
        given such term in section 1861(r) of the Social Security Act 
        (42 U.S.C. 1395x(r)).
            (2) Carrier.--The term ``carrier'' means a carrier (as 
        defined in section 1842(f) of the Social Security Act (42 
        U.S.C. 1395u(f))) with a contract under title XVIII of such Act 
        to administer benefits under part B of such title.
            (3) Secretary.--The term ``Secretary'' means the Secretary 
        of Health and Human Services.
            (4) HCFA.--The term ``HCFA'' means the Health Care 
        Financing Administration.
            (5) Medicare program.--The term ``medicare program'' means 
        the program under title XVIII of the Social Security Act.

SEC. 5. OVERPAYMENTS UNDER THE MEDICARE PROGRAM.

    (a) Individualized Notice.--If a carrier proceeds with a post-
payment audit of a physician under the medicare program, the carrier 
shall provide the physician with an individualized notice of billing 
problems, such as a personal visit or carrier-to-physician telephone 
conversation during normal working hours, within 3 months of initiating 
such audit. The notice should include suggestions to the physician on 
how the billing problem may be remedied.
    (b) Repayment of Overpayments Without Penalty.--The Secretary shall 
permit physicians to repay medicare overpayments within 3 months 
without penalty or interest and without threat of denial of other 
claims based upon extrapolation. If a physician should discover an 
overpayment before a carrier notifies the physician of the error, the 
physician may reimburse the medicare program without penalty and the 
Secretary may not audit or target the physician on the basis of such 
repayment, unless other evidence of fraudulent billing exists.
    (c) Treatment of First-Time Billing Errors.--If a physician's 
medicare billing error was a first-time error and the physician has not 
previously been the subject of a post-payment audit, the carrier may 
not assess a fine through extrapolation of such an error to other 
claims, unless the physician has submitted a fraudulent claim.
    (d) Timely Notice of Problem Claims Before Using Extrapolation.--A 
carrier may seek reimbursement or penalties against a physician based 
on extrapolation of a medicare claim only if the carrier has informed 
the physician of potential problems with the claim within one year 
after the date the claim was submitted for reimbursement.
    (e) Submission of Additional Information.--A physician may submit 
additional information and documentation to dispute a carrier's charges 
of overpayment without waiving the physician's right to a hearing by an 
administrative law judge.
    (f) Limitation on Delay in Payment.--Following a post-payment 
audit, a carrier that is conducting a pre-payment screen on a physician 
service under the medicare program may not delay reimbursements for 
more than one month and as soon as the physician submits a corrected 
claim, the carrier shall eliminate application of such a pre-payment 
screen.

SEC. 6. ENFORCEMENT PROVISIONS UNDER THE MEDICARE PROGRAM.

    If a physician is suspected of fraud or wrongdoing in the medicare 
program, inspectors associated with the Office of Inspector General of 
the Department of Health and Human Services--
            (1) may not enter the physician's private office with a gun 
        or deadly weapon to make an arrest; and
            (2) may not make such an arrest without a valid warrant of 
        arrest, unless the physician is fleeing or deemed dangerous.
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