[Congressional Bills 107th Congress]
[From the U.S. Government Publishing Office]
[H.R. 1128 Introduced in House (IH)]
107th CONGRESS
1st Session
H. R. 1128
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
March 20, 2001
Mr. Thornberry introduced the following bill; which was referred to the
Committee on Energy and 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 Paperwork Reduction and
Fraud Prevention Act of 2001''.
SEC. 2. NATIONAL BIPARTISAN 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.
(3) Regulatory and appeals process reform.--Reforms in the
medicare regulatory and appeals processes in order to ensure
that the Secretary of Health and Human Services provides
appropriate guidance to physicians, providers of services, and
ambulance providers that are attempting to properly submit
claims under the medicare program and to ensure that the
Secretary does not target inadvertent billing errors.
(c) Membership.--
(1) Number and appointment.--The Commission shall be
composed of 17 members, of whom--
(A) four shall be appointed by the President;
(B) six shall be appointed by the Majority Leader
of the Senate, in consultation with the Minority Leader
of the Senate, of whom not more than 4 shall be of the
same political party;
(C) six shall be appointed by the Speaker of the
House of Representatives, in consultation with the
Minority Leader of the House of Representatives, of
whom not more than 4 shall be of the same political
party; and
(D) one, who shall serve as Chairman of the
Commission, appointed jointly by the President,
Majority Leader of the Senate, and the Speaker of the
House of Representatives.
(2) Appointment.--Members of the Commission shall be
appointed by not later than 90 days after the date of the
enactment of this Act.
(d) Incorporation of Bipartisan Commission Provisions.--The
provisions of paragraphs (3) through (8) of subsection (c) and
subsections (d), (e), and (h) of section 4021 of the Balanced Budget
Act of 1997 shall apply to the Commission under this section in the
same manner as they applied to the National Bipartisan Commission on
the Future of Medicare under such section.
(e) Report.--Not later than December 31, 2001, the Commission shall
submit a report to the President and Congress which shall contain a
detailed statement of only those recommendations, findings, and
conclusions of the Commission that receive the approval of at least 11
members of the Commission.
(f) Termination.--The Commission shall terminate 30 days after the
date of submission of the report required in subsection (e).
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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