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The following information was obtained from the
United States Congressional Digest via Thomas, the electronic
data base of the U.S. Congress.
Bill Summary & Status for the 104th
Congress
H.R. 3103 became Public Law: 104-191,
(became law 08/21/96)
SPONSOR: Rep Archer (other
Archer bills) (introduced 03/18/96)
MAJOR LEGISLATION
DIGEST: (REVISED AS OF 07/31/96)
Health Insurance Portability
and Accountability Act of 1996 -
Title II: Preventing Health Care Fraud and Abuse;
Administrative Simplification (sic) -
Subtitle A:
Fraud and Abuse Control Program - Amends
title XI of the Social Security Act (SSA) to require the Secretary
of Health and Human Services (HHS), acting through HHS' Office
of Inspector General (IG), and the Attorney General to establish
a program to:
(1) coordinate Federal, State, and local law enforcement
programs to control health care fraud and abuse;
(2) conduct investigations, audits, and inspections relating
to the delivery of and payment for health care;
(3) facilitate enforcement of certain provisions of title
XI and other Acts applicable to health care fraud and abuse;
(4) provide for the modification and establishment of safe
harbors and to issue advisory opinions and special fraud alerts;
and
(5) provide for the reporting and disclosure of certain final
adverse actions against health care providers, suppliers,
or practitioners pursuant to the data collection system established
below.
(Sec. 201) Establishes the Health Care Fraud and Abuse
Control Account (Account) in Medicare's Federal Hospital Insurance
Trust Fund (Trust Fund) to hold the criminal fines and civil
monetary penalties and assessments obtained from Federal health
care cases, as well as property forfeiture proceeds resulting
from such cases, and other specified amounts for financing
the program above and the Medicare Integrity Program established
by this title. Makes certain appropriations to the Trust Fund
and Account, earmarking certain amounts for activities of
HHS' IG with respect to the Medicare and Medicaid programs
under SSA titles XVIII and XIX. Requires the HHS Secretary
and the Attorney General to jointly submit a report to the
Congress with regard to Trust Fund appropriations. Directs
the Comptroller General to submit a similar report to the
Congress analyzing Trust Fund operations.
(Sec. 202) Establishes the Medicare Integrity Program
under which the HHS Secretary shall promote the integrity
of the Medicare program by entering into contracts with certain
eligible private entities to: (1) review the activities of
Medicare service providers and audit cost reports to determine
whether payment should not have been made; (2) educate service
providers, beneficiaries, and other persons with respect to
payment and benefit issues; and (3) develop and periodically
update a list of items of durable medical equipment subject
to prior authorization. Details the process for entering into
contracts. Sets certain limitations on contractor liability.
Prohibits fiscal intermediaries under Medicare part A (Hospital
Insurance) and carriers under Medicare part B (Supplementary
Medical Insurance) from carrying out certain activities under
Medicare to the extent the activity is carried out pursuant
to a contract under the Medicare Integrity Program.
(Sec. 203) Directs the HHS Secretary to provide an
explanation of Medicare benefits with respect to each furnished
item or service for which payment may be made to an individual
without regard to whether or not a deductible or coinsurance
may be imposed.
Directs the HHS Secretary to establish a program for encouraging
individuals to: (1) report information on fraud and abuse
under Medicare or other Federal or State health care programs;
and (2) submit suggestions on methods to improve the efficiency
of the Medicare program. Provides for the payment to such
individuals of a portion of: (1) any amounts collected due
to any such reports; or (2) any savings resulting from any
such suggestions which are adopted.
(Sec. 204) Amends SSA title XI to require application
of criminal penalties for acts involving the Medicare program
to similar violations of any plan or program that provides
health benefits, whether directly, through insurance, or otherwise,
which is funded directly, in whole or in part, by the Federal
Government, except the Federal Employees' Health Benefits
Program (Federal care health programs).
(Sec. 205) Directs the HHS Secretary to periodically
publish a notice in the Federal Register soliciting proposals
for: (1) modifications to existing safe harbors issued under
the Medicare and Medicaid Patient and Program Protection Act
of 1987; (2) additional safe harbors specifying payment practices
that shall not be treated as a criminal offense or serve as
the basis for an exclusion; (3) advisory opinions by the HHS
IG with regard to, among other matters, prohibited remuneration
constituting grounds for the imposition of a sanction; and
(4) special fraud alerts by the HHS IG, upon request, with
regard to suspect practices under the Medicare program or
a State health care program. Requires the Secretary to issue
appropriate implementing regulations.
Subtitle B: Revisions to Current Sanctions for Fraud
and Abuse - Excludes from participation in Medicare
and State health care programs any individual or entity convicted
after the enactment of this Act of a felony related to: (1)
fraud in connection with the delivery of a health care item
or service; or (2) a controlled substance.
(Sec. 212) Revises specified current sanctions involving
exclusion for fraud and abuse under Medicare and State health
care programs, among other changes establishing minimum periods
of exclusion for: (1) certain individuals and entities subject
to permissive exclusion from Medicare and State health care
programs; and (2) practitioners and persons failing to meet
certain statutory obligations with regard to services or items.
(Sec. 213) Authorizes the permissive exclusion of
individuals with a direct or indirect ownership or control
interest in certain sanctioned entities.
(Sec. 214) Repeals the prerequisite that a health
care practitioner or person be determined "unwilling or unable"
to comply substantially with a corrective action plan before
sanctions may be imposed (thus permitting the Secretary to
exclude such practitioner or person from eligibility to provide
services for failure to comply with a corrective action plan,
regardless of circumstances).
(Sec. 215) Permits the imposition of intermediate
sanctions on Medicare health maintenance organizations in
addition to the current option of termination. Provides additional
intermediate sanctions for miscellaneous program violations.
(Sec. 216) Provides an additional specified exception
to anti-kickback penalties for risk-sharing arrangements.
(Sec. 217) Creates a criminal penalty under SSA title
XI for fraudulent disposition of assets in order to obtain
Medicaid benefits.
Subtitle C: Data Collection - Directs the
HHS Secretary to establish a national health care fraud and
abuse data collection program for reporting final adverse
actions against health care providers, suppliers, or practitioners
and maintain a database of such information. Requires each
Government agency and health plan to report to the Secretary
any final adverse action taken against such provider, supplier,
or practitioner.
(Sec. 221) Allows the HHS Secretary to establish reasonable
fees for disclosure of information in the database.
Subtitle D: Civil
(1) the exclusion from participation in Federal and State
health care programs of persons subject to penalties and assessments
for applicable program violations;
(2) modifications in the amounts of various specified penalties
and assessments, including the sanctions against health care
practitioners who violate their statutory obligations with
regard to the services or items ordered or provided by them
to a covered beneficiary or recipient;
(3) a prohibition against offering inducements to individuals
enrolled under Medicare or a State health care program;
(4) subjecting to civil money penalties certain excluded
individuals retaining an ownership or controlling interest
in a participating entity if they knew or should have known
of the action constituting the basis for the exclusion of
such entity at the time of violation;
(5) a specific definition, for such penalty purposes, of
remuneration which includes the waiver of coinsurance and
deductible amounts and transfers of items or services for
free or for other than fair market value; and
(6) a penalty for false certification for home health services.
Subtitle E: Revisions to Criminal Law -
Amends the Federal criminal code to set penalties for the
commission of health care fraud, theft or embezzlement in
connection with health care, false statements relating to
health care matters, obstruction of criminal investigations
of Federal health care offenses, and laundering of monetary
instruments in connection with a Federal health care offense.
(Sec. 247) Provides for injunctive relief relating
to covered Federal health care offenses, as well as for property
forfeitures.
(Sec. 248) Establishes investigative demand procedures,
including limits on the disclosure of health information about
an individual in any administrative, civil, or criminal action
or investigation.
Subtitle F: Administrative Simplification
- Amends SSA title XI to add a new part C (Administrative
Simplification) for development of an electronic system for:
(1) processing health care information consistent with the
goal of improving the operation of the overall health care
system; and
(2) reducing related administrative costs through the HHS
Secretary's adoption of certain standards for information
transactions (including enrollment, disenrollment, claims
attachments, and referral certification and authorization)
and data elements for such transactions, as well as standards
relating to security and performance of specified tasks. Requires
the Secretary, in adopting such standards, to rely on recommendations
of the National Committee on Vital and Health Statistics.
(Sec. 261) Provides penalties for violations of this
subtitle, including wrongful disclosure of individually identifiable
health information.
(Sec. 263) Amends the Public Health Service Act to
provide for a change in the membership and duties of the National
Committee on Vital and Health Statistics, including responsibility
for advising the HHS Secretary and the Congress on the implementation
of the administrative simplification requirements of this
subtitle.
(Sec. 264) Directs the HHS Secretary to submit to
specified congressional committees detailed recommendations
on standards with respect to the privacy of individually identifiable
health information.
Subtitle G: Duplication and Coordination of Medicare-Related
Plans - Declares that certain health insurance policies
(other than Medicare supplemental policies) are not considered
to duplicate benefits under Medicare, Medicaid, or other health
insurance policies, if they:
(1) provide health care benefits only for long-term care,
nursing home care, home health care, or community-based care,
or any combination thereof;
(2) coordinate against or exclude items and services available
or paid for under Medicare or another health insurance policy;
and
(3) disclose such coordination or exclusion, in policies
sold or issued on or after a specified date, in the policy's
outline of coverage.
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