SEC. 231. SOCIAL SECURITY ACT CIVIL MONETARY PENALTIES.
Title[ Title II\Subtitle D Contents
Subtitle D--Civil Monetary Penalties
(a) General Civil Monetary Penalties.--Section 1128A (42 U.S.C.
1320a-7a) is amended as follows:
(1) In the third sentence of subsection (a), by striking
``programs under title XVIII'' and inserting ``Federal health
care programs (as defined in section 1128B(f)(1))''.
(2) In subsection (f)--
(A) by redesignating paragraph (3) as paragraph
(4); and
(B) by inserting after paragraph (2) the following
new paragraph:
``(3) With respect to amounts recovered arising out of a
claim under a Federal health care program (as defined in section
1128B(f)), the portion of such amounts as is determined to have
been paid by the program shall be repaid to the program, and the
portion of such amounts attributable to the amounts recovered
under this section by reason of the amendments made by the
Health Insurance Portability and Accountability Act of 1996 (as
estimated by the Secretary) shall be deposited into the Federal
Hospital Insurance Trust Fund pursuant to section
1817(k)(2)(C).''.
(3) In subsection (i)--
(A) in paragraph (2), by striking ``title V, XVIII,
XIX, or XX of this Act'' and inserting ``a Federal
health care program (as defined in section 1128B(f))'',
(B) in paragraph (4), by striking ``a health
insurance or medical services program under title XVIII
or XIX of this Act'' and inserting ``a Federal health
care program (as so defined)'', and
(C) in paragraph (5), by striking ``title V, XVIII,
XIX, or XX'' and inserting ``a Federal health care
program (as so defined)''.
(4) By adding at the end the following new subsection:
``(m)(1) For purposes of this section, with respect to a Federal
health care program not contained in this Act, references to the
Secretary in this section shall be deemed to be references to the
Secretary or Administrator of the department or agency with jurisdiction
over such program and references to the Inspector General of the
Department of Health and Human Services in this section shall be deemed
to be references to the Inspector General of the applicable department
or agency.
``(2)(A) The Secretary and Administrator of the departments and
agencies referred to in paragraph (1) may include in any action pursuant
to this section, claims within the jurisdiction of other Federal
departments or agencies as long as the following conditions are
satisfied:
``(i) The case involves primarily claims submitted to the
Federal health care programs of the department or agency
initiating the action.
``(ii) The Secretary or Administrator of the department or
agency initiating the action gives notice and an opportunity to
participate in the investigation to the Inspector General of the
department or agency with primary jurisdiction over the Federal
health care programs to which the claims were submitted.
``(B) If the conditions specified in subparagraph (A) are fulfilled,
the Inspector General of the department or agency initiating the action
is authorized to exercise all powers granted under the Inspector General
Act of 1978 (5 U.S.C. App.) with respect to the claims submitted to the
other departments or agencies to the same manner and extent as provided
in that Act with respect to claims submitted to such departments or
agencies.''.
(b) Excluded Individual Retaining Ownership or Control Interest in
Participating Entity.--Section 1128A(a) (42 U.S.C. 1320a-7a(a)) is
amended--
(1) by striking ``or'' at the end of paragraph (1)(D);
(2) by striking ``, or'' at the end of paragraph (2) and
inserting a semicolon;
(3) by striking the semicolon at the end of paragraph (3)
and inserting ``; or''; and
(4) by inserting after paragraph (3) the following new
paragraph:
``(4) in the case of a person who is not an organization,
agency, or other entity, is excluded from participating in a
program under title XVIII or a State health care program in
accordance with this subsection or under section 1128 and who,
at the time of a violation of this subsection--
``(A) retains a direct or indirect ownership or
control interest in an entity that is participating in a
program under title XVIII or a State health care
program, and who knows or should know of the action
constituting the basis for the exclusion; or
``(B) is an officer or managing employee (as defined
in section 1126(b)) of such an entity;''.
(c) Modifications of Amounts of Penalties and Assessments.--Section
1128A(a) (42 U.S.C. 1320a-7a(a)), as amended by subsection (b), is
amended in the matter following paragraph (4)--
(1) by striking ``$2,000'' and inserting ``$10,000'';
(2) by inserting ``; in cases under paragraph (4), $10,000
for each day the prohibited relationship occurs'' after ``false
or misleading information was given''; and
(3) by striking ``twice the amount'' and inserting ``3 times
the amount''.
(d) Clarification of Level of Knowledge Required for Imposition of
Civil Monetary Penalties.--
(1) In general.--Section 1128A(a) (42 U.S.C. 1320a-7a(a)) is
amended--
(A) in paragraphs (1) and (2), by inserting
``knowingly'' before ``presents'' each place it appears;
and
(B) in paragraph (3), by striking ``gives'' and
inserting ``knowingly gives or causes to be given''.
(2) Definition of standard.--Section 1128A(i) (42 U.S.C.
1320a-7a(i)), as amended by subsection (h)(2), is amended by
adding at the end the following new paragraph:
``(7) The term `should know' means that a person, with
respect to information--
``(A) acts in deliberate ignorance of the truth or
falsity of the information; or
``(B) acts in reckless disregard of the truth or
falsity of the information,
and no proof of specific intent to defraud is required.''.
(e) Claim for Item or Service Based on Incorrect Coding or Medically
Unnecessary Services.--Section 1128A(a)(1) (42 U.S.C. 1320a-7a(a)(1)),
as amended by subsection (b), is amended--
(1) in subparagraph (A) by striking ``claimed,'' and
inserting ``claimed, including any person who engages in a
pattern or practice of presenting or causing to be presented a
claim for an item or service that is based on a code that the
person knows or should know will result in a greater payment to
the person than the code the person knows or should know is
applicable to the item or service actually provided,'';
(2) in subparagraph (C), by striking ``or'' at the end;
(3) in subparagraph (D), by striking the semicolon and
inserting ``, or''; and
(4) by inserting after subparagraph (D) the following new
subparagraph:
``(E) is for a pattern of medical or other items or
services that a person knows or should know are not
medically necessary;''.
(f) Sanctions Against Practitioners and Persons for Failure To
Comply With Statutory Obligations.--Section 1156(b)(3) (42 U.S.C. 1320c-
5(b)(3)) is amended by striking ``the actual or estimated cost'' and
inserting ``up to $10,000 for each instance''.
(g) Procedural Provisions.--Section 1876(i)(6) (42 U.S.C.
1395mm(i)(6)), as amended by section 215(a)(2), is amended by adding at
the end the following new subparagraph:
``(D) The provisions of section 1128A (other than subsections (a)
and (b)) shall apply to a civil money penalty under subparagraph (B)(i)
or (C)(i) in the same manner as such provisions apply to a civil money
penalty or proceeding under section 1128A(a).''.
(h) Prohibition Against Offering Inducements to Individuals Enrolled
Under Programs or Plans.--
(1) Offer of remuneration.--Section 1128A(a) (42 U.S.C.
1320a-7a(a)), as amended by subsection (b), is amended--
(A) by striking ``or'' at the end of paragraph (3);
(B) by striking the semicolon at the end of
paragraph (4) and inserting ``; or''; and
(C) by inserting after paragraph (4) the following
new paragraph:
``(5) offers to or transfers remuneration to any individual
eligible for benefits under title XVIII of this Act, or under a
State health care program (as defined in section 1128(h)) that
such person knows or should know is likely to influence such
individual to order or receive from a particular provider,
practitioner, or supplier any item or service for which payment
may be made, in whole or in part, under title XVIII, or a State
health care program (as so defined);''.
(2) Remuneration defined.--Section 1128A(i) (42 U.S.C.
1320a-7a(i)) is amended by adding at the end the following new
paragraph:
``(6) The term `remuneration' includes the waiver of
coinsurance and deductible amounts (or any part thereof), and
transfers of items or services for free or for other than fair
market value. The term `remuneration' does not include--
``(A) the waiver of coinsurance and deductible
amounts by a person, if--
``(i) the waiver is not offered as part of any
advertisement or solicitation;
``(ii) the person does not routinely waive
coinsurance or deductible amounts; and
``(iii) the person--
``(I) waives the coinsurance and
deductible amounts after determining in
good faith that the individual is in
financial need;
``(II) fails to collect coinsurance
or deductible amounts after making
reasonable collection
efforts; or
``(III) provides for any permissible
waiver as specified in section
1128B(b)(3) or in regulations issued by
the Secretary;
``(B) differentials in coinsurance and deductible
amounts as part of a benefit plan design as long as the
differentials have been disclosed in writing to all
beneficiaries, third party payers, and providers, to
whom claims are presented and as long as the
differentials meet the standards as defined in
regulations promulgated
by the Secretary not later than 180 days after the date
of the enactment of the Health Insurance Portability and
Accountability Act of 1996; or
``(C) incentives given to individuals to promote the
delivery of preventive care as determined by the
Secretary in regulations so promulgated.''.
(i) Effective <<NOTE: 42 USC 1320a-7a note.>> Date.--The amendments
made by this section shall apply to acts or omissions occurring on or
after January 1, 1997.
Contents
Contents
Prev
Next
Last
