text: 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.
target: Directs the Secretary of Health and Human Services to 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.
  Sets forth provisions concerning: (1) policy development regarding evaluation and management guidelines; and (2) medicare overpayments.
feat_title: Health Care Fraud Prevention and Paperwork Reduction Act of 2000