text: SECTION 1. SHORT TITLE.
  
      This Act may be cited as the ``Federal Employees Health Benefits 
  Provider Integrity Amendments of 1997''.
  
  SEC. 2. DEBARMENT AND OTHER SANCTIONS.
  
      (a) Amendments.--Section 8902a of title 5, United States Code, is 
  amended--
              (1) in subsection (a)--
                      (A) in paragraph (1)--
                              (i) by striking ``and'' at the end of 
                          subparagraph (B);
                              (ii) by striking the period at the end and 
                          inserting ``; and''; and
                              (iii) by adding at the end the following:
              ``(D) the term `should know' means that a person, with 
          respect to information, acts in deliberate ignorance of, or in 
          reckless disregard of, the truth or falsity of the information, 
          and no proof of specific intent to defraud is required.''; and
                      (B) in paragraph (2)(A), by striking ``subsection 
                  (b) or (c)'' and inserting ``subsection (b), (c), or 
                  (d)'';
              (2) in subsection (b)--
                      (A) by striking ``The Office of Personnel 
                  Management may bar'' and inserting ``The Office of 
                  Personnel Management shall bar''; and
                      (B) by amending paragraph (5) to read as follows:
              ``(5) Any provider that is currently suspended or excluded 
          from participation under any program of the Federal Government 
          involving procurement or nonprocurement activities.'';
              (3) by redesignating subsections (c) through (i) as 
          subsections (d) through (j), respectively, and by inserting 
          after subsection (b) the following:
      ``(c) The Office may bar the following providers of health care 
  services from participating in the program under this chapter:
              ``(1) Any provider--
                      ``(A) whose license to provide health care services 
                  or supplies has been revoked, suspended, restricted, or 
                  not renewed, by a State licensing authority for reasons 
                  relating to the provider's professional competence, 
                  professional performance, or financial integrity; or
                      ``(B) that surrendered such a license while a 
                  formal disciplinary proceeding was pending before such 
                  an authority, if the proceeding concerned the 
                  provider's professional competence, professional 
                  performance, or financial integrity.
              ``(2) Any provider that is an entity directly or indirectly 
          owned, or with a 5 percent or more controlling interest, by an 
          individual who is convicted of any offense described in 
          subsection (b), against whom a civil monetary penalty has been 
          assessed under subsection (d), or who has been debarred from 
          participation under this chapter.
              ``(3) Any individual who directly or indirectly owns or has 
          a controlling interest in an entity and who knows or should 
          know of the action constituting the basis for the entity's 
          conviction of any offense described in subsection (b), 
          assessment with a civil monetary penalty under subsection (d), 
          or debarment from participation under this chapter.
              ``(4) Any provider that the Office determines, in 
          connection with claims presented under this chapter, has 
          charged for health care services or supplies in an amount 
          substantially in excess of such provider's customary charge for 
          such services or supplies (unless the Office finds there is 
          good cause for such charge), or charged for health care 
          services or supplies which are substantially in excess of the 
          needs of the covered individual or which are of a quality that 
          fails to meet professionally recognized standards for such 
          services or supplies.
              ``(5) Any provider that the Office determines has committed 
          acts described in subsection (d).'';
              (4) in subsection (d) (as so redesignated by paragraph (3)) 
          by amending paragraph (1) to read as follows:
              ``(1) in connection with claims presented under this 
          chapter, that a provider has charged for a health care service 
          or supply which the provider knows or should have known 
          involves--
                      ``(A) an item or service not provided as claimed,
                      ``(B) charges in violation of applicable charge 
                  limitations under section 8904(b), or
                      ``(C) an item or service furnished during a period 
                  in which the provider was debarred from participation 
                  under this chapter pursuant to a determination by the 
                  Office under this section, other than as permitted 
                  under subsection (g)(2)(B);'';
              (5) in subsection (f) (as so redesignated by paragraph (3)) 
          by inserting after ``under this section'' the first place it 
          appears the following: ``(where such debarment is not 
          mandatory)'';
              (6) in subsection (g) (as so redesignated by paragraph 
          (3))--
                      (A) by striking ``(g)(1)'' and all that follows 
                  through the end of paragraph (1) and inserting the 
                  following:
      ``(g)(1)(A) Except as provided in subparagraph (B), debarment of a 
  provider under subsection (b) or (c) shall be effective at such time 
  and upon such reasonable notice to such provider, and to carriers and 
  covered individuals, as shall be specified in regulations prescribed by 
  the Office. Any such provider that is debarred from participation may 
  request a hearing in accordance with subsection (h)(1).
      ``(B) Unless the Office determines that the health or safety of 
  individuals receiving health care services warrants an earlier 
  effective date, the Office shall not make a determination adverse to a 
  provider under subsection (c)(5) or (d) until such provider has been 
  given reasonable notice and an opportunity for the determination to be 
  made after a hearing as provided in accordance with subsection 
  (h)(1).'';
                      (B) in paragraph (3)--
                              (i) by inserting ``of debarment'' after 
                          ``notice''; and
                              (ii) by adding at the end the following: 
                          ``In the case of a debarment under paragraph 
                          (1), (2), (3), or (4) of subsection (b), the 
                          minimum period of debarment shall not be less 
                          than 3 years, except as provided in paragraph 
                          (4)(B)(ii).'';
                      (C) in paragraph (4)(B)(i)(I) by striking 
                  ``subsection (b) or (c)'' and inserting ``subsection 
                  (b), (c), or (d)''; and
                      (D) by striking paragraph (6);
              (7) in subsection (h) (as so redesignated by paragraph (3)) 
          by striking ``(h)(1)'' and all that follows through the end of 
          paragraph (2) and inserting the following:
      ``(h)(1) Any provider of health care services or supplies that is 
  the subject of an adverse determination by the Office under this 
  section shall be entitled to reasonable notice and an opportunity to 
  request a hearing of record, and to judicial review as provided in this 
  subsection after the Office renders a final decision. The Office shall 
  grant a request for a hearing upon a showing that due process rights 
  have not previously been afforded with respect to any finding of fact 
  which is relied upon as a cause for an adverse determination under this 
  section. Such hearing shall be conducted without regard to subchapter 
  II of chapter 5 and chapter 7 of this title by a hearing officer who 
  shall be designated by the Director of the Office and who shall not 
  otherwise have been involved in the adverse determination being 
  appealed. A request for a hearing under this subsection shall be filed 
  within such period and in accordance with such procedures as the Office 
  shall prescribe by regulation.
      ``(2) Any provider adversely affected by a final decision under 
  paragraph (1) made after a hearing to which such provider was a party 
  may seek review of such decision in the United States District Court 
  for the District of Columbia or for the district in which the plaintiff 
  resides or has his or her principal place of business by filing a 
  notice of appeal in such court within 60 days after the date the 
  decision is issued, and by simultaneously sending copies of such notice 
  by certified mail to the Director of the Office and to the Attorney 
  General. In answer to the appeal, the Director of the Office shall 
  promptly file in such court a certified copy of the transcript of the 
  record, if the Office conducted a hearing, and other evidence upon 
  which the findings and decision complained of are based. The court 
  shall have power to enter, upon the pleadings and evidence of record, a 
  judgment affirming, modifying, or setting aside, in whole or in part, 
  the decision of the Office, with or without remanding the case for a 
  rehearing. The district court shall not set aside or remand the 
  decision of the Office unless there is not substantial evidence on the 
  record, taken as whole, to support the findings by the Office of a 
  cause for action under this section or unless action taken by the 
  Office constitutes an abuse of discretion.''; and
              (8) in subsection (i) (as so redesignated by paragraph 
          (3))--
                      (A) by striking ``subsection (c)'' and inserting 
                  ``subsection (d)''; and
                      (B) by adding at the end the following: ``The 
                  amount of a penalty or assessment as finally determined 
                  by the Office, or other amount the Office may agree to 
                  in compromise, may be deducted from any sum then or 
                  later owing by the United States to the party against 
                  whom the penalty or assessment has been levied.''.
      (b) Effective Date.--
              (1) In general.--Except as provided in paragraph (2), the 
          amendments made by this section shall take effect on the date 
          of the enactment of this Act.
              (2) Exceptions.--(A) Paragraphs (2), (3), and (5) of 
          section 8902a(c) of title 5, United States Code, as amended by 
          subsection (a)(3), shall apply only to the extent that the 
          misconduct which is the basis for debarment under such 
          paragraph (2), (3), or (5), as applicable, occurs after the 
          date of the enactment of this Act.
      (B) Paragraph (1)(B) of section 8902a(d) of title 5, United States 
  Code, as amended by subsection (a)(4), shall apply only with respect to 
  charges which violate section 8904(b) of such title for items or 
  services furnished after the date of the enactment of this Act.
      (C) Paragraph (3) of section 8902a(g) of title 5, United States 
  Code, as amended by subsection (a)(6)(B), shall apply only with respect 
  to debarments based on convictions occurring after the date of the 
  enactment of this Act.
  
  SEC. 3. AMENDMENT TO THE SOCIAL SECURITY ACT.
  
      Section 1128B(f)(1) of the Social Security Act (42 U.S.C. 1320a-
  7b(f)(1)), as amended by section 204(a)(7) of the Health Insurance 
  Portability and Accountability Act of 1996 (Public Law 104-191; 110 
  Stat. 2000), is amended by striking ``(other than the health insurance 
  program under chapter 89 of title 5, United States Code)''.
target: Federal Employees Health Benefits Provider Integrity Amendments of 1997 - Amends Federal law, with respect to Federal employees' health insurance coverage under the Federal Employees Health Benefits Program (FEHB), to revise provisions regarding the debarment of any health care provider found to have engaged in fraudulent practices, including requiring (currently permitting) debarment for certain fraudulent practices. 
  (Sec. 3) Amends the Social Security Act, as amended by the Health Insurance Portability and Accountability Act of 1996, to apply certain criminal health antifraud and abuse sanctions to fraud and abuse involving the FEHB Program.
feat_title: Federal Employees Health Benefits Provider Integrity Amendments of 1997