H.R. 3200/Division B/Title VI/Subtitle C

{{SECTION|SEC. 1631.|SEC. 1631}}. ENHANCED CMS PROGRAM PROTECTION AUTHORITY.

 * (a) In General.—
 * Title XI of the Social Security Act (42 U.S.C. 1301 et seq.) is amended by inserting after section 1128F the following new section:

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``{{SECTION|SEC. 1128G.|SEC. 1128G}}. ENHANCED PROGRAM AND PROVIDER PROTECTIONS IN THE MEDICARE, MEDICAID, AND CHIP PROGRAMS.
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 * ``(a) Certain authorized screening, enhanced oversight periods, and enrollment moratoria.—
 * ``(1) In general.—For periods beginning after January 1, 2011, in the case that the Secretary determines there is a significant risk of fraudulent activity (as determined by the Secretary based on relevant complaints, reports, referrals by law enforcement or other sources, data analysis, trending information, or claims submissions by providers of services and suppliers) with respect to a category of provider of services or supplier of items or services, including a category within a geographic area, under title XVIII, XIX, or XXI, the Secretary may impose any of the following requirements with respect to a provider of services or a supplier (whether such provider or supplier is initially enrolling in the program or is renewing such enrollment):
 * ``(A) Screening under paragraph (2).
 * ``(B) Enhanced oversight periods under paragraph (3).
 * ``(C) Enrollment moratoria under paragraph (4).


 * ``In applying this subsection for purposes of title XIX and XXI the Secretary may require a State to carry out the provisions of this subsection as a requirement of the State plan under title XIX or the child health plan under title XXI. Actions taken and determinations made under this subsection shall not be subject to review by a judicial tribunal.


 * ``(2) Screening.—For purposes of paragraph (1), the Secretary shall establish procedures under which screening is conducted with respect to providers of services and suppliers described in such paragraph. Such screening may include—
 * ``(A) licensing board checks;
 * ``(B) screening against the list of individuals and entities excluded from the program under title XVIII, XIX, or XXI;
 * ``(C) the excluded provider list system;
 * ``(D) background checks; and
 * ``(E) unannounced pre-enrollment or other site visits.


 * ``(3) Enhanced oversight period.—For purposes of paragraph (1), the Secretary shall establish procedures to provide for a period of not less than 30 days and not more than 365 days during which providers of services and suppliers described in such paragraph, as the Secretary determines appropriate, would be subject to enhanced oversight, such as required or unannounced (or required and unannounced) site visits or inspections, prepayment review, enhanced review of claims, and such other actions as specified by the Secretary, under the programs under titles XVIII, XIX, and XXI. Under such procedures, the Secretary may extend such period for more than 365 days if the Secretary determines that after the initial period such additional period of oversight is necessary.


 * ``(4) Moratorium on enrollment of providers and suppliers.—For purposes of paragraph (1), the Secretary, based upon a finding of a risk of serious ongoing fraud within a program under title XVIII, XIX, or XXI, may impose a moratorium on the enrollment of providers of services and suppliers within a category of providers of services and suppliers (including a category within a specific geographic area) under such title. Such a moratorium may only be imposed if the Secretary makes a determination that the moratorium would not adversely impact access of individuals to care under such program.


 * ``(5) Clarification.—Nothing in this subsection shall be interpreted to preclude or limit the ability of a State to engage in provider screening or enhanced provider oversight activities beyond those required by the Secretary.´´.


 * (b) Conforming Amendments.—
 * (1) Medicaid.—
 * Section 1902(a) of the Social Security Act (42 U.S.C. 42 U.S.C. 1396a(a)) is amended—
 * (A) in paragraph (23), by inserting before the semicolon at the end the following: ``or by a person to whom or entity to which a moratorium under section 1128G(a)(4) is applied during the period of such moratorium´´;


 * (B) in paragraph (72); by striking at the end ``and´´;


 * (C) in paragraph (73), by striking the period at the end and inserting ``and´´; and


 * (D) by adding after paragraph (73) the following new paragraph:


 * ``(74) provide that the State will enforce any determination made by the Secretary under subsection (a) of section 1128G (relating to a significant risk of fraudulent activity with respect to a category of provider or supplier described in such subsection (a) through use of the appropriate procedures described in such subsection (a)), and that the State will carry out any activities as required by the Secretary for purposes of such subsection (a).´´.


 * (2) CHIP.—
 * Section 2102 of such Act (42 U.S.C. 1397bb) is amended by adding at the end the following new subsection:


 * ``(d) Program Integrity.—A State child health plan shall include a description of the procedures to be used by the State—
 * ``(1) to enforce any determination made by the Secretary under subsection (a) of section 1128G (relating to a significant risk of fraudulent activity with respect to a category of provider or supplier described in such subsection through use of the appropriate procedures described in such subsection); and


 * ``(2) to carry out any activities as required by the Secretary for purposes of such subsection.´´.


 * (3) Medicare.—
 * Section 1866(j) of such Act (42 U.S.C. 1395cc(j)) is amended by adding at the end the following new paragraph:


 * ``(3) Program integrity.—The provisions of section 1128G(a) apply to enrollments and renewals of enrollments of providers of services and suppliers under this title.´´.

{{SECTION|SEC. 1632.|SEC. 1632}}. ENHANCED MEDICARE, MEDICAID, AND CHIP PROGRAM DISCLOSURE REQUIREMENTS RELATING TO PREVIOUS AFFILIATIONS.

 * (a) In General.—
 * Section 1128G of the Social Security Act, as inserted by section 1631, is amended by adding at the end the following new subsection:


 * ``(b) Enhanced Program Disclosure Requirements.—
 * ``(1) Disclosure.—A provider of services or supplier who submits on or after July 1, 2011, an application for enrollment and renewing enrollment in a program under title XVIII, XIX, or XXI shall disclose (in a form and manner determined by the Secretary) any current affiliation or affiliation within the previous 10-year period with a provider of services or supplier that has uncollected debt or with a person or entity that has been suspended or excluded under such program, subject to a payment suspension, or has had its billing privileges revoked.


 * ``(2) Enhanced safeguards.—If the Secretary determines that such previous affiliation of such provider or supplier poses a risk of fraud, waste, or abuse, the Secretary may apply such enhanced safeguards as the Secretary determines necessary to reduce such risk associated with such provider or supplier enrolling or participating in the program under title XVIII, XIX, or XXI. Such safeguards may include enhanced oversight, such as enhanced screening of claims, required or unannounced (or required and unannounced) site visits or inspections, additional information reporting requirements, and conditioning such enrollment on the provision of a surety bond.


 * ``(3) Authority to deny participation.—If the Secretary determines that there has been at least one such affiliation and that such affiliation or affiliations, as applicable, of such provider or supplier poses a serious risk of fraud, waste, or abuse, the Secretary may deny the application of such provider or supplier.´´.


 * (b) Conforming Amendments.—
 * (1) Medicaid.—
 * Paragraph (74) of section 1902(a) of such Act (42 U.S.C. 1396a(a)), as added by section 1631(b)(1), is amended—
 * (A) by inserting ``or subsection (b) of such section (relating to disclosure requirements)´´ before ``, and that the State´´; and


 * (B) by inserting before the period the following: ``and apply any enhanced safeguards, with respect to a provider or supplier described in such subsection (b), as the Secretary determines necessary under such subsection (b)´´.


 * (2) CHIP.—
 * Subsection (d) of section 2102 of such Act (42 U.S.C. 1397bb), as added by section 1631(b)(2), is amended—
 * (A) in paragraph (1), by striking at the end ``and´´;


 * (B) in paragraph (2) by striking the period at the end and inserting ``; and´´ and


 * (C) by adding at the end the following new paragraph:


 * ``(3) to enforce any determination made by the Secretary under subsection (b) of section 1128G (relating to disclosure requirements) and to apply any enhanced safeguards, with respect to a provider or supplier described in such subsection, as the Secretary determines necessary under such subsection.´´.

{{SECTION|SEC. 1633.|SEC. 1633}}. REQUIRED INCLUSION OF PAYMENT MODIFIER FOR CERTAIN EVALUATION AND MANAGEMENT SERVICES.

 * Section 1848 of the Social Security Act (42 U.S.C. 1395w–4), as amended by section 4101 of the HITECH Act (Public Law 111-5), is amended by adding at the end the following new subsection:


 * ``(p) Payment modifier for certain evaluation and management services.—The Secretary shall establish a payment modifier under the fee schedule under this section for evaluation and management services (as specified in section 1842(b)(16)(B)(ii)) that result in the ordering of additional services (such as lab tests), the prescription of drugs, the furnishing or ordering of durable medical equipment in order to enable better monitoring of claims for payment for such additional services under this title, or the ordering, furnishing, or prescribing of other items and services determined by the Secretary to pose a high risk of waste, fraud, and abuse. The Secretary may require providers of services or suppliers to report such modifier in claims submitted for payment.´´.

{{SECTION|SEC. 1634.|SEC. 1634}}. EVALUATIONS AND REPORTS REQUIRED UNDER MEDICARE INTEGRITY PROGRAM.

 * (a) In General.—
 * Section 1893(c) of the Social Security Act (42 U.S.C. 1395ddd(c)) is amended—
 * (1) in paragraph (3), by striking at the end ``and´´;


 * (2) by redesignating paragraph (4) as paragraph (5); and


 * (3) by inserting after paragraph (3) the following new paragraph:


 * ``(4) for the contract year beginning in 2011 and each subsequent contract year, the entity provides assurances to the satisfaction of the Secretary that the entity will conduct periodic evaluations of the effectiveness of the activities carried out by such entity under the Program and will submit to the Secretary an annual report on such activities; and´´.


 * (b) Reference to Medicaid Integrity Program.—
 * For a similar provision with respect to the Medicaid Integrity Program, see section 1752.

{{SECTION|SEC. 1635.|SEC. 1635}}. REQUIRE PROVIDERS AND SUPPLIERS TO ADOPT PROGRAMS TO REDUCE WASTE, FRAUD, AND ABUSE.

 * (a) In General.—
 * Section 1874 of the Social Security Act (42 U.S.C. 42 U.S.C. 1395kk) is amended by adding at the end the following new subsection:


 * ``(d) Compliance programs for providers of services and suppliers.—
 * ``(1) In general.—The Secretary may disenroll a provider of services or a supplier (other than a physician or a skilled nursing facility) under this title (or may impose any civil monetary penalty or other intermediate sanction under paragraph (4)) if such provider of services or supplier fails to, subject to paragraph (5), establish a compliance program that contains the core elements established under paragraph (2).


 * ``(2) Establishment of core elements.—The Secretary, in consultation with the Inspector General of the Department of Health and Human Services, shall establish core elements for a compliance program under paragraph (1). Such elements may include written policies, procedures, and standards of conduct, a designated compliance officer and a compliance committee; effective training and education pertaining to fraud, waste, and abuse for the organization’s employees and contractors; a confidential or anonymous mechanism, such as a hotline, to receive compliance questions and reports of fraud, waste, or abuse; disciplinary guidelines for enforcement of standards; internal monitoring and auditing procedures, including monitoring and auditing of contractors; procedures for ensuring prompt responses to detected offenses and development of corrective action initiatives, including responses to potential offenses; and procedures to return all identified overpayments to the programs under this title, title XIX, and title XXI.


 * ``(3) Timeline for implementation.—The Secretary shall determine a timeline for the establishment of the core elements under paragraph (2) and the date on which a provider of services and suppliers (other than physicians) shall be required to have established such a program for purposes of this subsection.


 * ``(4) CMS enforcement authority.—The Administrator for the Centers of Medicare & Medicaid Services shall have the authority to determine whether a provider of services or supplier described in subparagraph (3) has met the requirement of this subsection and to impose a civil monetary penalty not to exceed $50,000 for each violation. The Secretary may also impose other intermediate sanctions, including corrective action plans and additional monitoring in the case of a violation of this subsection.


 * ``(5) Pilot program.—The Secretary may conduct a pilot program on the application of this subsection with respect to a category of providers of services or suppliers (other than physicians) that the Secretary determines to be a category which is at high risk for waste, fraud, and abuse before implementing the requirements of this subsection to all providers of services and suppliers described in paragraph (3).´´.


 * (b) Reference to Similar Medicaid Provision.—
 * For a similar provision with respect to the Medicaid program under title XIX of the Social Security Act, see section 1753.

{{SECTION|SEC. 1636.|SEC. 1636}}. MAXIMUM PERIOD FOR SUBMISSION OF MEDICARE CLAIMS REDUCED TO NOT MORE THAN 12 MONTHS.

 * (a) Purpose.—
 * In general, the 36-month period currently allowed for claims filing under parts A, B, C, and, D of title XVIII of the Social Security Act presents opportunities for fraud schemes in which processing patterns of the Centers for Medicare & Medicaid Services can be observed and exploited. Narrowing the window for claims processing will not overburden providers and will reduce fraud and abuse.


 * (b) Reducing Maximum Period for Submission.—
 * (1) Part A.—
 * Section 1814(a) of the Social Security Act (42 U.S.C. 1395f(a)) is amended—
 * (A) in paragraph (1), by strikeing ``period of 3 calendar years´´ and all that follows and inserting ``period of 1 calendar year from which such services are furnished; and´´; and


 * (B) by adding at the end the following new sentence: ``In applying paragraph (1), the Secretary may specify exceptions to the 1 calendar year period specified in such paragraph.´´.


 * (2) Part B.—
 * Section 1835(a) of such Act (42 U.S.C. 1395n(a)) is amended—
 * (A) in paragraph (1), by strikeing ``period of 3 calendar years´´ and all that follows and inserting ``period of 1 calendar year from which such services are furnished; and´´; and


 * (B) by adding at the end the following new sentence: ``In applying paragraph (1), the Secretary may specify exceptions to the 1 calendar year period specified in such paragraph.´´.


 * (3) Parts C and D.—
 * Section 1857(d) of such Act is amended by adding at the end the following new paragraph:


 * ``(7) Period for submission of claims.—The contract shall require an MA organization or PDP sponsor to require any provider of services under contract with, in partnership with, or affiliated with such organization or sponsor to ensure that, with respect to items and services furnished by such provider to an enrollee of such organization, written request, signed by such enrollee, except in cases in which the Secretary finds it impracticable for the enrollee to do so, is filed for payment for such items and services in such form, in such manner, and by such person or persons as the Secretary may by regulation prescribe, no later than the close of the 1 calendar year period after such items and services are furnished. In applying the previous sentence, the Secretary may specify exceptions to the 1 calendar year period specified.´´.


 * (c) Effective Date.—
 * The amendments made by subsection (b) shall be effective for items and services furnished on or after January 1, 2011.

{{SECTION|SEC. 1637.|SEC. 1637}}. PHYSICIANS WHO ORDER DURABLE MEDICAL EQUIPMENT OR HOME HEALTH SERVICES REQUIRED TO BE MEDICARE ENROLLED PHYSICIANS OR ELIGIBLE PROFESSIONALS.

 * (a) DME.—
 * Section 1834(a)(11)(B) of the Social Security Act (42 U.S.C. 1395m(a)(11)(B)) is amended by striking ``physician´´ and inserting ``physician enrolled under section 1866(j) or an eligible professional under section 1848(k)(3)(B)´´.


 * (b) Home health services.—
 * (1) Part A.—
 * Section 1814(a)(2) of such Act (42 U.S.C. 1395(a)(2)) is amended in the matter preceding subparagraph (A) by inserting ``in the case of services described in subparagraph (C), a physician enrolled under section 1866(j) or an eligible professional under section 1848(k)(3)(B),´´ before ``or, in the case of services´´.


 * (2) Part B.—
 * Section 1835(a)(2) of such Act (42 U.S.C. 1395n(a)(2)) is amended in the matter preceding subparagraph (A) by inserting ``, or in the case of services described in subparagraph (A), a physician enrolled under section 1866(j) or an eligible professional under section 1848(k)(3)(B),´´ after ``a physician´´.


 * (c) Discretion to Expand Application.—
 * The Secretary may extend the requirement applied by the amendments made by subsections (a) and (b) to durable medical equipment and home health services (relating to requiring certifications and written orders to be made by enrolled physicians and health professions) to other categories of items or services under this title, including covered part D drugs as defined in section 1860D–2(e), if the Secretary determines that such application would help to reduce the risk of waste, fraud, and abuse with respect to such other categories under title XVIII of the Social Security Act.


 * (d) Effective Date.—
 * The amendments made by this section shall apply to written orders and certifications made on or after July 1, 2010.

{{SECTION|SEC. 1638.|SEC. 1638}}. REQUIREMENT FOR PHYSICIANS TO PROVIDE DOCUMENTATION ON REFERRALS TO PROGRAMS AT HIGH RISK OF WASTE AND ABUSE.

 * (a) Physicians and Other Suppliers.—
 * Section 1842(h) of the Social Security Act, as amended by section 1635, is further amended by adding at the end the following new paragraph:


 * ``(10) The Secretary may disenroll, for a period of not more than one year for each act, a physician or supplier under section 1866(j) if such physician or supplier fails to maintain and, upon request of the Secretary, provide access to documentation relating to written orders or requests for payment for durable medical equipment, certifications for home health services, or referrals for other items or services written or ordered by such physician or supplier under this title, as specified by the Secretary.´´.


 * (b) Providers of Services.—
 * Section 1866(a)(1) of such Act (42 U.S.C. 1395cc), as amended by section 1635, is further amended—
 * (1) in subparagraph (V), by striking at the end ``and´´;


 * (2) in subparagraph (W), by striking the period at the end and adding ``; and´´; and


 * (3) by adding at the end the following new subparagraph:


 * ``(X) maintain and, upon request of the Secretary, provide access to documentation relating to written orders or requests for payment for durable medical equipment, certifications for home health services, or referrals for other items or services written or ordered by the provider under this title, as specified by the Secretary.´´.


 * (c) OIG Permissive Exclusion Authority.—
 * Section 1128(b)(11) of the Social Security Act (42 U.S.C. 1320a–7(b)(11)) is amended by inserting ``, ordering, referring for furnishing, or certifying the need for´´ after ``furnishing´´.


 * (d) Effective Date.—
 * The amendments made by this section shall apply to orders, certifications, and referrals made on or after January 1, 2010.

{{SECTION|SEC. 1639.|SEC. 1639}}. FACE TO FACE ENCOUNTER WITH PATIENT REQUIRED BEFORE PHYSICIANS MAY CERTIFY ELIGIBILITY FOR HOME HEALTH SERVICES OR DURABLE MEDICAL EQUIPMENT UNDER MEDICARE.

 * (a) Condition of Payment for Home Health Services.—
 * (1) Part A.—
 * Section 1814(a)(2)(C) of such Act is amended—
 * (A) by striking ``and such services´´ and inserting ``such services´´; and


 * (B) by inserting after ``care of a physician´´ the following: ``, and, in the case of a certification or recertification made by a physician after January 1, 2010, prior to making such certification the physician must document that the physician has had a face-to-face encounter (including through use of telehealth and other than with respect to encounters that are incident to services involved) with the individual during the 6-month period preceding such certification, or other reasonable timeframe as determined by the Secretary´´.


 * (2) Part B.—
 * Section 1835(a)(2)(A) of the Social Security Act is amended—
 * (A) by striking ``and´´ before ``(iii)´´; and


 * (B) by inserting after ``care of a physician´´ the following: ``, and (iv) in the case of a certification or recertification after January 1, 2010, prior to making such certification the physician must document that the physician has had a face-to-face encounter (including through use of telehealth and other than with respect to encounters that are incident to services involved) with the individual during the 6-month period preceding such certification or recertification, or other reasonable timeframe as determined by the Secretary´´.


 * (b) Condition of Payment for Durable Medical Equipment.—
 * Section 1834(a)(11)(B) of the Social Security Act (42 U.S.C. 1395m(a)(11)(B)) is amended by adding at the end the following: ``and shall require that such an order be written pursuant to the physician documenting that the physician has had a face-to-face encounter (including through use of telehealth and other than with respect to encounters that are incident to services involved) with the individual involved during the 6-month period preceding such written order, or other reasonable timeframe as determined by the Secretary´´.


 * (c) Application to Other Areas Under Medicare.—
 * The Secretary may apply the face-to-face encounter requirement described in the amendments made by subsections (a) and (b) to other items and services for which payment is provided under title XVIII of the Social Security Act based upon a finding that such an decision would reduce the risk of waste, fraud, or abuse.


 * (d) Application to Medicaid and CHIP.—
 * The requirements pursuant to the amendments made by subsections (a) and (b) shall apply in the case of physicians making certifications for home health services under title XIX or XXI of the Social Security Act, in the same manner and to the same extent as such requirements apply in the case of physicians making such certifications under title XVIII of such Act.

{{SECTION|SEC. 1640.|SEC. 1640}}. EXTENSION OF TESTIMONIAL SUBPOENA AUTHORITY TO PROGRAM EXCLUSION INVESTIGATIONS.

 * (a) In General.—
 * Section 1128(f) of the Social Security Act (42 U.S.C. 1320a–7(f)) is amended by adding at the end the following new paragraph:


 * ``(4) The provisions of subsections (d) and (e) of section 205 shall apply with respect to this section to the same extent as they are applicable with respect to title II. The Secretary may delegate the authority granted by section 205(d) (as made applicable to this section) to the Inspector General of the Department of Health and Human Services or the Administrator of the Centers for Medicare & Medicaid Services for purposes of any investigation under this section.´´.


 * (b) Effective Date.—
 * The amendment made by subsection (a) shall apply to investigations beginning on or after January 1, 2010.

{{SECTION|SEC. 1641.|SEC. 1641}}. REQUIRED REPAYMENTS OF MEDICARE AND MEDICAID OVERPAYMENTS.

 * Section 1128G of the Social Security Act, as inserted by section 1631 and amended by section 1632, is further amended by adding at the end the following new subsection:


 * ``(c) Reports on and repayment of overpayments identified through internal audits and reviews.—
 * ``(1) Reporting and returning overpayments.—If a person knows of an overpayment, the person must—
 * ``(A) report and return the overpayment to the Secretary, the State, an intermediary, a carrier, or a contractor, as appropriate, at the correct address, and


 * ``(B) notify the Secretary, the State, intermediary, carrier, or contractor to whom the overpayment was returned in writing of the reason for the overpayment.


 * ``(2) Timing.—An overpayment must be reported and returned under paragraph (1)(A) by not later than the date that is 60 days after the date the person knows of the overpayment.
 * ``Any known overpayment retained later than the applicable date specified in this paragraph creates an obligation as defined in section 3729(b)(3) of title 31 of the United States Code.


 * ``(3) Clarification.—Repayment of any overpayments (or refunding by withholding of future payments) by a provider of services or supplier does not otherwise limit the provider or supplier’s potential liability for administrative obligations such as applicable interests, fines, and specialties or civil or criminal sanctions involving the same claim if it is determined later that the reason for the overpayment was related to fraud by the provider or supplier or the employees or agents of such provider or supplier.


 * ``(4) Definitions.—In this subsection:
 * ``(A) Knows.—The term ‘knows’ has the meaning given the terms ‘knowing’ and ‘knowingly’ in section 3729(b) of title 31 of the United States Code.


 * ``(B) Overpayment.—The term ``overpayment´´ means any finally determined funds that a person receives or retains under title XVIII, XIX, or XXI to which the person, after applicable reconciliation, is not entitled under such title.


 * ``(C) Person.—The term ‘person’ means a provider of services, supplier, Medicaid managed care organization (as defined in section 1903(m)(1)(A)), Medicare Advantage organization (as defined in section 1859(a)(1)), or PDP sponsor (as defined in section 1860D–41(a)(13)), but excluding a beneficiary.´´.

{{SECTION|SEC. 1642.|SEC. 1642}}. EXPANDED APPLICATION OF HARDSHIP WAIVERS FOR OIG EXCLUSIONS TO BENEFICIARIES OF ANY FEDERAL HEALTH CARE PROGRAM.

 * Section 1128(c)(3)(B) of the Social Security Act (42 U.S.C. 1320a–7(c)(3)(B)) is amended by striking ``individuals entitled to benefits under part A of title XVIII or enrolled under part B of such title, or both´´ and inserting ``beneficiaries (as defined in section 1128A(i)(5)) of that program´´.

{{SECTION|SEC. 1643.|SEC. 1643}}. ACCESS TO CERTAIN INFORMATION ON RENAL DIALYSIS FACILITIES.

 * Section 1881(b) of the Social Security Act (42 U.S.C. 1395rr(b)) is amended by adding at the end the following new paragraph:


 * ``(15) For purposes of evaluating or auditing payments made to renal dialysis facilities for items and services under this section under paragraph (1), each such renal dialysis facility, upon the request of the Secretary, shall provide to the Secretary access to information relating to any ownership or compensation arrangement between such facility and the medical director of such facility or between such facility and any physician.´´.

{{SECTION|SEC. 1644.|SEC. 1644}}. BILLING AGENTS, CLEARINGHOUSES, OR OTHER ALTERNATE PAYEES REQUIRED TO REGISTER UNDER MEDICARE.

 * (a) Medicare.—
 * Section 1866(j)(1) of the Social Security Act (42 U.S.C. 1395cc(j)(1)) is amended by adding at the end the following new subparagraph:


 * ``(D) Billing agents and clearinghouses required to be register under Medicare.—Any agent, clearinghouse, or other alternate payee that submits claims on behalf of a health care provider must be registered with the Secretary in a form and manner specified by the Secretary.´´.


 * (b) Medicaid.—
 * For a similar provision with respect to the Medicaid program under title XIX of the Social Security Act, see section 1759.


 * (c) Effective Date.—
 * The amendment made by subsection (a) shall apply to claims submitted on or after January 1, 2012.

{{SECTION|SEC. 1645.|SEC. 1645}}. CONFORMING CIVIL MONETARY PENALTIES TO FALSE CLAIMS ACT AMENDMENTS.

 * Section 1128A of the Social Security Act, as amended by sections 1611, 1612, 1613, and 1615, is further amended—
 * (1) in subsection (a)—
 * (A) in paragraph (1), by striking ``to an officer, employee, or agent of the United States, or of any department or agency thereof, or of any State agency (as defined in subsection (i)(1))´´;


 * (B) in paragraph (4)—
 * (i) by striking ``participating in a program under title XVIII or a State health care program´´ and inserting ``participating in a Federal health care program (as defined in section 1128B(f))´´; and


 * (ii) in subparagraph (A), by striking ``title XVIII or a State health care program´´ and inserting ``a Federal health care program (as defined in section 1128B(f))´´;


 * (C) by striking ``or´´ at the end of paragraph (10);


 * (D) by inserting after paragraph (11) the following new paragraphs:


 * ``(12) conspires to commit a violation of this section; or
 * ``(13) knowingly makes, uses, or causes to be made or used, a false record or statement material to an obligation to pay or transmit money or property to a Federal health care program, or knowingly conceals or knowingly and improperly avoids or decreases an obligation to pay or transmit money or property to a Federal health care program;´´; and


 * (E) in the matter following paragraph (13), as inserted by subparagraph (D), by striking ``or in cases under paragraph (11), $50,000 for each such violation´´ and inserting ``in cases under paragraph (11), $50,000 for each such violation, in cases under paragraph (12), $50,000 for any violation described in this section committed in furtherance of the conspiracy involved; or in cases under paragraph (13), $50,000 for each false record or statement, or concealment, avoidance, or decrease´´; and


 * (F) in the second sentence, by striking ``such false statement or misrepresentation)´´ and inserting ``such false statement or misrepresentation, in cases under paragraph (12), an assessment of not more than 3 times the total amount that would otherwise apply for any violation described in this section committed in furtherance of the conspiracy involved, or in cases under paragraph (13), an assessment of not more than 3 times the total amount of the obligation to which the false record or statment was material or that was avoided or decreased)´´.


 * (2) in subsection (c)(1), by striking ``six years´´ and inserting ``10 years´´; and


 * (3) in subsection (i)—
 * (A) by amending paragraph (2) to read as follows:


 * ``(2) The term ``claim´´ means any application, request, or demand, whether under contract, or otherwise, for money or property for items and services under a Federal health care program (as defined in section 1128B(f)), whether or not the United States or a State agency has title to the money or property, that—
 * ``(A) is presented or caused to be presented to an officer, employee, or agent of the United States, or of any department or agency thereof, or of any State agency (as defined in subsection (i)(1)); or


 * ``(B) is made to a contractor, grantee, or other recipient if the money or property is to be spent or used on the Federal health care program’s behalf or to advance a Federal health care program interest, and if the Federal health care program—
 * ``(i) provides or has provided any portion of the money or property requested or demanded; or


 * ``(ii) will reimburse such contractor, grantee, or other recipient for any portion of the money or property which is requested or demanded.´´;


 * (B) by amending paragraph (3) to read as follows:


 * ``(3) The term ‘item or service’ means, without limitation, any medical, social, management, administrative, or other item or service used in connection with or directly or indirectly related to a Federal health care program.´´;


 * (C) in paragraph (6)—
 * (i) in subparagraph (C), by striking at the end ``or´´;
 * (ii) in the first subparagraph (D), by striking at the end the period and inserting ``; or´´; and
 * (iii) by redesignating the second subparagraph (D) as a subparagraph (E);


 * (D) by amending paragraph (7) to read as follows:


 * ``(7) The terms ‘knowing’, ‘knowingly’, and ‘should know’ mean that a person, with respect to information—
 * ``(A) has actual knowledge of the information;
 * ``(B) acts in deliberate ignorance of the truth or falsity of the information; or
 * ``(C) acts in reckless disregard of the truth or falsity of the information;
 * ``and require no proof of specific intent to defraud.´´; and


 * (E) by adding at the end the following new paragraphs:


 * ``(8) The term ‘obligation’ means an established duty, whether or not fixed, arising from an express or implied contractual, grantor-grantee, or licensor-licensee relationship, from a fee-based or similar relationship, from statute or regulation, or from the retention of any overpayment.
 * ``(9) The term ‘material’ means having a natural tendency to influence, or be capable of influencing, the payment or receipt of money or property.´´.