Page:United States Statutes at Large Volume 86.djvu/1450

 1408

PUBLIC LAW 92-603-OCT. 30, 1972 .. j,

42 USC 139Sf. 42 USC 1395d.

Erroneous certification, nonapplicability.

Effective date.

[86 STAT.

"Payment for Posthospital Home Health Services

" (i)(l) An individual shall be presumed to require the services specified in subsection (a)(2)(D) of this section for purposes of making payment to a home health agency (subject to the provisions of section 1812) for posthospital home health services furnished by such agency to such individual if— " (A) the certification and plan referred to in subsection (a)(2) (D) of this section are submitted in timely fashion prior to the first visit by such agency, " (B) such certification states that the medical condition of the individual is a condition designated in regulations, and " (C) there is compliance with such other requirements and procedures as may be specified in regulations, but only for services furnished during such limited numbers of visits with respect to such conditions of the individual as may be prescribed in regulations by the Secretary, taking into account the medical severity of such conditions, the degree of incapacity, and the minimum period of home confinement generally needed for such conditions, and such other factors affecting the type of care to be provided as the Secretary deems pertinent. "(2) If the Secretary determines with respect to a physician that such physician is submitting with some frequency (A) erroneous certifications that individuals have conditions designated in regulations as provided in this subsection or (B) plans for providing services which are inappropriate, the provisions of paragraph (1) shall not apply, after the effective date of such determination, in any case in which such physician submits a certification or plan referred to in subparagraph (A) or (B) of paragraph (1)." (b) The amendment made by subsection (a) and any regulations adopted pursuant to such amendment shall apply with respect to plans of care initiated on or after January 1, 1973, and with respect to admission to skilled nursing facilities and Iiome health plans initiated on or after such date. AUTHORITY OF SECRETARY TO TER3IINA1'E PAYMENTS TO SUPPLIERS OF SERVICES

SEC. 229. (a) Section 1862 of the Social Security Act (as amended Ante, p. 1382. by section 210 of this Act) is further amended by adding at the end thereof the following new subsection: " (d)(1) 'No payment may be made under this title with respect to any item or services furnished to an individual by a person where the Secretary determines under this subsection that such person— " (A) has knowingly and willfully made, or caused to be made, any false statement or representation of a material fact for use in an application for payment under this title or for use in determining the right to a payment under this title; " (B) has submitted or caused to be submitted (except in the ' case of a provider of services), bills or requests for payment under this title containing charges (or in applicable cases requests for payment of costs to such person) for services rendered which the Secretary finds, with the concurrence of the appropriate program Post, p. 1409. review team appointed pursuant to paragraph (4), to be substantially in excess of such person's customary charges (or in applicable cases substantially in excess of such person's costs) for such services, unless the Secretary finds there is good cause for such bills

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