SEC. 1128E.
[42 U.S.C. 1320a-7e] (a)
GENERAL PURPOSE.—Not later than January 1,
1997, the Secretary shall establish a national health care fraud
and abuse data collection program for the reporting of final
adverse actions (not including settlements in which no findings
of liability have been made) against health care providers,
suppliers, or practitioners as required by subsection (b), with
access as set forth in subsection (c), and shall maintain a
database of the information collected under this section.
(b)
REPORTING OF INFORMATION.—
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(1) IN GENERAL.—Each Government agency and
health plan shall report any final adverse action (not including
settlements in which no findings of liability have been made)
taken against a health care provider, supplier, or practitioner.
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(2) INFORMATION TO BE REPORTED.—The
information to be reported under paragraph (1) includes:
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(A) The name and TIN (as defined in section 7701(a)(41) of the
Internal Revenue Code of 1986) of any health care provider,
supplier, or practitioner who is the subject of a final adverse
action.
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(B) The name (if known) of any health care entity with which a
health care provider, supplier, or practitioner, who is the
subject of a final adverse action, is affiliated or associated.
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(C) The nature of the final adverse action and whether such
action is on appeal.
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(D) A description of the acts or omissions and injuries upon
which the final adverse action was based, and such other
information as the Secretary determines by regulation is
required for appropriate interpretation of information reported
under this section.
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(3) CONFIDENTIALITY.—In determining what
information is required, the Secretary shall include procedures
to assure that the privacy of individuals receiving health care
services is appropriately protected.
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(4) TIMING AND FORM OF REPORTING.—The
information required to be reported under this subsection shall
be reported regularly (but not less often than monthly) and in
such form and manner as the Secretary prescribes. Such
information shall first be required to be reported on a date
specified by the Secretary.
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(5) TO WHOM REPORTED.—The information
required to be reported under this subsection shall be reported
to the Secretary.
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(6) SANCTIONS FOR FAILURE TO REPORT.—
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(A) HEALTH PLANS.—Any health plan that fails
to report information on an adverse action required to be
reported under this subsection shall be subject to a civil money
penalty of not more than $25,000 for each such adverse action
not reported. Such penalty shall be imposed and collected in the
same manner as civil money penalties under subsection (a) of
section 1128A are imposed and collected under that section.
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(B) GOVERNMENTAL AGENCIES.—The Secretary
shall provide for a publication of a public report that
identifies those Government agencies that have failed to report
information on adverse actions as required to be reported under
this subsection.
(c)
DISCLOSURE AND CORRECTION OF INFORMATION.—
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(1) DISCLOSURE.—With respect to the
information about final adverse actions (not including
settlements in which no findings of liability have been made)
reported to the Secretary under this section with respect to a
health care provider, supplier, or practitioner, the Secretary
shall, by regulation, provide for—
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(A) disclosure of the information, upon request, to the health
care provider, supplier, or licensed practitioner, and
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(B) procedures in the case of disputed accuracy of the
information.
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(2) CORRECTIONS.—Each Government agency and
health plan shall report corrections of information already
reported about any final adverse action taken against a health
care provider, supplier, or practitioner, in such form and
manner that the Secretary prescribes by regulation.
(d)
ACCESS TO REPORTED INFORMATION.—
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(1) AVAILABILITY.—The information in the
database maintained under this section shall be available to
Federal and State government agencies and health plans pursuant
to procedures that the Secretary shall provide by regulation.
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(2) FEES FOR DISCLOSURE.—The Secretary may
establish or approve reasonable fees for the disclosure of
information in such database (other than with respect to
requests by Federal agencies). The amount of such a fee shall be
sufficient to recover the full costs of operating the database.
Such fees shall be available to the Secretary or, in the
Secretary's discretion to the agency designated under this
section to cover such costs.
(e)
PROTECTION FROM LIABILITY FOR REPORTING.—No
person or entity, including the agency designated by the
Secretary in subsection (b)(5) shall be held liable in any civil
action with respect to any report made as required by this
section, without knowledge of the falsity of the information
contained in the report.
(f)
COORDINATION WITH NATIONAL PRACTITIONER DATA
BANK.—The Secretary shall implement this section in
such a manner as to avoid duplication with the reporting
requirements established for the National Practitioner Data Bank
under the Health Care Quality Improvement Act of 1986 (42 U.S.C.
11101 et seq.).
(g)
DEFINITIONS AND SPECIAL RULES.—For purposes
of this section:
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(1) FINAL ADVERSE ACTION.—
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(A) IN GENERAL.—The term “final
adverse action” includes:
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(i) Civil judgments against a health care provider, supplier, or
practitioner in Federal or State court related to the delivery
of a health care item or service.
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(ii) Federal or State criminal convictions related to the
delivery of a health care item or service.
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(iii) Actions by Federal or State agencies responsible for the
licensing and certification of health care providers, suppliers,
and licensed health care practitioners, including—
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(I) formal or official actions, such as revocation or suspension
of a license (and the length of any such suspension), reprimand,
censure or probation,
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(II) any other loss of license or the right to apply for, or
renew, a license of the provider, supplier, or practitioner,
whether by operation of law, voluntary surrender,
non-renewability, or otherwise, or
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(III) any other negative action or finding by such Federal or
State agency that is publicly available information.
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(iv) Exclusion from participation in Federal or State health
care programs (as defined in sections 1128B(f) and 1128(h),
respectively).
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(v) Any other adjudicated actions or decisions that the
Secretary shall establish by regulation.
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(B) EXCEPTION.—The term does not include any
action with respect to a malpractice claim.
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(2) PRACTITIONER.—The terms “licensed
health care practitioner”, “licensed
practitioner”, and “practitioner” mean, with
respect to a State, an individual who is licensed or otherwise
authorized by the State to provide health care services (or any
individual who, without authority holds himself or herself out
to be so licensed or authorized).
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(3) GOVERNMENT AGENCY.—The term
“Government agency” shall include:
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(A) The Department of Justice.
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(B) The Department of Health and Human Services.
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(C) Any other Federal agency that either administers or provides
payment for the delivery of health care services, including, but
not limited to the Department of Defense and the Department of
Veterans Affairs.
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(D) State law enforcement agencies.
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(E) State medicaid fraud control units.
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(F) Federal or State agencies responsible for licensing and
certification of health care providers and licensed health care
practitioners.
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(4) HEALTH PLAN.—The term “health
plan” has the meaning given such term by section 1128C(c).
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(5) DETERMINATION OF CONVICTION.—For
purposes of paragraph (1), the existence of a conviction shall
be determined under paragraphs (1) through (4) of section 1128(i).