article: 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program under this chapter: ``(1) Any provider-- ``(A) whose license to provide health care services or supplies has been revoked, suspended, restricted, or not renewed, by a State licensing authority for reasons relating to the provider's professional competence, professional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)''.
summary: 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.