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United States Code (Last Updated: May 24, 2014) |
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Title 42. THE PUBLIC HEALTH AND WELFARE |
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Chapter 7. SOCIAL SECURITY |
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SubChapter XI. GENERAL PROVISIONS, PEER REVIEW, AND ADMINISTRATIVE SIMPLIFICATION |
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Part A. General Provisions |
§ 1320a–7a. Civil monetary penalties
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(a) Improperly filed claims Any person (including an organization, agency, or other entity, but excluding a beneficiary, as defined in subsection (i)(5) of this section) that— (1) knowingly presents or causes 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) of this section), a claim (as defined in subsection (i)(2) of this section) that the Secretary determines— (A) is for a medical or other item or service that the person knows or should know was not provided as claimed, including any person who engages in a pattern or practice of presenting or causing to be presented a claim for an item or service that is based on a code that the person knows or should know will result in a greater payment to the person than the code the person knows or should know is applicable to the item or service actually provided, (B) is for a medical or other item or service and the person knows or should know the claim is false or fraudulent, (C) is presented for a physician’s service (or an item or service incident to a physician’s service) by a person who knows or should know that the individual who furnished (or supervised the furnishing of) the service— (i) was not licensed as a physician, (ii) was licensed as a physician, but such license had been obtained through a misrepresentation of material fact (including cheating on an examination required for licensing), or (iii) represented to the patient at the time the service was furnished that the physician was certified in a medical specialty by a medical specialty board when the individual was not so certified, (D) is for a medical or other item or service furnished during a period in which the person was excluded from the Federal health care program (as defined in section 1320a–7b(f) of this title) under which the claim was made pursuant to Federal law. of subchapter XX of this chapter. (2) The term “claim” means an application for payments for items and services under a Federal health care program (as defined in section 1320a–7b(f) of this title). (3) The term “item or service” includes (A) any particular item, device, medical supply, or service claimed to have been provided to a patient and listed in an itemized claim for payment, and (B) in the case of a claim based on costs, any entry in the cost report, books of account or other documents supporting such claim. (4) The term “agency of the United States” includes any contractor acting as a fiscal intermediary, carrier, or fiscal agent or any other claims processing agent for a Federal health care program (as so defined). (5) The term “beneficiary” means an individual who is eligible to receive items or services for which payment may be made under a Federal health care program (as so defined) but does not include a provider, supplier, or practitioner. (6) The term “remuneration” includes the waiver of coinsurance and deductible amounts (or any part thereof), and transfers of items or services for free or for other than fair market value. The term “remuneration” does not include— (A) the waiver of coinsurance and deductible amounts by a person, if— (i) the waiver is not offered as part of any advertisement or solicitation; (ii) the person does not routinely waive coinsurance or deductible amounts; and (iii) the person— (I) waives the coinsurance and deductible amounts after determining in good faith that the individual is in financial need; or (II) fails to collect coinsurance or deductible amounts after making reasonable collection efforts; (B) subject to subsection (n) of this section, any permissible practice described in any subparagraph of section 1320a–7b(b)(3) of this title or in regulations issued by the Secretary; (C) differentials in coinsurance and deductible amounts as part of a benefit plan design as long as the differentials have been disclosed in writing to all beneficiaries, third party payers, and providers, to whom claims are presented and as long as the differentials meet the standards as defined in regulations promulgated by the Secretary not later than 180 days after August 21, 1996 ;(D) incentives given to individuals to promote the delivery of preventive care as determined by the Secretary in regulations so promulgated; (E) a reduction in the copayment amount for covered OPD services under section 1395l(t)(5)(B) 13 of this title; or 8 (F) any other remuneration which promotes access to care and poses a low risk of harm to patients and Federal health care programs (as defined in section 1320a–7b(f) of this title and designated by the Secretary under regulations); (G) the offer or transfer of items or services for free or less than fair market value by a person, if— (i) the items or services consist of coupons, rebates, or other rewards from a retailer; (ii) the items or services are offered or transferred on equal terms available to the general public, regardless of health insurance status; and (iii) the offer or transfer of the items or services is not tied to the provision of other items or services reimbursed in whole or in part by the program under subchapter XVIII or a State health care program (as defined in section 1320a–7(h) of this title); (H) the offer or transfer of items or services for free or less than fair market value by a person, if— (i) the items or services are not offered as part of any advertisement or solicitation; (ii) the items or services are not tied to the provision of other services reimbursed in whole or in part by the program under subchapter XVIII or a State health care program (as so defined); (iii) there is a reasonable connection between the items or services and the medical care of the individual; and (iv) the person provides the items or services after determining in good faith that the individual is in financial need; or (I) effective on a date specified by the Secretary (but not earlier than January 1, 2011 ), the waiver by a PDP sponsor of a prescription drug plan under part D of subchapter XVIII or an MA organization offering an MA–PD plan under part C of such subchapter of any copayment for the first fill of a covered part D drug (as defined in section 1395w–102(e) of this title) that is a generic drug for individuals enrolled in the prescription drug plan or MA–PD plan, respectively.(7) The term “should know” means that a person, with respect to information— (A) acts in deliberate ignorance of the truth or falsity of the information; or (B) acts in reckless disregard of the truth or falsity of the information, and no proof of specific intent to defraud is required. (j) Subpoenas (1) The provisions of subsections (d) and (e) of section 405 of this title shall apply with respect to this section to the same extent as they are applicable with respect to subchapter II of this chapter. The Secretary may delegate the authority granted by section 405(d) of this title (as made applicable to this section) to the Inspector General of the Department of Health and Human Services for purposes of any investigation under this section. (2) The Secretary may delegate authority granted under this section and under section 1320a–7 of this title to the Inspector General of the Department of Health and Human Services. (k) Injunctions Whenever the Secretary has reason to believe that any person has engaged, is engaging, or is about to engage in any activity which makes the person subject to a civil monetary penalty under this section, the Secretary may bring an action in an appropriate district court of the United States (or, if applicable, a United States court of any territory) to enjoin such activity, or to enjoin the person from concealing, removing, encumbering, or disposing of assets which may be required in order to pay a civil monetary penalty if any such penalty were to be imposed or to seek other appropriate relief.
(l) Liability of principal for acts of agent A principal is liable for penalties, assessments, and an exclusion under this section for the actions of the principal’s agent acting within the scope of the agency.
(m) Claims within jurisdiction of other departments or agencies (1) For purposes of this section, with respect to a Federal health care program not contained in this chapter, references to the Secretary in this section shall be deemed to be references to the Secretary or Administrator of the department or agency with jurisdiction over such program and references to the Inspector General of the Department of Health and Human Services in this section shall be deemed to be references to the Inspector General of the applicable department or agency. (2) (A) The Secretary and Administrator of the departments and agencies referred to in paragraph (1) may include in any action pursuant to this section, claims within the jurisdiction of other Federal departments or agencies as long as the following conditions are satisfied: (i) The case involves primarily claims submitted to the Federal health care programs of the department or agency initiating the action. (ii) The Secretary or Administrator of the department or agency initiating the action gives notice and an opportunity to participate in the investigation to the Inspector General of the department or agency with primary jurisdiction over the Federal health care programs to which the claims were submitted. (B) If the conditions specified in subparagraph (A) are fulfilled, the Inspector General of the department or agency initiating the action is authorized to exercise all powers granted under the Inspector General Act of 1978 (5 U.S.C. App.) with respect to the claims submitted to the other departments or agencies to the same manner and extent as provided in that Act with respect to claims submitted to such departments or agencies. (n) Safe harbor for payment of medigap premiums (1) Subparagraph (B) of subsection (i)(6) of this section shall not apply to a practice described in paragraph (2) unless— (A) the Secretary, through the Inspector General of the Department of Health and Human Services, promulgates a rule authorizing such a practice as an exception to remuneration; and (B) the remuneration is offered or transferred by a person under such rule during the 2-year period beginning on the date the rule is first promulgated. (2) A practice described in this paragraph is a practice under which a health care provider or facility pays, in whole or in part, premiums for medicare supplemental policies for individuals entitled to benefits under part A of subchapter XVIII of this chapter pursuant to section 426–1 of this title.
References In Text
The Federal Rules of Civil Procedure, referred to in subsec. (c)(1), are set out in the Appendix to Title 28, Judiciary and Judicial Procedure.
The Health Insurance Portability and Accountability Act of 1996, referred to in subsec. (f)(3), is Pub. L. 104–191,
Division A of subchapter XX, referred to in subsec. (i)(1), was in the original a reference to subtitle 1 of title XX, which was translated as if referring to subtitle A of title XX of the Social Security Act, to reflect the probable intent of Congress. Title XX of the Act, enacting subchapter XX of this chapter, does not contain a subtitle 1.
Section 1395l(t)(5)(B) of this title, referred to in subsec. (i)(6)(E), was redesignated section 1395l(t)(8)(B) of this title by Pub. L. 106–113, div. B, § 1000(a)(6) [title II, §§ 201(a)(1), 202(a)(2)],
The Inspector General Act of 1978, referred to in subsec. (m)(2)(B), is Pub. L. 95–452,
Amendments
2010—Subsec. (a). Pub. L. 111–148, § 6408(a)(3)(B), which directed substitution of “act, in cases under paragraph (8), $50,000 for each false record or statement, or in cases under paragraph (9), $15,000 for each day of the failure described in such paragraph)” for “act)” in first sentence, was executed by making the substitution for “act” to reflect the probable intent of Congress. See amendment by Pub. L. 111–148, § 6402(d)(2)(A)(iv) below.
Pub. L. 111–148, § 6408(a)(3)(A), which directed substitution of “in cases under paragraph (7)” for “or in cases under paragraph (7)” in first sentence, was executed by making the substitution for “in cases under paragraph (7)” resulting in no change in text and to reflect the probable intent of Congress. See amendment by Pub. L. 111–148, § 6402(d)(2)(A)(iv) below.
Pub. L. 111–148, § 6402(d)(2)(A)(iv), (v), in concluding provisions, struck out “or” after “prohibited relationship occurs;” and substituted “act; or in cases under paragraph (9), $50,000 for each false statement or misrepresentation of a material fact)” for “act)” and “purpose; or in cases under paragraph (9), an assessment of not more than 3 times the total amount claimed for each item or service for which payment was made based upon the application containing the false statement or misrepresentation of a material fact)” for “purpose)”.
Subsec. (a)(1)(D). Pub. L. 111–148, § 6402(d)(2)(A)(i), which directed substitution of “was excluded from the Federal health care program (as defined in section 1320a–7b(f) of this title) under which the claim was made pursuant to Federal law.” for “ ‘was excluded’ and all that follows through the period at the end”, was executed by making the substitution for “was excluded from the program under which the claim was made pursuant to a determination by the Secretary under this section or under section 1320a–7, 1320c–5, 1320c–9(b) (as in effect on
Subsec. (a)(6). Pub. L. 111–148, §§ 6402(d)(2)(A)(ii), 6408(a)(1), amended par. (6) identically, striking out “or” at the end.
Subsec. (a)(8), (9). Pub. L. 111–148, § 6408(a)(2), added pars. (8) and (9) relating to false or fraudulent claims for payment for items and services furnished under a Federal health care program and failure to grant timely access to the Inspector General of the Department of Health and Human Services, respectively.
Pub. L. 111–148, § 6402(d)(2)(A)(iii), added pars. (8) and (9) relating to orders or prescriptions for persons excluded from a Federal health care program; and false statements, omissions, or misrepresentations in applications, bids, or contracts to participate or enroll as a provider of services or a supplier under a Federal health care program, respectively.
Subsec. (a)(10). Pub. L. 111–148, § 6402(d)(2)(A)(iii), added par. (10).
Subsec. (i)(1). Pub. L. 111–148, § 6703(d)(3)(B), inserted “division A of” after “subchapter V of this chapter or”.
Subsec. (i)(6)(C). Pub. L. 111–148, § 6402(d)(2)(B)(i), struck out “or” at the end.
Subsec. (i)(6)(D). Pub. L. 111–148, § 6402(d)(2)(B)(ii), in subpar. (D) relating to incentives given to individuals to promote delivery, substituted a semicolon for the period.
Subsec. (i)(6)(E). Pub. L. 111–148, § 6402(d)(2)(B)(iii), redesignated subpar. (D) relating to a reduction in copayment amount for covered OPD services as (E) and substituted “; or” for the period.
Subsec. (i)(6)(F) to (I). Pub. L. 111–148, § 6402(d)(2)(B)(iv), added pars. (F) to (I).
1998—Subsec. (i)(6)(B). Pub. L. 105–277, § 5201(a), amended subpar. (B) generally. Prior to amendment, subpar. (B) read as follows: “any permissible waiver as specified in section 1320a–7b(b)(3) of this title or in regulations issued by the Secretary;”.
Subsec. (n). Pub. L. 105–277, § 5201(b)(1), added subsec. (n).
1997—Subsec. (a). Pub. L. 105–33, § 4304(b)(2), in concluding provisions, substituted “occurs; or in cases under paragraph (7), $50,000 for each such act).” for “occurs).” and inserted “(or, in cases under paragraph (7), damages of not more than 3 times the total amount of remuneration offered, paid, solicited, or received, without regard to whether a portion of such remuneration was offered, paid, solicited, or received for a lawful purpose)” after “of such claim”.
Subsec. (a)(6). Pub. L. 105–33, § 4304(a), added par. (6).
Subsec. (a)(7). Pub. L. 105–33, § 4304(b)(1), added par. (7).
Subsec. (b)(1). Pub. L. 105–33, § 4201(c)(1), substituted “critical access” for “rural primary care” in introductory and concluding provisions.
Subsec. (i)(6)(A)(iii). Pub. L. 105–33, § 4331(e)(1), inserted “or” at end of subcl. (I), struck out “or” at end of subcl. (II), and struck out subcl. (III) which read as follows: “provides for any permissible waiver as specified in section 1320a–7b(b)(3) of this title or in regulations issued by the Secretary;”.
Subsec. (i)(6)(B). Pub. L. 105–33, § 4523(c)(1), which directed amendment of par. (6) by striking “or” at end of subpar. (B), could not be executed because the word “or” did not appear at end of subpar. (B) subsequent to amendment by Pub. L. 105–33, § 4331(e)(2), (3). See below.
Pub. L. 105–33, § 4331(e)(3), added subpar. (B). Former subpar. (B) redesignated (C).
Subsec. (i)(6)(C). Pub. L. 105–33, § 4523(c)(2), which directed amendment of par. (6) by substituting “; or” for the period at end of subpar. (C), could not be executed because there was not a period at the end of subpar. (C) subsequent to amendment by Pub. L. 105–33, § 4331(e)(2). See below.
Pub. L. 105–33, § 4331(e)(2), redesignated subpar. (B) as (C). Former subpar. (C) redesignated (D).
Subsec. (i)(6)(D). Pub. L. 105–33, § 4523(c), added subpar. (D) relating to a reduction in copayment amount for covered OPD services.
Pub. L. 105–33, § 4331(e)(2), redesignated subpar. (C), relating to incentives given to individuals to promote delivery, as (D).
1996—Subsec. (a). Pub. L. 104–191, § 231(c), in concluding provisions, substituted “$10,000” for “$2,000”, inserted “; in cases under paragraph (4), $10,000 for each day the prohibited relationship occurs” after “false or misleading information was given”, and substituted “3 times the amount” for “twice the amount”.
Pub. L. 104–191, § 231(a)(1), in concluding provisions, substituted “Federal health care programs (as defined in section 1320a–7b(f)(1) of this title)” for “programs under subchapter XVIII of this chapter”.
Subsec. (a)(1). Pub. L. 104–191, § 231(d)(1)(A), inserted “knowingly” before “presents” in introductory provisions.
Subsec. (a)(1)(A). Pub. L. 104–191, § 231(e)(1), substituted “claimed, including any person who engages in a pattern or practice of presenting or causing to be presented a claim for an item or service that is based on a code that the person knows or should know will result in a greater payment to the person than the code the person knows or should know is applicable to the item or service actually provided,” for “claimed,”.
Subsec. (a)(1)(E). Pub. L. 104–191, § 231(e)(2)–(4), added subpar. (E).
Subsec. (a)(2). Pub. L. 104–191, § 231(d)(1)(A), inserted “knowingly” before “presents”.
Subsec. (a)(3). Pub. L. 104–191, § 231(d)(1)(B), substituted “knowingly gives or causes to be given” for “gives”.
Subsec. (a)(4). Pub. L. 104–191, § 231(b), added par. (4).
Subsec. (a)(5). Pub. L. 104–191, § 231(h)(1), added par. (5).
Subsec. (b)(3). Pub. L. 104–191, § 232(a), added par. (3).
Subsec. (f)(3), (4). Pub. L. 104–191, § 231(a)(2), added par. (3) and redesignated former par. (3) as (4).
Subsec. (i)(2). Pub. L. 104–191, § 231(a)(3)(A), substituted “a Federal health care program (as defined in section 1320a–7b(f) of this title)” for “subchapter V, XVIII, XIX, or XX of this chapter”.
Subsec. (i)(4). Pub. L. 104–191, § 231(a)(3)(B), substituted “a Federal health care program (as so defined)” for “a health insurance or medical services program under subchapter XVIII or XIX of this chapter”.
Subsec. (i)(5). Pub. L. 104–191, § 231(a)(3)(C), substituted “a Federal health care program (as so defined)” for “subchapter V, XVIII, XIX, or XX of this chapter”.
Subsec. (i)(6). Pub. L. 104–191, § 231(h)(2), added par. (6).
Subsec. (i)(7). Pub. L. 104–191, § 231(d)(2), added par. (7).
Subsec. (m). Pub. L. 104–191, § 231(a)(4), added subsec. (m).
1990—Subsec. (b)(1). Pub. L. 101–508, § 4731(b)(1), struck out “or an entity with a contract under section 1396b(m) of this title” before “knowingly makes a payment” in introductory provisions.
Pub. L. 101–508, § 4204(a)(3), struck out “, an eligible organization with a risk-sharing contract under section 1395mm of this title,” after “primary care hospital” in introductory provisions, struck out “or organization” after “primary care hospital” in concluding provisions, redesignated subpar. (C) as (B), and struck out former subpar. (B) which read as follows: “in the case of an eligible organization or an entity, are enrolled with the organization or entity, and”.
Subsec. (j). Pub. L. 101–508, § 4753, made an amendment to subsec. (j) identically to that of Pub. L. 101–508, § 4207(h). See below.
Pub. L. 101–508, § 4207(h), formerly § 4027(h), as renumbered by Pub. L. 103–432, designated existing provisions as par. (1) and added par. (2).
1989—Subsec. (a)(1)(D), (2)(C), (4). Pub. L. 101–234 repealed Pub. L. 100–360, § 202(c), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 Amendment note below.
Subsec. (b)(1). Pub. L. 101–239 substituted “hospital or a rural primary care hospital” for “hospital” in introductory and concluding provisions.
1988—Subsec. (a). Pub. L. 100–360, § 411(k)(10)(D), added Pub. L. 100–203, § 4118(e)(10)(A), see 1987 Amendment note below.
Subsec. (a)(1). Pub. L. 100–360, § 411(k)(10)(B)(ii)(I), (II), as amended by Pub. L. 100–485, § 608(d)(26)(H), amended directory language of Pub. L. 100–203, § 4118(e)(1), see 1987 Amendment note below.
Subsec. (a)(1)(D). Pub. L. 100–360, § 411(k)(10)(D), as amended by Pub. L. 100–485, § 608(d)(26)(K)(i), added Pub. L. 100–203, § 4118(e)(6), see 1987 Amendment note below.
Pub. L. 100–360, § 202(c)(2)(A), struck out “or” after semicolon.
Subsec. (a)(2)(C). Pub. L. 100–360, § 202(c)(2)(B), inserted “or to be a participating pharmacy under section 1395u(o) of this title” after “section 1395u(h)(1) of this title”.
Subsec. (a)(3). Pub. L. 100–360, § 411(k)(10)(B)(ii)(I), (II), as amended by Pub. L. 100–485, § 608(d)(26)(H), made technical amendment to directory language of Pub. L. 100–203, § 4118(e)(1)(A), see 1987 Amendment note below.
Subsec. (a)(4). Pub. L. 100–360, § 202(c)(2)(C)–(E), added par. (4) relating to participating or nonparticipating pharmacies.
Subsec. (b)(1)(A). Pub. L. 100–360, § 411(e)(3), added Pub. L. 100–203, § 4039(h)(1)(A), see 1987 Amendment note below.
Subsec. (b)(2). Pub. L. 100–360, § 411(e)(3), added Pub. L. 100–203, § 4039(h)(1)(B), see 1987 Amendment note below.
Subsec. (c)(1). Pub. L. 100–360, § 411(k)(10)(D), added Pub. L. 100–203, § 4118(e)(7), see 1987 Amendment note below.
Subsec. (i). Pub. L. 100–360, § 411(k)(10)(D), added Pub. L. 100–203, § 4118(e)(8), see 1987 Amendment note below.
Subsec. (i)(1). Pub. L. 100–360, § 411(k)(10)(D), added Pub. L. 100–203, § 4118(e)(9), see 1987 Amendment note below.
Subsec. (i)(2). Pub. L. 100–360, § 411(k)(10)(D), added Pub. L. 100–203, § 4118(e)(10)(B), see 1987 Amendment note below.
Subsec. (i)(5). Pub. L. 100–485, § 608(d)(26)(J), amended directory language of Pub. L. 100–203, § 4118(e)(10)(C), see 1987 Amendment note below.
Pub. L. 100–360, § 411(k)(10)(D), added Pub. L. 100–203, § 4118(e)(10)(C), see 1987 Amendment note below.
Subsec. (l). Pub. L. 100–485, § 608(d)(26)(I), inserted “for penalties, assessments, and an exclusion” after “liable”.
Pub. L. 100–360, § 411(k)(10)(B)(ii)(III), added Pub. L. 100–203, § 4118(e)(1)(B), see 1987 Amendment note below.
1987—Subsec. (a). Pub. L. 100–203, § 4118(e)(10)(A), as added by Pub. L. 100–360, § 411(k)(10)(D), inserted “, but excluding a beneficiary, as defined in subsection (i)(5) of this section” in introductory provisions.
Pub. L. 100–93, § 3(a)(3)(B), in concluding provisions, inserted “(or, in cases under paragraph (3), $15,000 for each individual with respect to whom false or misleading information was given)” before period at end of first sentence, and inserted at end “In addition the Secretary may make a determination in the same proceeding to exclude the person from participation in the programs under subchapter XVIII of this chapter and to direct the appropriate State agency to exclude the person from participation in any State health care program.”
Subsec. (a)(1). Pub. L. 100–203, § 4118(e)(1)(A), formerly § 4118(e)(1), as amended by Pub. L. 100–360, § 411(k)(10)(B)(ii)(I), (II), as amended by Pub. L. 100–485, § 608(d)(26)(H), substituted “or should know” for “or has reason to know” in subpars. (A) to (C).
Pub. L. 100–93, § 3(a)(1), substituted “the Secretary determines” for “the Secretary determines is for a medical or other item or service” in introductory provisions and substituted subpars. (A) to (D) for former subpars. (A) and (B) which read as follows:
“(A) that the person knows or has reason to know was not provided as claimed, or
“(B) payment for which may not be made under the program under which such claim was made, pursuant to a determination by the Secretary under section 1320a–7, 1320c–9(b), or 1395y(d) of this title, or pursuant to a determination by the Secretary under section 1395cc(b)(2) of this title with respect to which the Secretary has initiated termination proceedings; or”.
Subsec. (a)(1)(D). Pub. L. 100–203, § 4118(e)(6), as added by Pub. L. 100–360, § 411(k)(10)(D), as amended by Pub. L. 100–485, § 608(d)(26)(K)(i), substituted “excluded from” for “excluded under” and inserted “or as a result of the application of the provisions of section 1395u(j)(2) of this title”.
Subsec. (a)(2). Pub. L. 100–93, § 3(a)(2), inserted “(or other requirement of a State plan under subchapter XIX of this chapter)” after “State agency” in subpar. (B) and added subpar. (D).
Subsec. (a)(3). Pub. L. 100–203, § 4118(e)(1)(A), as amended by Pub. L. 100–360, § 411(k)(10)(B)(ii)(I), (II), as amended by Pub. L. 100–485, § 608(d)(26)(H), substituted “or should know” for “or has reason to know”.
Pub. L. 100–93, § 3(a)(3)(A), added par. (3).
Subsec. (b)(1)(A). Pub. L. 100–203, § 4039(h)(1)(A), as added by Pub. L. 100–360, § 411(e)(3), substituted “subchapter XVIII” for “subchapter XVII”.
Subsec. (b)(2). Pub. L. 100–203, § 4039(h)(1)(B), as added by Pub. L. 100–360, § 411(e)(3), substituted “$2,000 for each” for “$2,000 for”.
Subsec. (c)(1). Pub. L. 100–203, § 4118(e)(7), as added by Pub. L. 100–360, § 411(k)(10)(D), inserted “, request for payment, or other occurrence described in this section” and “, the request for payment was made, or the occurrence took place”.
Pub. L. 100–93, § 3(b), (c), substituted “penalty, assessment, or exclusion” for “penalty or assessment” and inserted provision that the Secretary not initiate an action under this section with respect to a claim later than six years after the claim was presented and that the Secretary initiate an action in the manner authorized by Rule 4 of the Federal Rules of Civil Procedure.
Subsec. (d). Pub. L. 100–93, § 3(c), substituted “penalty, assessment, or exclusion” for “penalty or assessment” in introductory provisions.
Subsec. (f)(1)(A). Pub. L. 100–93, § 3(d), substituted “bearing the same proportion to the total amount recovered as the State’s share of the amount paid by the State agency for such claim bears to the total amount paid” for “equal to the State’s share of the amount paid by the State agency”.
Subsec. (g). Pub. L. 100–93, § 3(c), substituted “penalty, assessment, or exclusion” for “penalty or assessment” in two places.
Subsec. (h). Pub. L. 100–93, § 3(c), (e), substituted “penalty, assessment, or exclusion” for “penalty or assessment” in two places and inserted “the appropriate State agency or agencies administering or supervising the administration of State health care programs (as defined in section 1320a–7(h) of this title),” after “professional organization,”.
Subsec. (i). Pub. L. 100–203, § 4118(e)(8), as added by Pub. L. 100–360, § 411(k)(10)(D), substituted “this section” for “this subsection” in introductory provisions.
Subsec. (i)(1). Pub. L. 100–203, § 4118(e)(9), as added by Pub. L. 100–360, § 411(k)(10)(D), inserted “or subchapter XX of this chapter”.
Subsec. (i)(2). Pub. L. 100–203, § 4118(e)(10)(B), as added by Pub. L. 100–360, § 411(k)(10)(D), substituted “for payments for items and services under subchapter V, XVIII, XIX, or XX of this chapter” for “submitted by—
“(A) a provider of services or other person, agency, or organization that furnishes an item or service under subchapter XVIII of this chapter, or
“(B) a person, agency, or organization that furnishes an item or service for which medical assistance is provided under subchapter XIX of this chapter, or
“(C) a person, agency, or organization that provides an item or service for which payment is made under subchapter V of this chapter or from an allotment to a State under such subchapter,
to the United States or a State agency, or agent thereof, for payment for health care services under subchapter XVIII or XIX of this chapter or for any item or service under subchapter V of this chapter”.
Subsec. (i)(5). Pub. L. 100–203, § 4118(e)(10)(C), as added by Pub. L. 100–360, § 411(k)(10)(D), and amended by Pub. L. 100–485, § 608(d)(26)(J), added par. (5).
Subsecs. (j), (k). Pub. L. 100–93, § 3(f), added subsecs. (j) and (k).
Subsec. (l). Pub. L. 100–203, § 4118(e)(1)(B), as added by Pub. L. 100–360, § 411(k)(10)(B)(ii)(III), added subsec. (l).
1986—Subsec. (a)(1). Pub. L. 99–509, § 9313(c)(1)(B), substituted “(i)(1)” and “(i)(2)” for “(h)(1)” and “(h)(2)”, respectively.
Subsec. (b). Pub. L. 99–509, § 9313(c)(1)(D), (E), added subsec. (b). Former subsec. (b) redesignated (c).
Subsec. (c). Pub. L. 99–509, § 9313(c)(1)(A), (D), redesignated subsec. (b) as (c) and substituted “subsection (a) or (b)” for “subsection (a)” in pars. (1) and (2). Former subsec. (c) redesignated (d).
Subsec. (c)(3). Pub. L. 99–509, § 9317(a), added par. (3).
Subsec. (c)(4). Pub. L. 99–509, § 9317(b), added par. (4).
Subsec. (d). Pub. L. 99–509, § 9313(c)(1)(A), (D), redesignated subsec. (c) as (d) and substituted “subsection (a) or (b)” for “subsection (a)” in introductory provisions. Former subsec. (d) redesignated (e).
Subsecs. (e), (f). Pub. L. 99–509, § 9313(c)(1)(D), redesignated subsecs. (d) and (e) as (e) and (f), respectively. Former subsec. (f) redesignated (g).
Subsec. (g). Pub. L. 99–509, § 9313(c)(1)(A), (C), (D), redesignated subsec. (f) as (g) and substituted “subsection (a) or (b)” for “subsection (a)” and “subsection (e)” for “subsection (d)”. Former subsec. (g) redesignated (h).
Subsec. (h). Pub. L. 99–509, § 9313(c)(1)(A), (D), redesignated subsec. (g) as (h) and substituted “subsection (a) or (b)” for “subsection (a)”. Former subsec. (h) redesignated (i).
Subsec. (i). Pub. L. 99–509, § 9313(c)(1)(D), redesignated subsec. (h) as (i).
1984—Subsec. (a)(2)(C). Pub. L. 98–369, § 2306(f)(1), added cl. (C).
Subsec. (g). Pub. L. 98–369, § 2354(a)(3), substituted “utilization and quality control peer review organization” for “Professional Standards Review Organization”.
1982—Subsec. (a). Pub. L. 97–248 redesignated as part of par. (1) preceding subpar. (A) provisions formerly preceding par. (1), in subpar. (B) substituted “or pursuant to a determination by the Secretary under section 1395cc(b)(2) of this title with respect to which the Secretary has initiated termination proceedings;” for “or 1395cc(b)(2) of this title,”, and in par. (2) substituted “presents or causes to be presented to any person a request for payment which is in violation of the terms of (A) an assignment under section 1842(b)(3)(B)(ii), or (B) an agreement with a State agency not to charge a person for an item or service in excess of the amount permitted to be charged” for “is submitted in violation of an agreement between the person and the United States or a State agency”.
Effective Date Of Amendment
Amendment by section 6408(a) of Pub. L. 111–148 applicable to acts committed on or after
Pub. L. 105–277, div. J, title V, § 5201(d),
Amendment by section 4201(c)(1) of Pub. L. 105–33 applicable to services furnished on or after
Pub. L. 105–33, title IV, § 4304(c),
Amendment by section 4331(e) of Pub. L. 105–33 effective as if included in the enactment of the Health Insurance Portability and Accountability Act of 1996, Pub. L. 104–191, see section 4331(f) of Pub. L. 105–33, set out as a note under section 1320a–7e of this title.
Pub. L. 104–191, title II, § 231(i),
Pub. L. 104–191, title II, § 232(b),
Pub. L. 101–234, title II, § 201(c),
Amendment by Pub. L. 100–485 effective as if included in the enactment of the Medicare Catastrophic Coverage Act of 1988, Pub. L. 100–360, see section 608(g)(1) of Pub. L. 100–485, set out as a note under section 704 of this title.
Amendment by section 202(c)(2) of Pub. L. 100–360 applicable to items dispensed on or after
Except as specifically provided in section 411 of Pub. L. 100–360, amendment by section 411(e)(3), (k)(10)(B)(ii), (D) of Pub. L. 100–360, as it relates to a provision in the Omnibus Budget Reconciliation Act of 1987, Pub. L. 100–203, effective as if included in the enactment of that provision in Pub. L. 100–203, see section 411(a) of Pub. L. 100–360, set out as a Reference to OBRA; Effective Date note under section 106 of Title 1, General Provisions.
Pub. L. 100–203, title IV, § 4118(e)(14), formerly § 4118(e)(3),
Amendment by Pub. L. 100–93 effective at end of fourteen-day period beginning
Pub. L. 99–509, title IX, § 9313(c)(2),
Pub. L. 99–509, title IX, § 9317(d)(1), (2),
Amendment by section 2354(a)(3) of Pub. L. 98–369 effective
Amendment by Pub. L. 97–248 effective as if originally included as part of this section as this section was amended by the Omnibus Budget Reconciliation Act of 1981, Pub. L. 97–35, see section 137(d)(2) of Pub. L. 97–248, set out as a note under section 1396a of this title.
Miscellaneous
Pub. L. 105–277, div. J, title V, § 5201(e),
Pub. L. 105–277, div. J, title V, § 5201(b)(2),
Pub. L. 101–234, title II, § 201(a),
Pub. L. 99–509, title IX, § 9313(c)(3),