42 USC 1320a-7c - Fraud and abuse control program

U.S Code last checked for updates: Nov 22, 2024

§ 1320a–7c.

Fraud and abuse control program

(a)

Establishment of program

(1)

In general

Not later than January 1, 1997, the Secretary, acting through the Office of the Inspector General of the Department of Health and Human Services, and the Attorney General shall establish a program—

(A)

to coordinate Federal, State, and local law enforcement programs to control fraud and abuse with respect to health plans,

(B)

to conduct investigations, audits, evaluations, and inspections relating to the delivery of and payment for health care in the United States,

(C)

to facilitate the enforcement of the provisions of sections 1320a–7, 1320a–7a, and 1320a–7b of this title and other statutes applicable to health care fraud and abuse, and

(D)

to provide for the modification and establishment of safe harbors and to issue advisory opinions and special fraud alerts pursuant to section 1320a–7d of this title.

(2)

Coordination with health plans

(3)

Guidelines

(A)

In general

(B)

Information guidelines

(i)

In general

(ii)

Confidentiality

(iii)

Qualified immunity for providing information

(4)

Ensuring access to documentation

(5)

Authority of Inspector General

(6)

Public-private partnership for waste, fraud, and abuse detection

(A)

In general

(B)

Contract with trusted third party

(C)

Duties of partnership

The partnership shall—

(i)

provide technical and operational support to facilitate data sharing between partners in the partnership;

(ii)

analyze data so shared to identify fraudulent and aberrant billing patterns;

(iii)

conduct aggregate analyses of health care data so shared across Federal, State, and private health plans for purposes of detecting fraud, waste, and abuse schemes;

(iv)

identify outlier trends and potential vulnerabilities of partners in the partnership with respect to such schemes;

(v)

refer specific cases of potential unlawful conduct to appropriate governmental entities;

(vi)

convene, not less than annually, meetings with partners in the partnership for purposes of providing updates on the partnership’s work and facilitating information sharing between the partners;

(vii)

enter into data sharing and data use agreements with partners in the partnership in such a manner so as to ensure the partnership has access to data necessary to identify waste, fraud, and abuse while maintaining the confidentiality and integrity of such data;

(viii)

provide partners in the partnership with plan-specific, confidential feedback on any aberrant billing patterns or potential fraud identified by the partnership with respect to such partner;

(ix)

establish a process by which entities described in subparagraph (A) may enter the partnership and requirements such entities must meet to enter the partnership;

(x)

provide appropriate training, outreach, and education to partners based on the results of data analyses described in clauses (ii) and (iii); and

(xi)

perform such other duties as the Secretary determines appropriate.

(D)

Substance use disorder treatment analysis

(E)

Executive board

(i)

Executive board composition

(I)

In general

(II)

Chairs

(ii)

Meetings

(iii)

Executive board duties

The duties of the executive board shall include the following:

(I)

Providing strategic direction for the partnership, including membership criteria and a mission statement.

(II)

Communicating with the leadership of the Department of Health and Human Services and the Department of Justice and the various private health sector associations.

(F)

Reports

Not later than January 1, 2023, and every 2 years thereafter, the Secretary shall submit to Congress and make available on the public website of the Centers for Medicare & Medicaid Services a report containing—

(i)

a review of activities conducted by the partnership over the 2-year period ending on the date of the submission of such report, including any progress to any objectives established by the partnership;

(ii)

any savings voluntarily reported by health plans participating in the partnership attributable to the partnership during such period;

(iii)

any savings to the Federal Government attributable to the partnership during such period;

(iv)

any other outcomes attributable to the partnership, as determined by the Secretary, during such period; and

(v)

a strategic plan for the 2-year period beginning on the day after the date of the submission of such report, including a description of any emerging fraud and abuse schemes, trends, or practices that the partnership intends to study during such period.

(G)

Funding

(H)

Transitional provisions

(I)

Nonapplicability of FACA

(J)

Implementation

(K)

Definition

For purposes of this paragraph, the term “trusted third party” means an entity that—

(i)

demonstrates the capability to carry out the duties of the partnership described in subparagraph (C);

(ii)

complies with such conflict of interest standards determined appropriate by the Secretary; and

(iii)

meets such other requirements as the Secretary may prescribe.

(b)

Additional use of funds by Inspector General

(1)

Reimbursements for investigations

(2)

Crediting

(c)

“Health plan” defined

For purposes of this section, the term “health plan” means a plan or program that provides health benefits, whether directly, through insurance, or otherwise, and includes—

(1)

a policy of health insurance;

(2)

a contract of a service benefit organization; and

(3)

a membership agreement with a health maintenance organization or other prepaid health plan.

(Aug. 14, 1935, ch. 531, title XI, § 1128C, as added Pub. L. 104–191, title II, § 201(a), Aug. 21, 1996, 110 Stat. 1992; amended Pub. L. 111–148, title VI, § 6403(c), Mar. 23, 2010, 124 Stat. 766; Pub. L. 116–260, div. CC, title I, § 124(a), Dec. 27, 2020, 134 Stat. 2957; Pub. L. 117–286, § 4(b)(78), Dec. 27, 2022, 136 Stat. 4351.)

cite as: 42 USC 1320a-7c