
From the U.S. Code Online via GPO Access
[wais.access.gpo.gov]
[Laws in effect as of January 23, 2000]
[Document not affected by Public Laws enacted between
  January 23, 2000 and December 4, 2001]
[CITE: 42USC1320a-7e]

 
                 TITLE 42--THE PUBLIC HEALTH AND WELFARE
 
                       CHAPTER 7--SOCIAL SECURITY
 
   SUBCHAPTER XI--GENERAL PROVISIONS, PEER REVIEW, AND ADMINISTRATIVE 
                             SIMPLIFICATION
 
                       Part A--General Provisions
 
Sec. 1320a-7e. Health care fraud and abuse data collection 
        program
        

(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) of this 
section, with access as set forth in subsection (c) of this section, and 
shall maintain a database of the information collected under this 
section.

(b) Reporting of information

                           (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.

                   (2) Information to be reported

        The information to be reported under paragraph (1) includes:
            (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.
            (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.
            (C) The nature of the final adverse action and whether such 
        action is on appeal.
            (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.

                         (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.

                  (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.

                        (5) To whom reported

        The information required to be reported under this subsection 
    shall be reported to the Secretary.

                 (6) Sanctions for failure to report

        (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 1320a-7a of this title 
        are imposed and collected under that section.

        (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

                           (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--
            (A) disclosure of the information, upon request, to the 
        health care provider, supplier, or licensed practitioner, and
            (B) procedures in the case of disputed accuracy of the 
        information.

                           (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

                          (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.

                       (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) of this section 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:

                      (1) Final adverse action

        (A) In general

            The term ``final adverse action'' includes:
                (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.
                (ii) Federal or State criminal convictions related to 
            the delivery of a health care item or service.
                (iii) Actions by Federal or State agencies responsible 
            for the licensing and certification of health care 
            providers, suppliers, and licensed health care 
            practitioners, including--
                    (I) formal or official actions, such as revocation 
                or suspension of a license (and the length of any such 
                suspension), reprimand, censure or probation,
                    (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
                    (III) any other negative action or finding by such 
                Federal or State agency that is publicly available 
                information.

                (iv) Exclusion from participation in Federal or State 
            health care programs (as defined in sections 1320a-7b(f) and 
            1320a-7(h) of this title, respectively).
                (v) Any other adjudicated actions or decisions that the 
            Secretary shall establish by regulation.

        (B) Exception

            The term does not include any action with respect to a 
        malpractice claim.

                          (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).

                        (3) Government agency

        The term ``Government agency'' shall include:
            (A) The Department of Justice.
            (B) The Department of Health and Human Services.
            (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.
            (D) State law enforcement agencies.
            (E) State medicaid fraud control units.
            (F) Federal or State agencies responsible for the licensing 
        and certification of health care providers and licensed health 
        care practitioners.

                           (4) Health plan

        The term ``health plan'' has the meaning given such term by 
    section 1320a-7c(c) of this title.

                   (5) Determination of conviction

        For purposes of paragraph (1), the existence of a conviction 
    shall be determined under paragraphs (1) through (4) of section 
    1320a-7(i) of this title.

(Aug. 14, 1935, ch. 531, title XI, Sec. 1128E, as added Pub. L. 104-191, 
title II, Sec. 221(a), Aug. 21, 1996, 110 Stat. 2009; amended Pub. L. 
105-33, title IV, Sec. 4331(a)(2), (b), (d), Aug. 5, 1997, 111 Stat. 
395, 396.)

                       References in Text

    The Internal Revenue Code of 1986, referred to in subsec. (b)(2)(A), 
is classified generally to Title 26, Internal Revenue Code.
    The Health Care Quality Improvement Act of 1986, referred to in 
subsec. (f), is title IV of Pub. L. 99-660, Nov. 14, 1986, 100 Stat. 
3784, as amended, which is classified generally to chapter 117 
(Sec. 11101 et seq.) of this title. For complete classification of this 
Act to the Code, see Short Title note set out under section 11101 of 
this title and Tables.


                               Amendments

    1997--Subsec. (b)(6). Pub. L. 105-33, Sec. 4331(d), added par. (6).
    Subsec. (g)(3)(C). Pub. L. 105-33, Sec. 4331(a)(2), substituted 
``Department of Veterans Affairs'' for ``Veterans' Administration''.
    Subsec. (g)(5). Pub. L. 105-33, Sec. 4331(b), substituted 
``paragraphs (1) through (4)'' for ``paragraph (4)''.


                    Effective Date of 1997 Amendment

    Section 4331(f) of Pub. L. 105-33 provided that:
    ``(1) In general.--Except as provided in this subsection, the 
amendments made by this section [amending this section and sections 
1320a-7, 1320a-7a, and 1320a-7d of this title] shall be effective as if 
included in the enactment of the Health Insurance Portability and 
Accountability Act of 1996 [Pub. L. 104-191].
    ``(2) Federal health program.--The amendments made by subsection (c) 
[amending section 1320a-7 of this title] shall take effect on the date 
of the enactment of this Act [Aug. 5, 1997].
    ``(3) Sanction for failure to report.--The amendment made by 
subsection (d) [amending this section] shall apply to failures occurring 
on or after the date of the enactment of this Act.''

                  Section Referred to in Other Sections

    This section is referred to in section 1320a-7c of this title.
