Health Care Fraud Prevention and Paperwork Reduction Act of 1995

TABLE OF CONTENTS:

Title I: Fraud and Abuse

Subtitle A: Amendments to Anti-Fraud and Abuse

Provisions Applicable to Medicare, Medicaid, and

State Health Care Programs

Subtitle B: Establishment of All-Payer Health Care

Fraud and Abuse Control Program

Subtitle C: Application of Fraud and Abuse Authorities

Under the Social Security Act to Other Payers

Subtitle D: Advisory Opinions on Kickbacks and

Self-Referral

Subtitle E: Preemption of State Corporate Practice Laws

Title II: Information Systems and Administrative

Simplification

Health Care Fraud Prevention and Paperwork Reduction Act of 1995 - Title I: Fraud and Abuse - Subtitle A: Amendments to Anti-Fraud and Abuse Provisions Applicable to Medicare, Medicaid, and State Health Care Programs - Amends the Social Security Act (SSA) title XI anti-fraud and abuse provisions applicable to Medicare, Medicaid, and State health care programs and concerning penalties and exclusionary matters, among other changes providing for: (1) civil monetary penalties for additional specified violations, including anti-kickback violations; (2) modifications to anti-kickback exceptions; (3) revisions in civil and criminal penalties; (4) deposit of penalties collected into the account established below; (5) private right of action in certain cases; and (6) mandatory exclusion from Medicare and State health care program participation for certain individuals convicted of a criminal felony relating to health care fraud.

Subtitle B: Establishment of All-Payer Health Care Fraud and Abuse Control Program - Requires the Secretary of Health and Human Services and the Attorney General to establish a program to coordinate their functions, as well as those of other organizations, with respect to the prevention, detection, and control of health care fraud and abuse. Authorizes appropriations.

(Sec. 112) Establishes in the Treasury the All-Payer Health Care Fraud and Abuse Control Account for use in the program established above.

Subtitle C: Application of Fraud and Abuse Authorities Under the Social Security Act to Other Payers - Applies civil monetary penalty provisions under SSA title XI (as amended by this Act), as well as certain criminal penalty provisions, to similar specified violations with respect to all payers.

Subtitle D: Advisory Opinions on Kickbacks and Self-Referral - Directs the Secretary to establish a process for issuing certain advisory opinions, for a fee, to requesting individuals or entities concerning whether their conduct constitutes grounds for imposition of a sanction or denial of payment for a service rendered.

Subtitle E: Preemption of State Corporate Practice Laws - Preempts State and local laws prohibiting corporate practice of medicine.

Title II: Information Systems and Administrative Simplification - Requires issuance to health benefit plan beneficiaries, including Medicare and Medicaid beneficiaries, of a uniform card similar to a credit card with encoded electronic information for use in obtaining entitled items or services verified along with beneficiary enrollment under a new system the Secretary shall establish for facilitating electronic claims payment, in addition to enrollment verification. Requires submission of claims in a uniform format pursuant to standards the Secretary shall also establish, including standards for electronic reporting of specific claim elements, that incorporate specified requirements, taking into account certain task force and other specified recommendations. Provides for uniform electronic hospital cost reporting under Medicare, with civil money penalties to ensure appropriate enrollment reporting and claims submission.