Laws: Cases and Codes : U.S. Code : Title 42 : Section 1320a-7a
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U.S. Code as of:
01/19/04
Section 1320a-7a - Notes
SOURCE
(Aug. 14, 1935, ch. 531, title XI, Sec. 1128A, as added Pub. L.
97-35, title XXI, Sec. 2105(a), Aug. 13, 1981, 95 Stat. 789;
amended Pub. L. 97-248, title I, Sec. 137(b)(26), Sept. 3, 1982, 96
Stat. 380; Pub. L. 98-369, div. B, title III, Secs. 2306(f)(1),
2354(a)(3), July 18, 1984, 98 Stat. 1073, 1100; Pub. L. 99-509,
title IX, Secs. 9313(c)(1), 9317(a), (b), Oct. 21, 1986, 100 Stat.
2003, 2008; Pub. L. 100-93, Sec. 3, Aug. 18, 1987, 101 Stat. 686;
Pub. L. 100-203, title IV, Secs. 4039(h)(1), 4118(e)(1), (6)-(10),
Dec. 22, 1987, 101 Stat. 1330-155, as amended Pub. L. 100-360,
title IV, Sec. 411(e)(3), (k)(10)(B)(ii), (D), July 1, 1988, 102
Stat. 775, 794, 795; Pub. L. 100-360, title II, Sec. 202(c)(2),
July 1, 1988, 102 Stat. 715; Pub. L. 100-485, title VI, Sec.
608(d)(26)(H)-(K)(i), Oct. 13, 1988, 102 Stat. 2422; Pub. L.
101-234, title II, Sec. 201(a), Dec. 13, 1989, 103 Stat. 1981; Pub.
L. 101-239, title VI, Sec. 6003(g)(3)(D)(i), Dec. 19, 1989, 103
Stat. 2153; Pub. L. 101-508, title IV, Secs. 4204(a)(3), 4207(h),
formerly 4027(h), 4731(b)(1), 4753, Nov. 5, 1990, 104 Stat.
1388-109, 1388-123, 1388-195, 1388-208, renumbered Sec. 4207(h),
Pub. L. 103-432, title I, Sec. 160(d)(4), Oct. 31, 1994, 108 Stat.
4444; Pub. L. 104-191, title II, Secs. 231(a)-(e), (h), 232(a),
Aug. 21, 1996, 110 Stat. 2012-2015; Pub. L. 105-33, title IV, Secs.
4201(c)(1), 4304(a), (b), 4331(e), 4523(c), Aug. 5, 1997, 111 Stat.
373, 383, 396, 449; Pub. L. 105-277, div. J, title V, Sec. 5201(a),
(b)(1), Oct. 21, 1998, 112 Stat. 2681-916.)
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, Aug. 21, 1996,
110 Stat. 1936. For complete classification of this Act to the
Code, see Short Title of 1996 Amendments note set out under section
201 of this title and Tables.
Section 1395l(t)(5)(B) of this title, referred to in subsec.
(i)(6)(D), was redesignated section 1395l(t)(8)(B) of this title by
Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, Secs.
201(a)(1), 202(a)(2)], Nov. 29, 1999, 113 Stat. 1536, 1501A-336,
1501A-342.
The Inspector General Act of 1978, referred to in subsec.
(m)(2)(B), is Pub. L. 95-452, Oct. 12, 1978, 92 Stat. 1101, as
amended, which is set out in the Appendix to Title 5, Government
Organization and Employees.
AMENDMENTS
1998 - Subsec. (i)(6)(B). Pub. L. 105-277, Sec. 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, Sec. 5201(b)(1), added subsec. (n).
1997 - Subsec. (a). Pub. L. 105-33, Sec. 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, Sec. 4304(a), added par. (6).
Subsec. (a)(7). Pub. L. 105-33, Sec. 4304(b)(1), added par. (7).
Subsec. (b)(1). Pub. L. 105-33, Sec. 4201(c)(1), substituted
"critical access" for "rural primary care" in introductory and
concluding provisions.
Subsec. (i)(6)(A)(iii). Pub. L. 105-33, Sec. 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, Sec. 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, Sec.
4331(e)(2), (3). See below.
Pub. L. 105-33, Sec. 4331(e)(3), added subpar. (B). Former
subpar. (B) redesignated (C).
Subsec. (i)(6)(C). Pub. L. 105-33, Sec. 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, Sec. 4331(e)(2). See below.
Pub. L. 105-33, Sec. 4331(e)(2), redesignated subpar. (B) as (C).
Former subpar. (C) redesignated (D).
Subsec. (i)(6)(D). Pub. L. 105-33, Sec. 4523(c), added subpar.
(D) relating to a reduction in copayment amount for covered OPD
services.
Pub. L. 105-33, Sec. 4331(e)(2), redesignated subpar. (C),
relating to incentives given to individuals to promote delivery, as
(D).
1996 - Subsec. (a). Pub. L. 104-191, Sec. 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, Sec. 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, Sec. 231(d)(1)(A), inserted
"knowingly" before "presents" in introductory provisions.
Subsec. (a)(1)(A). Pub. L. 104-191, Sec. 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, Sec. 231(e)(2)-(4), added
subpar. (E).
Subsec. (a)(2). Pub. L. 104-191, Sec. 231(d)(1)(A), inserted
"knowingly" before "presents".
Subsec. (a)(3). Pub. L. 104-191, Sec. 231(d)(1)(B), substituted
"knowingly gives or causes to be given" for "gives".
Subsec. (a)(4). Pub. L. 104-191, Sec. 231(b), added par. (4).
Subsec. (a)(5). Pub. L. 104-191, Sec. 231(h)(1), added par. (5).
Subsec. (b)(3). Pub. L. 104-191, Sec. 232(a), added par. (3).
Subsec. (f)(3), (4). Pub. L. 104-191, Sec. 231(a)(2), added par.
(3) and redesignated former par. (3) as (4).
Subsec. (i)(2). Pub. L. 104-191, Sec. 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, Sec. 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, Sec. 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, Sec. 231(h)(2), added par. (6).
Subsec. (i)(7). Pub. L. 104-191, Sec. 231(d)(2), added par. (7).
Subsec. (m). Pub. L. 104-191, Sec. 231(a)(4), added subsec. (m).
1990 - Subsec. (b)(1). Pub. L. 101-508, Sec. 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, Sec. 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, Sec. 4753, made an amendment to
subsec. (j) identically to that of Pub. L. 101-508, Sec. 4207(h).
See below.
Pub. L. 101-508, Sec. 4207(h), formerly Sec. 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, Sec. 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, Sec. 411(k)(10)(D), added
Pub. L. 100-203, Sec. 4118(e)(10)(A), see 1987 Amendment note
below.
Subsec. (a)(1). Pub. L. 100-360, Sec. 411(k)(10)(B)(ii)(I), (II),
as amended by Pub. L. 100-485, Sec. 608(d)(26)(H), amended
directory language of Pub. L. 100-203, Sec. 4118(e)(1), see 1987
Amendment note below.
Subsec. (a)(1)(D). Pub. L. 100-360, Sec. 411(k)(10)(D), as
amended by Pub. L. 100-485, Sec. 608(d)(26)(K)(i), added Pub. L.
100-203, Sec. 4118(e)(6), see 1987 Amendment note below.
Pub. L. 100-360, Sec. 202(c)(2)(A), struck out "or" after
semicolon.
Subsec. (a)(2)(C). Pub. L. 100-360, Sec. 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, Sec. 411(k)(10)(B)(ii)(I), (II),
as amended by Pub. L. 100-485, Sec. 608(d)(26)(H), made technical
amendment to directory language of Pub. L. 100-203, Sec.
4118(e)(1)(A), see 1987 Amendment note below.
Subsec. (a)(4). Pub. L. 100-360, Sec. 202(c)(2)(C)-(E), added
par. (4) relating to participating or nonparticipating pharmacies.
Subsec. (b)(1)(A). Pub. L. 100-360, Sec. 411(e)(3), added Pub. L.
100-203, Sec. 4039(h)(1)(A), see 1987 Amendment note below.
Subsec. (b)(2). Pub. L. 100-360, Sec. 411(e)(3), added Pub. L.
100-203, Sec. 4039(h)(1)(B), see 1987 Amendment note below.
Subsec. (c)(1). Pub. L. 100-360, Sec. 411(k)(10)(D), added Pub.
L. 100-203, Sec. 4118(e)(7), see 1987 Amendment note below.
Subsec. (i). Pub. L. 100-360, Sec. 411(k)(10)(D), added Pub. L.
100-203, Sec. 4118(e)(8), see 1987 Amendment note below.
Subsec. (i)(1). Pub. L. 100-360, Sec. 411(k)(10)(D), added Pub.
L. 100-203, Sec. 4118(e)(9), see 1987 Amendment note below.
Subsec. (i)(2). Pub. L. 100-360, Sec. 411(k)(10)(D), added Pub.
L. 100-203, Sec. 4118(e)(10)(B), see 1987 Amendment note below.
Subsec. (i)(5). Pub. L. 100-485, Sec. 608(d)(26)(J), amended
directory language of Pub. L. 100-203, Sec. 4118(e)(10)(C), see
1987 Amendment note below.
Pub. L. 100-360, Sec. 411(k)(10)(D), added Pub. L. 100-203, Sec.
4118(e)(10)(C), see 1987 Amendment note below.
Subsec. (l). Pub. L. 100-485, Sec. 608(d)(26)(I), inserted "for
penalties, assessments, and an exclusion" after "liable".
Pub. L. 100-360, Sec. 411(k)(10)(B)(ii)(III), added Pub. L.
100-203, Sec. 4118(e)(1)(B), see 1987 Amendment note below.
1987 - Subsec. (a). Pub. L. 100-203, Sec. 4118(e)(10)(A), as
added by Pub. L. 100-360, Sec. 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, Sec. 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, Sec. 4118(e)(1)(A), formerly
Sec. 4118(e)(1), as amended by Pub. L. 100-360, Sec.
411(k)(10)(B)(ii)(I), (II), as amended by Pub. L. 100-485, Sec.
608(d)(26)(H), substituted "or should know" for "or has reason to
know" in subpars. (A) to (C).
Pub. L. 100-93, Sec. 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, Sec. 4118(e)(6), as added by
Pub. L. 100-360, Sec. 411(k)(10)(D), as amended by Pub. L. 100-485,
Sec. 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, Sec. 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, Sec. 4118(e)(1)(A), as amended
by Pub. L. 100-360, Sec. 411(k)(10)(B)(ii)(I), (II), as amended by
Pub. L. 100-485, Sec. 608(d)(26)(H), substituted "or should know"
for "or has reason to know".
Pub. L. 100-93, Sec. 3(a)(3)(A), added par. (3).
Subsec. (b)(1)(A). Pub. L. 100-203, Sec. 4039(h)(1)(A), as added
by Pub. L. 100-360, Sec. 411(e)(3), substituted "subchapter XVIII"
for "subchapter XVII".
Subsec. (b)(2). Pub. L. 100-203, Sec. 4039(h)(1)(B), as added by
Pub. L. 100-360, Sec. 411(e)(3), substituted "$2,000 for each" for
"$2,000 for".
Subsec. (c)(1). Pub. L. 100-203, Sec. 4118(e)(7), as added by
Pub. L. 100-360, Sec. 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, Sec. 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, Sec. 3(c), substituted "penalty,
assessment, or exclusion" for "penalty or assessment" in
introductory provisions.
Subsec. (f)(1)(A). Pub. L. 100-93, Sec. 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, Sec. 3(c), substituted "penalty,
assessment, or exclusion" for "penalty or assessment" in two
places.
Subsec. (h). Pub. L. 100-93, Sec. 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, Sec. 4118(e)(8), as added by Pub.
L. 100-360, Sec. 411(k)(10)(D), substituted "this section" for
"this subsection" in introductory provisions.
Subsec. (i)(1). Pub. L. 100-203, Sec. 4118(e)(9), as added by
Pub. L. 100-360, Sec. 411(k)(10)(D), inserted "or subchapter XX of
this chapter".
Subsec. (i)(2). Pub. L. 100-203, Sec. 4118(e)(10)(B), as added by
Pub. L. 100-360, Sec. 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, Sec. 4118(e)(10)(C), as added by
Pub. L. 100-360, Sec. 411(k)(10)(D), and amended by Pub. L.
100-485, Sec. 608(d)(26)(J), added par. (5).
Subsecs. (j), (k). Pub. L. 100-93, Sec. 3(f), added subsecs. (j)
and (k).
Subsec. (l). Pub. L. 100-203, Sec. 4118(e)(1)(B), as added by
Pub. L. 100-360, Sec. 411(k)(10)(B)(ii)(III), added subsec. (l).
1986 - Subsec. (a)(1). Pub. L. 99-509, Sec. 9313(c)(1)(B),
substituted "(i)(1)" and "(i)(2)" for "(h)(1)" and "(h)(2)",
respectively.
Subsec. (b). Pub. L. 99-509, Sec. 9313(c)(1)(D), (E), added
subsec. (b). Former subsec. (b) redesignated (c).
Subsec. (c). Pub. L. 99-509, Sec. 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, Sec. 9317(a), added par. (3).
Subsec. (c)(4). Pub. L. 99-509, Sec. 9317(b), added par. (4).
Subsec. (d). Pub. L. 99-509, Sec. 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, Sec. 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, Sec. 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, Sec. 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, Sec. 9313(c)(1)(D), redesignated
subsec. (h) as (i).
1984 - Subsec. (a)(2)(C). Pub. L. 98-369, Sec. 2306(f)(1), added
cl. (C).
Subsec. (g). Pub. L. 98-369, Sec. 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".
SECTION REFERRED TO IN OTHER SECTIONS
This section is referred to in sections 262a, 299c-3, 704, 707,
1320a-3a, 1320a-7, 1320a-7b, 1320a-7c, 1320a-7d, 1320a-7e, 1320a-8,
1320b-10, 1320d-5, 1395b-5, 1395b-7, 1395i-3, 1395l, 1395m, 1395u,
1395w-2, 1395w-3a, 1395w-27, 1395w-141, 1395y, 1395cc, 13955dd,
1395mm, 1395nn, 1395ss, 1395bbb, 1396a, 1396b, 1396r, 1396r-6,
1396r-8, 1396t, 1396u, 1397d, 1397gg, 11131, 11137 of this title;
title 5 section 8904; title 10 section 1094.
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