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U.S. Code as of:
01/19/04
Section 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,
(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, and
(E) to provide for the reporting and disclosure of certain
final adverse actions against health care providers, suppliers,
or practitioners pursuant to the data collection system
established under section 1320a-7e of this title.
(2) Coordination with health plans
In carrying out the program established under paragraph (1),
the Secretary and the Attorney General shall consult with, and
arrange for the sharing of data with representatives of health
plans.
(3) Guidelines
(A) In general
The Secretary and the Attorney General shall issue guidelines
to carry out the program under paragraph (1). The provisions of
sections 553, 556, and 557 of title 5 shall not apply in the
issuance of such guidelines.
(B) Information guidelines
(i) In general
Such guidelines shall include guidelines relating to the
furnishing of information by health plans, providers, and
others to enable the Secretary and the Attorney General to
carry out the program (including coordination with health
plans under paragraph (2)).
(ii) Confidentiality
Such guidelines shall include procedures to assure that
such information is provided and utilized in a manner that
appropriately protects the confidentiality of the information
and the privacy of individuals receiving health care services
and items.
(iii) Qualified immunity for providing information
The provisions of section 1320c-6(a) of this title
(relating to limitation on liability) shall apply to a person
providing information to the Secretary or the Attorney
General in conjunction with their performance of duties under
this section.
(4) Ensuring access to documentation
The Inspector General of the Department of Health and Human
Services is authorized to exercise such authority described in
paragraphs (3) through (9) of section 6 of the Inspector General
Act of 1978 (5 U.S.C. App.) as necessary with respect to the
activities under the fraud and abuse control program established
under this subsection.
(5) Authority of Inspector General
Nothing in this chapter shall be construed to diminish the
authority of any Inspector General, including such authority as
provided in the Inspector General Act of 1978 (5 U.S.C. App.).
(b) Additional use of funds by Inspector General
(1) Reimbursements for investigations
The Inspector General of the Department of Health and Human
Services is authorized to receive and retain for current use
reimbursement for the costs of conducting investigations and
audits and for monitoring compliance plans when such costs are
ordered by a court, voluntarily agreed to by the payor, or
otherwise.
(2) Crediting
Funds received by the Inspector General under paragraph (1) as
reimbursement for costs of conducting investigations shall be
deposited to the credit of the appropriation from which initially
paid, or to appropriations for similar purposes currently
available at the time of deposit, and shall remain available for
obligation for 1 year from the date of the deposit of such funds.
(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.
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