Sec. 3. Limitation on application of physicians’ services and in-office ancillary services exceptions
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Section 1877(b) of the Social Security Act ( 42 U.S.C. 1395nn(b) ) is amended— in paragraph (1), by inserting , other than specified non-ancillary services, after section 1861(q)) ; and in paragraph (2), by inserting , specified non-ancillary services, after (excluding infusion pumps) . Section 1877(g) of the Social Security Act ( 42 U.S.C. 1395nn(g) ) is amended— in paragraph (3), by inserting , unless such bill or claim included a bill or claim for a specified non-ancillary service, in which case the civil money penalty shall be not more than $25,000 for each such service before the period at the end of the first sentence; and in paragraph (4), by inserting (or $150,000 if such referrals are for specified non-ancillary services) after $100,000 .
Section 1877(g) of the Social Security Act ( 42 U.S.C. 1395nn(g) ) is further amended by adding at the end the following new paragraph: Not later than 180 days after the date of the enactment of this paragraph, the Secretary, in consultation with the Inspector General of the Department of Health and Human Services, shall review compliance with subsection (a)(1) with respect to referrals for specified non-ancillary services in accordance with procedures established by the Secretary.
Such procedures— shall, for purposes of targeting types of entities that the Secretary determines represent a high risk of noncompliance with subsection (a)(1) with respect to such billing for such specified non-ancillary services, apply different levels of review based on such type; and may include prepayment reviews, claims audits, focused medical review, computer algorithms designed to identify payment or billing anomalies. . Section 1877(h) of the Social Security Act ( 42 U.S.C. 1395nn(h) ) is amended by adding at the end the following new paragraph:
The term specified non-ancillary service means a service that the Secretary has determined is not usually provided and completed during an office visit to a physician’s office in which the service is determined to be necessary, and includes the following: Anatomic pathology services, as defined by the Secretary and including the technical or professional component of the following: Surgical pathology. Cytopathology. Hematology. Blood banking. Pathology consultation and clinical laboratory interpretation services.
Radiation therapy services and supplies, as defined by the Secretary. Advanced diagnostic imaging studies (as defined in section 1834(e)(1)(B)). Physical therapy services (as described in paragraph (6)(B)). . Nothing in this section (or the amendments made by this section) shall be construed to affect the authority of the Secretary of Health and Human Services to waive the requirements imposed under the provisions of this section (or such amendments) under section 1899 of the Social Security Act ( 42 U.S.C. 1395jjj ).
The amendments made by subsections
(a)and
(b)shall apply to items and services furnished on or after the first day of the first month beginning more than 12 months after the date of the enactment of this Act.
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Sec. 3
Limitation on application of physicians’ services and in-office ancillary services exceptions
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