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The summary below was written by the Congressional Research Service, which is a nonpartisan division of the Library of Congress, and was published on Jul 23, 1987.
(Measure passed Senate, amended, in lieu of S. 661) Medicare and Medicaid Patient and Program Protection Act of 1987 - Amends part A (General Provisions) of title XI of the Social Security Act to direct the Secretary of Health and Human Services to exclude from participation in programs under title XVIII (Medicare) and to require the prohibition from participation in any State health care program of any individual or entity: (1) convicted of a criminal offense related to the delivery of an item or service under title XVIII or under titles XIX (Medicaid), V (Maternal and Child Health Block Grant), or XX (Block Grants to States for Social Services); or (2) convicted of a criminal offense related to neglect or abuse of patients in connection with the delivery of a health care item or service. Authorizes the Secretary to exclude from Medicare participation and to require the prohibition from participation in any State health care program of any individual or entity: (1) convicted of fraud with respect to any Federal, State, or locally financed health care program; (2) convicted of interfering with the investigation of health care fraud or patient abuse; (3) convicted of a felony for manufacturing, distributing, or dispensing a controlled substance; (4) whose health care license has been suspended or revoked; (5) suspended or excluded from participation in a Federal health care program; (6) claiming excessive charges or providing unnecessary services; (7) committing certain acts prohibited under title XI; (8) owned or controlled by an individual convicted of health care related crimes, fined for health care abuses, or excluded from Medicare or a State health care program; (9) failing to supply certain information; and (10) defaulting on health education loans or scholarship obligations made or secured by the Secretary. Authorizes the Secretary to exclude any hospital failing to comply with corrective action required under title XVIII. Sets forth provisions relating to notice requirements, judicial review, and period of exclusion. Provides that, before individuals or entities are excluded by reason of the Secretary's determination that they committed certain acts prohibited under title XI, such individuals or entities are entitled to a hearing by an administrative law judge, unless the health and safety of beneficiaries warrants earlier exclusion. Directs the Secretary to promptly notify each appropriate State agency administering or supervising the administration of a State health care program of each exclusion and the period of exclusion. Permits an excluded individual or entity to apply, following a period of exclusion, to the Secretary for reinstatement. Sets forth provisions providing for civil and criminal penalties for acts involving Medicare or State health care programs abuse, including penalties for physician misrepresentations. Requires a State, as a condition of Medicaid plan approval, to provide for the following: (1) a system of reporting any type of adverse action concluded against any health care practitioner or entity by the State or a local licensing authority; and (2) such access to documents as may be necessary by the Secretary. Requires the Secretary to provide suitable safeguards for the confidentiality of such information. Requires any health care provider providing health care services for which payment may be made under the Act to assure that services or items furnished will be: (1) provided economically and only when, and to the extent, medically necessary; (2) quality services which meet professionally recognized standards of health care; and (3) supported by evidence of medical necessity and quality in such form and fashion and at such time as may reasonably be required by a reviewing peer review organization in the exercise of its duties and responsibilities. Permits a State to exclude from Medicaid participation any individual or entity excluded under Medicare pursuant to the patient and program protection provisions. Requires a State in order to receive Federal payments with respect to a health maintenance organization (HMO) to exclude any HMO that: (1) could be excluded because of the conviction of the owners or managers of certain crimes; or (2) contracts with any individual or entity convicted of such crimes. Prohibits Federal payments with respect to any amount expended for items or services furnished by or at the direction of any individual or entity excluded from Medicaid participation because of the patient and program protection provisions. Prohibits a State under title V from making payments with respect to any amount expended for items or services furnished by or at the direction of any individual or entity excluded from participation pursuant to the patient and program protection provisions of title XI. Prohibits Federal payments with respect to any amount expended for items or services furnished by or at the direction of any individual or entity excluded from Medicare because of the patient and program protection provisions of title XI. Prohibits using a grant under title XX for payment for any item or service furnished by or at the direction of a person excluded from title XX participation because of the patient and program protection provisions of title XI. Revises disclosure requirements under part A of title XI. Revises Medicare provisions concerning agreements with providers. Modifies the Medicaid moratorium provisions of the Deficit Reduction Act of 1984 to consider a State's Medicaid plan to include any plan change and any policy or guideline delineated in the State Medicaid operation or program manuals submitted to the Secretary either before or after the enactment of that Act and whether or not approved or disapproved by the Secretary. Requires the Secretary to restore, for the duration of the moratorium, the policy in effect at the beginning of the moratorium regarding the period when homeownership by an institutionalized individual is permitted and the time permitted for the sale of a home. Amends the Medicare program to provide payment to beneficiaries for services rendered by an individual or entity which has been excluded from Medicare participation if such beneficiary did not know or have reason to know of the exclusion. Revises the definition under title XI of a "person with an ownership or control interest" in a provider of services under title V, XVIII, or XIX to limit reporting on ownership interests to those interests at or exceeding five percent of the entity's assets. Authorizes the Secretary to impose an intermediate sanction on a renal disease facility whose noncompliance with regulations the Secretary prescribes does not immediately jeopardize patient health and safety by denying it Medicare payments for services it provides after receiving notice of the sanction and before correcting its deficiencies. Provides that individuals who knowingly and willfully (currently, the intent must be knowing or willful) make a false statement or misrepresent a material fact in the sale of Medicare supplemental health insurance shall be guilty of a felony. Directs the Secretary to promulgate final regulations within two years of enactment of this Act specifying payment practices which shall not be considered as violations of the Social Security Act's anti-kickback provisions. Sets forth effective date provisions.
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