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PA Bulletin, Doc. No. 00-315


Federally Mandated Health Care Fraud and Abuse Reporting; Insurance Department Notice 2000-03

[30 Pa.B. 966]

   This notice is to advise all persons and entities currently engaged or participating, or seeking to engage or participate, in the business of accident and health insurance in this Commonwealth that Federal authorities have created a health care fraud and abuse data collection program and have proscribed penalties for any failure by government agencies or health plans to report to that data collection program certain final adverse actions taken against health care providers, suppliers or practitioners.

   The Healthcare Insurance Portability and Accountability Act (HIPAA) of 1996 (P. L. 104-191, August 21, 1996) through amendment of the Social Security Act, Title XI (42 U.S.C. 1301 et seq.) provided that the Secretary, U. S. Department of Health and Human Services through that Department's Office of Inspector General establish a ''Fraud and Abuse Control Program'' and a ''Health Care Fraud and Abuse Data Collection Program.''

   On October 26, 1999 a Final Rule (45 CFR Part 61) was published by the U. S. Department of Health and Human Services implementing the statutory requirements of section 1128E of the Social Security Act, as added by section 221(a) of HIPAA, establishing requirements applicable to Federal and State Government agencies and to Health Plans for reporting to a Healthcare Integrity Protection Data Bank (HIPDB).

   The Pennsylvania Insurance Department believes that all insurance entities now or since August 21, 1996 engaged in the business of insurance in Pennsylvania and meeting a Federal definition of Health Plan as defined by Section 61.3, 45 CFR Part 61 must register with and report to HIPDB final adverse actions taken since August 21, 1996 against health care providers, suppliers or practitioners as defined by that Section.

   Section 61.11(d), 45 CFR Part 61 provides that any health plan failing to report required final adverse actions will be subject to a civil monetary penalty of $25,000 for each such adverse action not reported.

   Section 61.11(d), 45 CFR Part 61 provides that the Secretary, U. S. Department of Health and Human Services will issue a public report of government agencies failing to make required reports.

   Procedures and documentation as to registration and reporting to HIPDB may be viewed and obtained through the HIPDB Internet Site at or by calling the HIPDB Help Line at (800) 767-6732.

   Questions regarding this notice may be referred in writing to: Dennis C. Shoop, Director, Bureau of Enforcement, Insurance Department, Strawberry Square, 12th floor, Harrisburg, PA 17120, (717) 783-2627, (717) 772-4334.

Insurance Commissioner

[Pa.B. Doc. No. 00-315. Filed for public inspection February 18, 2000, 9:00 a.m.]

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