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House Committee on the JudiciaryThe Constitution and Civil JusticeIntroducedAugust 1st, 2013
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Fairness in Health Care Claims, Guidance, and Investigations Act
To amend the false claims provisions of title 31, United States Code, with respect to health care programs, and for other purposes.
Fairness in Health Care Claims, Guidance, and Investigations Act - Amends the False Claims Act to set forth special rules for the investigation and prosecution of false claims submitted with respect to a federal health care program (i.e., a health care program funded by the federal government, a state health care program defined by the Social Security Act, or a health plan offered under the Patient Protection and Affordable Care Act). Requires the Attorney General to certify in writing, prior to requesting any information from a physician, hospital, or other provider or supplier of health care services in connection with an investigation reasonably expected to concern 10 or more claims submitted to a federal health care program by or on behalf of a single entity, that: (1) each agency responsible for promulgating relevant regulations, guidelines, and billing instructions relevant to any allegations of fraud has examined such regulations, guidelines, and instructions, all communications between the alleged perpetrator of the fraud and the agency, and each of the allegedly false claims; (2) the allegations under investigation are viewed as viable based on unambiguous regulations, guidelines, and billing instructions issued during the relevant time period; and (3) if proven to be true, the allegations will be pursued under the False Claims Act. Prohibits an action against a health care provider or supplier under the False Claims Act: (1) unless the amount of damages alleged to have been sustained by the government is a material amount, (2) if a claim is submitted in good faith reliance on erroneous information or written statements of federal policy provided by a federal agency or in good faith reliance on an audit or review by an agency of the entity submitting the claim or retaining an overpayment, or (3) if a claim is submitted in substantial compliance with a model compliance plan issued by the Secretary of Health and Human Services (HHS). Establishes the standard of proof necessary for a civil prosecution of a claim submitted with respect to a federal health care program as clear and convincing evidence (currently, a preponderance of the evidence is required for all other claims).