EXTRA BILLING LIMITS.

SEC. 123. EXTRA BILLING LIMITS. (a) Enforcement of Limits.— Section 1848(g) (42 U.S.C. 1395w–4(g)), as amended by section 13517(a) of OBRA-1993, is amended— (1) by amending paragraph (1) to read as follows: “(1) Limitation on actual charges.— “(A) In general.— In the case of a nonparticipating physician or nonparticipating supplier or other person (as defined in section 1842(i)(2)) who does not accept payment on an assignment-related basis for a physician’s service furnished with respect to an individual enrolled under this part, the following rules apply: “(i) Application of limiting charge.— No person may bill or collect an actual charge for the service in excess of the limiting charge described in paragraph (2) for such service. “(ii) No liability for excess charges.— No person is liable for payment of any amounts billed for the service in excess of such limiting charge. “(iii) Correction of excess charges.— If such a physician, supplier, or other person bills, but does not collect, an actual charge for a service in violation of clause (i), the physician, supplier, or other person shall reduce on a timely basis the actual charge billed for the service to an amount not to exceed the limiting charge for the service. “(iv) Refund of excess collections.— If such a physician, supplier, or other person collects an actual charge for a service in violation of clause (i), the physician, supplier, or other person shall provide on a timely basis a refund to the individual charged in the amount by which the amount collected exceeded the limiting charge for the service. The amount of such a refund shall be reduced to the extent the individual has an outstanding balance owed by the individual to the physician. “(B) Sanctions.— If a physician, supplier, or other person— “(i) knowingly and willfully bills or collects for services in violation of subparagraph (A)(i) on a repeated basis, or “(ii) fails to comply with clause (iii) or (iv) of subparagraph (A) on a timely basis, the Secretary may apply sanctions against the physician, supplier, or other person in accordance with paragraph (2) of section 1842(j). In applying this subparagraph, paragraph (4) of such section applies in the same manner as such paragraph applies to such section and any reference in such section to a physician is deemed also to include a reference to a supplier or other person under this subparagraph. “(C) Timely basis.— For purposes of this paragraph, a correction of a bill for an excess charge or refund of an amount with respect to a violation of subparagraph (A)(i) in the case of a service is considered to be provided ‘on a timely basis’, if the reduction or refund is made not later than 30 days after the date the physician, sup-108 STAT. 4411plier, or other person is notified by the carrier under this part of such violation and of the requirements of subparagraph (A).”; and (2) in paragraph (3)(B)— (A) by inserting after the first sentence the following: “No person is liable for payment of any amounts billed for such a service in violation of the previous sentence.”, and (B) in the last sentence, by striking “previous sentence” and inserting “first sentence”. (b) Clarification of Mandatory Assignment Rules for Certain Practitioners.— (1) In general.— Section 1842(b) (42 U.S.C. 1395u(b)), as amended by section 126(e), is amended by adding at the end the following new paragraph: “(18) (A) Payment for any service furnished by a practitioner described in subparagraph (C) and for which payment may be made under this part on a reasonable charge or fee schedule basis may only be made under this part on an assignment-related basis. “(B) A practitioner described in subparagraph (C) or other person may not bill (or collect any amount from) the individual or another person for any service described in subparagraph (A), except for deductible and coinsurance amounts applicable under this part. No person is liable for payment of any amounts billed for such a service in violation of the previous sentence. If a practitioner or other person knowingly and willfully bills (or collects an amount) for such a service in violation of such sentence, the Secretary may apply sanctions against the practitioner or other person in the same manner as the Secretary may apply sanctions against a physician in accordance with subsection (j)(2) in the same manner as such section applies with respect to a physician. Paragraph (4) of subsection (j) shall apply in this subparagraph in the same manner as such paragraph applies to such section. “(C) A practitioner described in this subparagraph is any of the following: “(i) A physician assistant, nurse practitioner, or clinical nurse specialist (as defined in section 1861(aa)(5)). “(ii) A certified registered nurse anesthetist (as defined in section 1861(bb)(2)). “(iii) A certified nurse-midwife (as defined in section 1861(gg)(2)). “(iv) A clinical social worker (as defined in section 1861(hh)(1)). “(v) A clinical psychologist (as defined by the Secretary for purposes of section 1861(ii)). “(D) For purposes of this paragraph, a service furnished by a practitioner described in subparagraph (C) includes any services and supplies furnished as incident to the service as would otherwise be covered under this part if furnished by a physician or as incident to a physician’s service.”. (2) Conforming amendments.— (A) Section 1833 (42 U.S.C. 13951) is amended— (i) in subsection (1)(5), by striking subparagraph (B) and redesignating subparagraph (C) as subparagraph (B); (ii) by striking subsection (p); and 108 STAT. 4412 (iii) in subsection (r), by striking paragraph (3) and redesignating paragraph (4) as paragraph (3). (B) Section 1842(b)(12) (42 U.S.C. 1395u(b)(12)) is amended by striking subparagraph (C). (c) Information on Extra-Billing Limits.— (1) Part of explanation of medicare benefits.— Section 1842(h)(7) (42 U.S.C. 1395u(h)(7)) is amended— (A) by striking “and” at the end of subparagraph (B), (B) in subparagraph (C), by striking “shall include”, (C) in subparagraph (C), by striking the period at the end and inserting “, and”, and (D) by adding at the end the following new subparagraph: “(D) in the case of services for which the billed amount exceeds the limiting charge imposed under section 1848(g), information regarding such applicable limiting charge (including information concerning the right to a refund under section 1848(g)(1)(A)(iv)).”. (2) Determinations by carriers.— Subparagraph (G) of section 1842(b)(3) (42 U.S.C. 1395u(b)(3)) is amended to read as follows: “(G) will, for a service that is furnished with respect to an individual enrolled under this part, that is not paid on an assignment-related basis, and that is subject to a limiting charge under section 1848(g)— “(i) determine, prior to making payment, whether the amount billed for such service exceeds the limiting charge applicable under section 1848(g)(2); “(ii) notify the physician, supplier, or other person periodically (but not less often than once every 30 days) of determinations that amounts billed exceeded such applicable limiting charges; and “(iii) provide for prompt response to inquiries of physicians, suppliers, and other persons concerning the accuracy of such limiting charges for their services;”. (d) Report on Charges in Excess of Limiting Charge.— Section 1848(g)(6)(B) (42 U.S.C. 1395w–4(g)(6)(B)) is amended by inserting “information on the extent to which actual charges exceed limiting charges, the number and types of services involved, and the average amount of excess charges and information” after “report to the Congress”. (e) Miscellaneous and Technical Amendments.— Section 1833(h)(5)(D) (42 U.S.C. 13951(h)(5)(D)) is amended— (1) by striking “paragraphs (2) and (3)” and by inserting “paragraph (2)”; and (2) by adding at the end the following: “Paragraph (4) of such section shall apply in this subparagraph in the same manner as such paragraph applies to such section.”. (f) Effective Dates.— (1) Enforcement; miscellaneous and technical amendments.— The amendments made by subsections (a) and (e) shall apply to services furnished on or after the date of the enactment of this Act; except that the amendments made by subsection (a) shall not apply to services of a nonparticipating supplier or other person furnished before January 1, 1995. 108 STAT. 4413 (2) Practitioners.— The amendments made by subsection (b) shall apply to services furnished on or after January 1, 1995. (3) EOMBs.— The amendments made by subsection (c)(1) shall apply to explanations of benefits provided on or after July 1, 1995. (4) Carrier determinations.— The amendments made by subsection (c)(2) shall apply to contracts as of January 1, 1995. (5) Report.— The amendment made by subsection (d) shall apply to reports for years beginning with 1995.