SENATE AMENDED
PRIOR PRINTER'S NOS. 781, 1783, 2007 PRINTER'S NO. 3766
3681
No. 700 Session of 1989
INTRODUCED BY KUKOVICH, JAROLIN, PRESSMANN, RITTER, ITKIN,
RICHARDSON, CAWLEY, HASAY, JACKSON, TIGUE, HAYDEN, BLAUM,
FEE, BELARDI, GIGLIOTTI, DeLUCA, KOSINSKI, COWELL, VEON,
CAPPABIANCA, FREEMAN, VAN HORNE, MICHLOVIC, LASHINGER,
TANGRETTI, JOSEPHS, KASUNIC, TRELLO, ROBINSON, YANDRISEVITS,
LAUGHLIN, MURPHY, HUGHES, PRESTON, DALEY, ACOSTA, PIEVSKY,
OLIVER, ROEBUCK, PERZEL, STISH, J. TAYLOR, RYBAK, CARN,
HARPER, WESTON, LEVDANSKY, MELIO, COLAIZZO, R. C. WRIGHT,
COHEN, RIEGER, HOWLETT, WILLIAMS, WAMBACH, BISHOP, LINTON,
JAMES, DONATUCCI, THOMAS, CALTAGIRONE, DOMBROWSKI, MRKONIC,
PISTELLA, D. W. SNYDER, RUDY, McHALE, EVANS, KAISER, SALOOM,
PETRARCA, BURD, MAINE, LUCYK, CORNELL, SCRIMENTI, DIETTERICK,
DeWEESE, McNALLY, WOZNIAK, KENNEY, PETRONE AND BELFANTI,
MARCH 13, 1989
SENATOR TILGHMAN, APPROPRIATIONS, IN SENATE, RE-REPORTED AS
AMENDED, JUNE 19, 1990
AN ACT
1 Prohibiting overcharges by health care practitioners for <--
2 services to certain patients.
3 PROHIBITING HEALTH CARE PRACTITIONERS FROM BALANCE BILLING FOR <--
4 SERVICES TO CERTAIN PATIENTS.
5 The General Assembly of the Commonwealth of Pennsylvania
6 hereby enacts as follows:
7 Section 1. Short title.
8 This act shall be known and may be cited as the Medicare <--
9 Overcharge Act HEALTH CARE PRACTITIONERS MEDICARE FEE CONTROL <--
10 ACT.
11 Section 2. Purposes.
1 (a) Legislative finding.--The General Assembly finds that
2 there exists in this Commonwealth a major crisis because of the
3 continuing escalation of costs for health care services. Because
4 of the continuing escalation of costs, an increasingly large
5 number of Pennsylvania citizens have severely limited access to
6 appropriate and timely health care. Senior citizens and the
7 disabled are disadvantaged by the continuing escalation of costs
8 for health care services. Increasing costs are also undermining
9 the quality of health care services currently being provided.
10 Further, the continuing escalation is negatively affecting the
11 economy of this Commonwealth and is restricting new economic
12 growth and impeding the creation of new job opportunities in
13 this Commonwealth.
14 (b) Declaration of policy.--The General Assembly declares
15 its policy to be that every person in this Commonwealth should <--
16 receive timely and appropriate health care services from any
17 provider operating in this Commonwealth; and that each provider
18 should offer and provide medically necessary health care
19 services to every person in this Commonwealth and IN ACCORDANCE <--
20 WITH THE PROVISIONS OF THIS ACT, PROVIDERS OF HEALTH CARE
21 SERVICES should not charge or collect from a beneficiary of
22 health insurance under Title XVIII of the Social Security Act
23 (Public Law 74-271, 42 U.S.C. § 301 et seq.), known as the
24 Medicare Program, an amount in excess of the reasonable charge
25 for the service provided, as determined by the United States
26 Secretary of Health and Human Services.
27 Section 3. Definitions.
28 The following words and phrases when used in this act shall
29 have the meanings given to them in this section unless the
30 context clearly indicates otherwise:
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1 "BALANCE BILLING." TO CHARGE OR COLLECT FROM A BENEFICIARY <--
2 OF HEALTH INSURANCE UNDER TITLE XVIII OF THE SOCIAL SECURITY ACT
3 (PUBLIC LAW 74-271, 42 U.S.C. § 301 ET SEQ.), KNOWN AS THE
4 MEDICARE PROGRAM, AN AMOUNT IN EXCESS OF THE REASONABLE CHARGE
5 FOR THE SERVICE PROVIDED, AS DETERMINED BY THE UNITED STATES
6 SECRETARY OF HEALTH AND HUMAN SERVICES.
7 "Healing arts." The science and skill of diagnosis,
8 prevention or treatment, in any manner whatsoever, of disease or
9 any ailment of the human body.
10 "Health care practitioner." An individual who is authorized
11 to practice some component of the healing arts by a license,
12 permit, certificate or registration issued by a Commonwealth
13 licensing agency or board. The term includes, but is not limited
14 to, a medical doctor, an osteopathic physician, a chiropractor,
15 a dentist, an optometrist, a pharmacist, a physical therapist, a
16 podiatrist, a professional nurse and a psychologist.
17 Section 4. Overcharges by health care practitioners prohibited. <--
18 It shall be unlawful for any health care practitioner, or any
19 primary health center, corporation, facility, institution or
20 other entity that employs a health care practitioner, to charge
21 or collect from a beneficiary of health insurance under Title
22 XVIII of the Social Security Act (Public Law 74-271, 42 U.S.C. §
23 301 et seq.), known as the Medicare Program, an amount in excess
24 of the reasonable charge for the service provided, as determined
25 by the United States Secretary of Health and Human Services.
26 SECTION 4. BALANCE BILLING BY HEALTH CARE PRACTITIONERS <--
27 PROHIBITED.
28 (A) GENERAL RULE.--IT SHALL BE UNLAWFUL FOR ANY HEALTH CARE
29 PRACTITIONER, OR ANY PRIMARY HEALTH CENTER, CORPORATION,
30 FACILITY, INSTITUTION OR OTHER ENTITY THAT EMPLOYS A HEALTH CARE
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1 PRACTITIONER, TO BALANCE BILL.
2 (B) EXCEPTION.--THE PROVISIONS OF SUBSECTION (A) SHALL NOT
3 APPLY IF THE FOR SERVICES PROVIDED IN THE OFFICE, HOME, NURSING <--
4 HOME OR PERSONAL CARE HOME WHICH ARE LISTED AS PROCEDURE CODES
5 90000 THROUGH 90170, 90300 THROUGH 90370, AND 90400 THROUGH
6 90470 AS PUBLISHED BY THE AMERICAN MEDICAL ASSOCIATION IN
7 CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION (CPT-4) OR ITS
8 SUCCESSORS WHICH ARE PROVIDED BY PHYSICIANS IN PRIVATE SOLO OR
9 PRIVATE GROUP PRACTICE WHO ARE:
10 (1) FAMILY PRACTITIONERS OR GENERAL INTERNISTS AS
11 DEFINED BY THE AMERICAN BOARD OF MEDICAL SPECIALTIES; OR
12 (2) GENERAL PRACTITIONERS OR GENERAL INTERNISTS AS
13 DEFINED BY THE AMERICAN OSTEOPATHIC BOARD OF GENERAL
14 PRACTICE. AND THE SERVICES ARE PROVIDED IN THE OFFICE, THE <--
15 HOME, OR IN A NURSING HOME. THE SERVICES ARE THOSE LISTED AS
16 PROCEDURE CODES 90000 THROUGH 90170, 90300 THROUGH 90370 AND
17 90400 THROUGH 90470 AS PUBLISHED IN THE PHYSICIANS' CURRENT
18 PROCEDURAL TERMINOLOGY, FOURTH EDITION (1986) BY THE AMERICAN
19 MEDICAL ASSOCIATION, AS AMENDED ANNUALLY, OR THEIR
20 EQUIVALENTS.
21 Section 5. Penalties and procedure.
22 (a) General penalties.--If a person violates section 4, the
23 licensing board of the Bureau of Professional and Occupational
24 Affairs under which the violator is licensed shall do the
25 following:
26 (1) Publicly reprimand the violator.
27 (2) Order the violator to repay the victim the amount of
28 excess payments made and received, plus interest on that
29 amount at the maximum legal rate from the date payment was
30 made until the date repayment is made.
19890H0700B3766 - 4 -
1 (b) Additional violations.--If a person violates section 4
2 more than once, the penalties set forth in subsection (a) shall
3 again be ordered. In addition, the following penalties shall be
4 imposed:
5 (1) For a second violation, a fine of $2,000.
6 (2) For a third violation, a fine of $5,000.
7 (3) For a fourth or subsequent violation, a fine of
8 $1,000 more than the last fine imposed.
9 (c) Disposition of fines collected.--Fines collected under
10 this section shall be deposited into the General Fund.
11 (d) Procedure.--Before a penalty may be imposed under this
12 section, a complaint shall be filed against the health care
13 practitioner and notice of and an opportunity for a hearing
14 shall be given. Either party to the complaint may appeal to the
15 Commonwealth Court from an adjudication of the licensing board
16 under 2 Pa.C.S. (relating to administrative law and procedure).
17 (E) EXCEPTIONS.--NO PENALTY IMPOSED UNDER THIS SECTION SHALL <--
18 BE CONSIDERED CAUSE TO WITHHOLD, SUSPEND, OR REVOKE THE LICENSE
19 OF A HEALTH CARE PRACTITIONER BY A LICENSING BOARD.
20 Section 6. Notice to Medicare beneficiaries.
21 (a) Practitioner's duty.--A sign which sets forth the
22 following shall be posted by licensed health care practitioners
23 who treat Medicare beneficiaries:
24 (1) The rights of Medicare patients under this act.
25 (2) The identification of the Department of State as the
26 proper State agency to receive patients' complaints relating
27 to overcharges BALANCE BILLING prohibited under this act. <--
28 (3) The address and telephone number of the Department
29 of State.
30 (b) Distribution of signs.--The signs posted by licensed
19890H0700B3766 - 5 -
1 health care practitioners, in accordance with subsection (a),
2 shall be composed, printed and distributed by the Bureau of
3 Professional and Occupational Affairs of the Department of
4 State. Distribution shall be to all health practitioners who
5 treat Medicare beneficiaries.
6 (c) Duty in the case of bilingual patients.--If a health
7 care practitioner treats Medicare beneficiaries whose primary
8 language skill is in a language other than English, the
9 practitioner shall notify the Bureau of Professional and
10 Occupational Affairs, which shall provide the practitioner with
11 a sign setting forth the information required under subsection
12 (a) in the appropriate language.
13 Section 7. Effective date.
14 This act shall take effect in 60 days.
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