42 U.S.C. § 1320a–7c — Fraud and abuse control program

(a) Establishment of program. By January 1, 1997, the Secretary, acting through the Department of Health and Human Services Inspector General, and the Attorney General must establish a program to coordinate Federal, State, and local fraud-and-abuse enforcement; investigate, audit, evaluate, and inspect health-care delivery and payment; enforce sections 1320a–7, 1320a–7a, 1320a–7b, and other applicable laws; and modify or establish safe harbors and issue advisory opinions and special fraud alerts under section 1320a–7d. They must consult health plans and arrange data sharing. They must issue implementation guidelines, including information-supply rules, confidentiality and patient-privacy protections, and qualified immunity for people providing information. The Inspector General may use the authority in section 406(a)(3)–(9) of title 5 as necessary, and nothing in this chapter reduces an Inspector General's authority. The subsection establishes a public-private partnership of health plans, Federal and State agencies, law-enforcement agencies, health-care anti-fraud organizations, and other entities the Secretary approves. The Secretary must contract with a trusted third party. The partnership must support data sharing; analyze shared data for fraudulent or unusual billing patterns; conduct combined analyses; identify outliers and vulnerabilities; refer possible unlawful conduct; meet with partners at least annually; use data-sharing and data-use agreements that preserve confidentiality and integrity; provide confidential plan-specific feedback; set entry requirements; provide training and education; and perform other duties the Secretary assigns. Within two years after December 27, 2020, the third party must analyze aberrant or fraudulent billing patterns involving substance-use-disorder treatment providers and suppliers. An executive board has Federal and private-sector representatives, is co-chaired by one of each, meets at least annually, sets strategic direction and membership criteria, and communicates with HHS, Justice, and private-sector associations. Beginning January 1, 2023, and every two years, the Secretary must report to Congress and post a CMS website report describing the partnership's activities, objectives, voluntarily reported health-plan savings, Federal savings, other outcomes, and a two-year strategic plan. The partnership uses funds otherwise available for the program. The subsection transfers specified functions and resources of the prior National Fraud Prevention Partnership, does not apply the Federal Advisory Committee Act, permits implementation by program instruction or otherwise, and defines "trusted third party" as an entity capable of the duties, meeting conflict-of-interest standards, and meeting other requirements. (b) Additional use of funds by Inspector General. (1) The Inspector General may receive and retain reimbursement for investigation, audit, and compliance-plan-monitoring costs when a court orders payment, the payor agrees voluntarily, or another stated basis applies. (2) Investigation-cost reimbursements must be credited to the original appropriation or a currently available similar appropriation and remain available for obligation for one year after deposit. (c) "Health plan" defined. A "health plan" is a plan or program providing health benefits directly, through insurance, or otherwise. It includes a health-insurance policy, a service-benefit organization's contract, and a membership agreement with a health maintenance organization or other prepaid health plan. This section does not define terms it merely uses.