PlainBillCongress, translated.Legislation. Context. Public interest.Sponsor introductory remarks on measure. (CR S10949-10951)
Congressional Research Service
Version 00 · Introduced in Senate · Oct 29, 2009
Prevent Health Care Fraud Act of 2009 - Establishes in the Department of Health and Human Services (HHS) the Office of the Deputy Secretary for Health Care Fraud Prevention. Requires the Office to: (1) direct the implementation within HHS of health care fraud prevention and detection recommendations made by federal and private sector antifraud and oversight entities; (2) routinely consult with HHS's Office of the Inspector General, the Attorney General, and private sector health care antifraud entities to identify emerging fraud issues requiring immediate action; (3) provide for the design, development, and operation of a predictive model antifraud system to analyze health care claims data in real-time to identify high risk claims activity and develop a comprehensive antifraud database for federal health agency activities; (4) promulgate and enforce regulations relating to the reporting of data claims to such system by federal health agencies; (5) establish thresholds for fraudulent, wasteful, or abusive claims for excluding providers or suppliers from participation in federal health programs and for the referral of claims to law enforcement entities; and (6) share antifraud information and best practices.
Sets forth requirements for the fraud prevention system, including that it shall: (1) allow viewing of all provider and patient activities across all federal health program payers; (2) provide for a centralized file for data from all government health insurance claims data sources; (3) provide real-time ability to identify high-risk behavior patterns across markets, geographies, and specialty group providers; (4) involve the implementation of a predictive modeling technology that is designed to prevent waste, fraud, and abuse; (5) systematically present scores, reason codes, and treatment actions for high-risk scored transactions; (6) monitor consumer transactions in real-time and monitor provider behavior at different stages within the transaction flow based upon provider, transaction, and consumer trends; and (7) not be designed to deny health care services or to negatively impact prompt-pay laws because assessments are late.
Directs the Deputy Secretary to: (1) prohibit the payment of any health care claim identified as potentially fraudulent, wasteful, or abusive until the claim has been verified as valid; and (2) provide maximum protection of personal privacy consistent with carrying out the Office's responsibilities.
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Directs the Secretary to establish procedures for the implementation of fraud and abuse detection methods under all federal health programs.
People & committees
Sen. LeMieux, George S. [R-FL] · R–FL
Legislative record
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Sponsor introductory remarks on measure. (CR S10949-10951)
Read twice and referred to the Committee on Health, Education, Labor, and Pensions.
Introduced in Senate
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Source last updated: Dec 4, 2025. Consult Congress.gov for the current record.
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