Summary: H.R.2116 — 100th Congress (1987-1988)All Information (Except Text)

There is one summary for H.R.2116. Bill summaries are authored by CRS.

Shown Here:
Introduced in House (04/22/1987)

PRO Due Process and Equity Amendments of 1987 - Amends part B (Peer Review) of title XI of the Social Security Act to give Medicare (title XVIII of the Act) providers 30 days to request a hearing, and such time as is thereafter needed to exhaust administrative and judicial remedies, before the decision of the Secretary of Health and Human Services to exclude the provider from Medicare participation takes effect, provided that such delay does not pose a severe and immediate threat to the health of Medicare beneficiaries. Provides that where the Secretary finds such an immediate threat to exist, the provider shall be immediately excluded from Medicare participation and be given a hearing within 30 days.

Directs the Secretary to act upon the recommendations regarding a provider's noncompliance with title XI requirements within five days of their submission if the PRO finds such noncompliance to pose an immediate threat to the health of Medicare beneficiaries, and, in any other case, within 120 days of the submittal of the recommendations.

Entitles Medicare providers to a reconsideration by PRO of that organization's denial of payment for services provided, and to further review where such reconsideration is adverse to the provider and certain jurisdictional criteria are satisfied.

Requires PROs to notify providers regarding any changes in the services reviewed or the review standards applied by PROs at least 30 days before such changes take effect.

Requires the Secretary to emphasize PRO educational activities as much as its sanctioning activities when entering into, reviewing, or terminating PRO contracts.

Directs PROs to make at least 50 percent of their review of small rural hospitals on-site reviews and take into account professionally recognized local health care standards as well as national and State standards in conducting such reviews.

Prohibits the finalization of a provider payment denial until at least 30 days after the PRO gives the provider reasonable notice of the proposed denial and a reasonable opportunity to discuss such denial.

Requires a PRO to include at least one hospital representative on its governing body.

Requires the random review of physician care to be conducted so that there is an equal likelihood and intensity of review for each physician sampled.