October 18th, 2016

New Government Rules for Medicare Claims (Part 1)

Organizations authorized by the Centers for Medicare and Medicaid Services (CMS) can receive extracts of Medicare Parts A and B claims data and Part D prescription drug event data for the purpose of evaluating provider performance.

These qualified entities (QEs) not only integrate Medicare fee-for service data with publicly available reports to generate performance measures, but also may provide or sell non-public reports or combined data to certain authorized users.

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Under the Qualified Entity Certification Program, QEs must release at least one public report annually on provider performance. QEs may also issue non-public reports or data releases to providers, suppliers, hospital associations and medical societies, as well as employers, insurers, provider/supplier associations, state entities and federal agencies.

Potential dangers in expanded data access

A final rule published in July 2016 authorizes QEs to buy Medicare claims and other federal data at the government’s cost — and then combine it with data from private payers, providers and other sources for resale. Further, the rule includes a clarification to allow the data to be used by contractors or business associates of authorized users.

Non-public analyses

Non-public analyses produced under the QE program must use data that has been de-identified according to HIPAA standards for covered entities. Identifiable data and analyses can also be issued to a class of providers or suppliers who have had a face-to-face or telehealth appointment with a patient in the previous 24 months.

The American Health Information Management Association is on record as stating that the privacy and security requirements of the QE program are “appropriate and adequate” and sufficiently aligned with HIPAA.

CMS intends that reporting and analysis including Medicare data “will make it easier for stakeholders throughout the healthcare system to make smarter and more informed healthcare decisions,” according to Niall Brennan, the agency’s chief data officer.

In addition, CMS said data usage under the program could have system-wide benefits, such as conducting analyses on chronically ill or other “resource-intensive” populations to increase care quality and drive down costs.

Third party data access

Nonetheless, allowing data access to third parties raises the possibility that it could be used for sales and marketing purposes. Pam Dixon, executive director of the World Privacy Forum expressed concern about contractors using the data in areas beyond healthcare quality improvement.

Dixon added that opening up the CMS dataset for use by additional organizations also provides a window to hackers who could access and resell the data on the black market.

Efficiency and transparency

Professionals who can help organizations in efforts to become more efficient and transparent through data analysis will find strong competition for their services. Click here for a closer look at the U.S. professional labor market and the importance of quality hires.

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