New Medicare claims data rules proposed

June 24, 2011

The Centers for Medicare & Medicaid Services (CMS) has proposed rules that would allow pre-qualified organizations to access Medicare data for the purpose of quality measurement.

The Centers for Medicare & Medicaid Services (CMS) has proposed rules that would allow pre-qualified organizations to access Medicare data for the purpose of quality measurement. The organizations could merge the Medicare data with private insurance data to create a report card ranking of doctors and hospitals.

"Making more Medicare data available can make it easier for employers and consumers to make smart decisions about their healthcare," said CMS Administrator Donald M. Berwick, MD in a press statement. "Performance reports that include Medicare data will result in higher quality and more cost effective care. And making our healthcare system more transparent promotes competition and drives costs down."

According to CMS, this new program would provide for the following activities:

• CMS would provide standardized extracts of Medicare claims data from Parts A, B, and D to qualified entities. The data can only be used to evaluate provider and supplier performance and to generate public reports detailing the results.
• The data provided to the qualified entity will cover one or more specified geographic area(s).
• The qualified entity would pay a fee that covers CMS' cost of making the data available.
• To receive the Medicare claims data, qualified entities would need to have claims data from other sources.
• To prevent mistakes, qualified entities must share the reports confidentially with providers and suppliers prior to their public release. This gives providers and suppliers an opportunity to review the reports and provide necessary corrections.
• Publicly released reports would contain aggregated information only, meaning that no individual patient/beneficiary data would be shared or be available.
• During the application process, qualified entities would need to demonstrate their capabilities to govern the access, use, and security of Medicare claims data. Qualified entities would be subject to strict security and privacy processes.
• CMS would continually monitor qualified entities, and entities that do not follow these procedures risk sanctions, including termination from the program.

In a statement regarding the announcement, Business Roundtable said the proposed rules, "are a key step in addressing rising healthcare costs for all Americans and mark another positive milestone toward ensuring consumers have timely and accurate information on healthcare costs and quality."