Public Release of Medicare Payment Data — Transparency and Privacy Concerns

For the first time, the Centers for Medicare & Medicaid Services (CMS) have released data on Medicare fees paid to health care providers. The new policy is intended to increase transparency regarding the $77 billion spent by government health care programs in 2012. The extensive database is called the Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File (Physician and Other Supplier PUF).

The Physician and Other Supplier PUF publicly discloses the following data for each doctor who billed CMS in 2012:

  • Physician’s name
  • Street address, city and state of doctor’s office
  • NPPES Credentials
  • Gender
  • National Provider Identifier (NPI)
  • Provider type
  • HCPCS code for the specific service provided
  • Number of services furnished
  • Number of Medicare beneficiaries
  • Bill for payment the physician submitted to the CMS
  • Amount Medicare paid for the service

The database does not contain patient information.

The American Medical Association (AMA) and other physician trade organizations fought the release of the Physician and Other Supplier PUF because the information could be misleading. CMS acknowledges that the system has limitations, including the following:

  • Only Medicare patient information is reflected, as opposed to that of patients covered by other federal programs, by private health insurance and those who are uninsured. Therefore, the data may not represent the entirety of a doctor’s practice.
  • Only billings and payments are released, with no indication as to quality of the care or the circumstances under which the treatment was provided. A patient may base decisions on which doctor is cheaper instead of which one is most appropriate for her or his needs.
  • The data do not adjust for the stage or severity of the disease being treated by a particular physician, and so may be skewed.
  • Medicare-allowed amounts and payments vary depending upon a variety of factors, such as geography and modifiers.

In a recent Medical Practice Insider article, the president of the Medical Group Management Association described another potential implication: “Releasing physicians’ financial data and NPI could make them susceptible to fraud.”

Medical doctors in New Jersey, New York and throughout the country with questions about the Physician and Other Supplier PUF should consult an attorney familiar with the evolving health care policies.

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Posted in: Compliance, Regulation