Medicare Claims: Will Everyone Know How Much You're Paid?

Leigh Page


March 20, 2014

In This Article

A Treasure Trove for Reporters and Attorneys?

Investigative reporters now rely heavily on data mining, and they've used it to look for physicians who overutilize services or routinely bill with higher, better-paying codes. Jay Want, MD, a payment and delivery reform consultant in Denver, said he generally supports opening up the data, but he called for restrictions to make sure reporters use it correctly. "I think it's reasonable to require that the data will be analyzed and published in a responsible way," he said.

For many years, reporters have been applying to CMS to get the data under the Freedom of Information Act (FOIA), which allows them to obtain federal information if they agree to certain restrictions. In 2010, the Wall Street Journal used the FOIA process to obtain Medicare claims data for an investigative article that revealed some physicians were ordering a high volume of certain diagnostic tests, purportedly to boost their income.[8] But owing to its FOIA agreement with CMS, the Journal was prohibited from naming the doctors. Objecting to this restriction, the newspaper challenged the 1979 ban on identifying physicians, which resulted in Judge Howard's decision last May.

Although CMS's new policy hasn't exactly opened the floodgates for reporters to finger physicians, it's now a possibility. When considering data requests from journalists, the agency is now committed to the FOIA standard, which involves weighing the public interest against physicians' privacy. This is a step beyond the agency's old policy, which, according to the 2013 court ruling, flatly stated that when a physician's privacy is at stake, the public interest was "not sufficient to compel disclosure."

On the other hand, some groups, such as malpractice attorneys, may not get access at all. In a letter to CMS last fall, the American Medical Association and dozens of other medical groups cited their concerns about lawyers getting the data.[9] CMS hasn't specifically ruled them out, but for what it's worth, CMS administrator Blum's listing of groups that may access the data didn't include attorneys.

Physicians have also raised concerns about competitors mining their claims data to find out inside information about their practice. Blum said that although providers could have access to the data, it would be for "improved care management and the delivery of healthcare at lower costs," and presumably not to see how well a rival practice is handling its billing function.

Data for Groups That Work With Physicians

One group seeking the data sees itself as physician-friendly. Regional Health Improvement Collaboratives (RHICs) are coalitions of physicians, payers, and state officials that mine claims data to help physicians improve their practice patterns.

RHICs, which have had to be content with commercial and Medicaid data, are very interested in adding Medicare's rich data set to create more granular reports, according to John Toussaint, MD, CEO of the ThedaCare Center for Healthcare Value in Appleton, Wisconsin. Dr. Toussaint is on the board of a RHIC, the Wisconsin Health Information Organization. "Without Medicare claims data, you don't always have enough data to be statistically reliable," he said, noting that the data must cover at least 30 episodes of care to be accurate.

CMS started making efforts to open up Medicare claims data to RHICs and similar groups in 2011, when it began the Qualified Entity Program, which allowed for the "evaluation of the performance of providers and suppliers."[10] But the program, created by the Affordable Care Act, has signed up only 12 organizations so far, even though there are more than 30 RHICs.[11,12]

Dr. Toussaint said the requirements for data-handling, written when the data were supposed to be locked away, are extremely burdensome. The SGR repeal bill would expand qualified entity requirements, however, and Dr. Toussaint has been meeting with congressional aides to ensure that the bill's language is workable.


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