Corporate Compliance

Note from the Instructor: Increasing Amounts of Data Available on Providers

Medicare Insider, June 9, 2015

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This week’s note from the instructor is written by Kimberly Anderwood Hoy Baker, JD, regulatory specialist for HCPro.  
Providers may be surprised at the information that can be easily downloaded about them from the CMS website. This week two fact sheets from CMS announced provider specific data sets available with detailed information on the types of claims and charges submitted to Medicare by hospitals and physicians. These documents show just a sampling of the information available. CMS maintains a website to provide access to Medicare Provider Utilization and Payment Data. The site contains data on inpatient and outpatient hospital charges as well as physician and non-physician provider data, including both charges and prescribing information. 
Inpatient hospital data, by specific hospital, is available for the top 100 DRGs by volume. The data includes information on the number of discharges, and averages charges and payments, including total payments from all sources. Individual sites for fiscal years 2011, 2012, and 2013 contain both hospital-specific and national/state aggregate downloadable files, in either Excel or Comma Separated Value files. The data allows providers and others to easily compare hospitals in a specific area or compare a hospital to statewide and national averages. 
The inpatient hospital data has been used by media and authors for dramatic effect, tending to focus on charges, which can have a surprisingly small correlation with what providers are paid from government payers. With the increasing use of creative contracting strategies and alternate payment models, charges may also bare little correlation to payments from other insurers either. Unfortunately for uninsured patients, these are the amounts they are billed, although many states have laws that limit the charges to or require discounts for uninsured patients. None of this information is generally taken into account in media articles looking to dramatize the data.  
The site also includes data on hospital outpatient charges for 30 common APCs, including minor procedures (e.g., debridements, excisions and biopsies, certain endoscopies and injections), diagnostic tests (e.g., ultrasounds, MRIs, cardiac and pulmonary tests), and clinic visits. Noticeably missing is data on surgical procedures such as vascular procedures, stenting, and pacemakers, which is included in the inpatient data. If outpatient charge and payment information was available for these procedures, it would allow an easier comparison between inpatient and outpatient payments from Medicare for these procedures, which has been very controversial since implementation of the 2-Midnight Rule.
While the hospital data is detailed, the physician data seems almost invasive. It lists the physician’s name, NPI, credentials, specialty, address, and even gender. Files are available for 2012 and 2013 and contain a line for each HCPCS code billed by the provider more than 10 times during the year. For privacy reasons, lines are not included for HCPCS codes billed 10 or fewer times per year. Information for each HCPCS code includes, among other things, allowed amounts, the provider’s average charges, and Medicare payment amounts.
Additionally, a separate site contains files that list each physician and the drugs they have prescribed during 2013 that were paid through Medicare Part D. The file contains a line for each drug prescribed and information such as the number of claims for the drug, number of days supplied, and cost of the drug for all patients as well as for beneficiaries over 65. The file also identifies expenditures for brand name and generic versions of the drug. 
The CMS website indicates the data is being made available as part of efforts to “make our healthcare system more affordable and accountable.” However, the detailed level of the data seems to lend itself to abuses. For example, pharmaceutical companies could use the data to market to physicians if the physician’s prescribing pattern indicates higher usage of generic versions or attorneys could use the data in cases against providers to compare them, fairly or unfairly, against other providers. And we’ve already seen the inpatient data used to make dramatic arguments that sometimes did not portray the reality of the financial picture for hospitals. Providers cannot exclude themselves from the data, but they should at least familiarize themselves with the data publicly available about them.

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