Fraud and Abuse Implications of the CMS Data Dump
Whistleblowers and their lawyers are likely already poring over the data contained in the data set released by the Health and Human Services Centers for Medicare and Medicaid Services (CMS) on April 9, as are others looking for ways the data can be used to attach some kind of legal liability for individual providers. CMS […]
Whistleblowers and their lawyers are likely already poring over the data contained in the data set released by the Health and Human Services Centers for Medicare and Medicaid Services (CMS) on April 9, as are others looking for ways the data can be used to attach some kind of legal liability for individual providers. CMS touts the release of the data as part of the Obama administration’s efforts to make the health care system more transparent, affordable, and accountable; however, the data contain no information about quality or outcomes. Released as raw data that include services sorted by providers and procedure codes and include charges and reimbursement, the data have as much chance of being misinterpreted as being useful. Providers may soon find themselves spending already scarce resources produced by CMS’s relentless reductions in reimbursements defending themselves against unfair and inaccurate accusations because of misinterpretations of the data. Other potential risks of the data dump include damage to a health care provider’s reputation or public image if data are misused or misinterpreted. There are already examples of this in newspaper articles and blogs concerning the data. For instance, two pathologists are named as among the top 10 recipients of Medicare payments in 2012 when, in fact, they simply head large group practices and as a result they are identified as the claim submitter when that is not the case. While the data release creates more legal risks for providers, it also has many other uses that can be beneficial to both patients and providers. For example, patients can use the information to make better choices, at least as far as cost is a consideration, when choosing a provider. Access by the Public The data were published by CMS in the form of public use files or PUFs and include information on the kinds of services furnished by health care providers to Medicare beneficiaries. The files are provided in various formats, one of which is a series of Microsoft Excel spreadsheets that consumers are likely familiar with and can manipulate. The spreadsheets are embedded with a tool that allows the user to sort the data in several different ways so they can be viewed from different perspectives. For instance, the data can be sorted by Healthcare Common Procedure Coding System codes, Medicare’s code set for identifying services which includes, in part, the American Medical Association’s Current Procedural Terminology codes. This can be used to determine what kinds of physicians or suppliers file the most claims for a certain procedure and what each charges for that particular service. An outlier provider, a provider who files claims for a significantly higher number of a particular procedure than other similar providers, may receive extra scrutiny from both the government and patients. From the government perspective, that physician may be gouging the system or ordering the procedure unnecessarily, while from a patient perspective, a physician who has performed a procedure many times may indicate expertise. Limitations on the data that must be considered by the user in order to correctly interpret information in the data set include the fact that they represent only a part of the physician or supplier’s overall practice. Another issue to be considered is that health care providers serving Medicare beneficiaries face a myriad of regulations and claims submittal requirements that they do not face when filing claims to other payers. In some cases these requirements can alter the choice of which test or service is ordered or performed. Patients may not be aware of these factors and their influence on a physician’s decisions. Other ways the information can be used include public scrutiny of physician office practices when the services are provided by, and paid directly to, a physician when the tests or services are performed in their own office as opposed to one who refers for services. A laboratory can use the data to construct a fairly accurate picture of another competing lab’s patient fee schedule and what their volumes are, at least for Medicare beneficiaries. What Is Missing The data release does not include any information about the quality of services provided or information about patient outcomes related to the numbers and types of services provided. Without such information, it is nearly impossible to use the data to help choose one particular laboratory provider over another. However, as the government continues on its quest to make the health care system transparent, it becomes more and more possible that a diligent patient could assemble a more complete picture of a provider using data collected by one or more of the quality reporting requirements for physicians and hospitals. That will be more difficult when it comes to laboratories because as yet no such quality reporting requirements exist. Takeaway: The release of such a huge amount of data in a raw format like the recent release of data by CMS is more likely to create problems for laboratories and other health care providers then to create opportunities, at least in the short term.