Third Annual Release of Medicare Payment Data Furthers Transparency Regarding Lab Payments

Once again, coinciding with U.S. Health and Human Services’ annual Health Datapalooza conference (see page 3), the Centers for Medicare & Medicaid Services (CMS) has released an updated public dataset regarding Medicare payments: the Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File (Physician and Other Supplier PUF). The release furthers the goal of transparency by making public the Medicare charges from and payments to physicians, labs and other providers. According to CMS’ press release regarding the dataset: “The release of timely, privacy-protected data is especially important as the Medicare increasingly pays providers based on the quality, rather than the quantity, of care they give patients. These initiatives contribute to a wide set of CMS activities focused on achieving better care, smarter spending, and healthier people throughout the health care system.”

What’s new this year
CMS said it has updated the dataset and its supplemental summary tables including “Medicare Physician and Other Supplier Aggregate Table” (i.e., one record per NPI) and the “Medicare State/National HCPCS Aggregate Tables.” to include standardized payment data so users can compare Medicare payment amounts across geographic areas. “Standardization removes geographic differences in payment rates for individual services, such as those that account for local wages or input prices and makes Medicare payments across geographic areas comparable.”

Additionally, now researchers don’t have to wait for annual extracts under Limited Data Sets (LDS) but can instead request updates to LDS claims files on a quarterly basis.

Details about the data
CMS reports the dataset includes more than 986,000 health care providers who “collectively received $91 billion in Medicare payments.” CMS’ website explains: “The Physician and Other Supplier PUF contains information on utilization, payment (allowed amount and Medicare payment), and submitted charges organized by National Provider Identifier (NPI), Healthcare Common Procedure Coding System (HCPCS) code, and place of service. This PUF is based on information from CMS administrative claims data for Medicare beneficiaries enrolled in the fee-forservice program. The data in the Physician and Other Supplier PUF covers calendar years 2012 through 2014 and contains 100% final-action physician/supplier Part B non-institutional line items for the Medicare fee-for-service population.”

Categories of information (columns in the database spreadsheet) include National Provider Identifier, provider name, provider credentials, entity type/gender of provider, provider address, provider type (i.e., Clinical laboratory), place of service, HCPCS code and description, number of services provided (the metrics counting the number of services varies by service), number of Medicare beneficiaries receiving the service, number of beneficiaries per day of service (this category removes double counting of beneficiaries receiving multiple services), average Medicare allowable amount, average submitted charge, average Medicare payment amount, average Medicare standardized amount.

Medicare defines the following terms used in the dataset as follows:

• Average Medicare Allowed Amount is the amount Medicare pays plus the deductible, coinsurance and any third party responsibility.
• Average Medicare Payment is the amount Medicare pays after that coinsurance and deductible are subtracted.
• Average Medicare Standardized Amount is the average amount Medicare paid after beneficiary deductible and coinsurance amounts are deducted and after the standardization of Medicare payment (i.e., removal of geographic differences in payment as discussed above) is applied.

How to Use Data
CMS has provided search functions, filters and tools to help users make sense of the vast amount of information available in the dataset. For example, users can search the data by entering a provider number, specific provider name or by searching for entity names containing a specific word. Data can also be organized using filters to search a specific type of provider in a specific state for a specific HCPCS code. Filters also allow users to compare providers to each other. Visual graphics tools improve understanding by offering a variety of ways to visually display search results. For example, once filters are applied to gather a specific set of information, that data can be visually displayed for easy comparison with bar graphs, line graphs, pie charts, bubbles and tree maps.

Privacy concerns dismissed
This dataset has been released despite concerns about privacy. No beneficiary identifying information is provided. Additionally, to prevent indirect exposure of Medicare beneficiaries, CMS indicates that any aggregated records from 10 or fewer beneficiaries are excluded from the Physician and Other Supplier PUF. HHS specifically addressed privacy concerns in a 2014 letter to the American Medical Association (AMA) explaining “the Department weighed the privacy interests of physicians and the public’s interest in shedding light on Government activities and operations and has determined that the public’s interest outweighs the privacy interests. The Department concluded that the data to be released would assist the public’s understanding of Medicare fraud, waste, and abuse, as well as shed light on payments to physicians for services furnished to Medicare beneficiaries, which are governed by statutory requirements that CMS must follow.” HHS cited the Wall Street Journal’s ability to use Medicare payment data to identify fraud as evidence of the public interest in the information. Therefore, it concluded “release of physician- identifiable payment information will serve a significant public interest by increasing transparency of Medicare payments to physicians, which are governed by statutory requirements, and shed light on Medicare fraud, waste, and abuse.”

Additionally, because the dataset informs the public about Medicare payments, types of services paid for under Medicare, and Medicare payments to specific providers, HHS argued it fostered “a more informed debate about the appropriate Medicare payment for particular services.” Finally, HHS stated publishing the data is in keeping with a shift under the Affordable Care Act toward greater transparency, coordination of care, and sharing of information to increase efficiency, quality, and value of care while lowering costs. HHS cited the various programs measuring quality of care and providing tools to help the public compare providers, as well as some state laws that require providers publicly reveal charges and payment information as evidence of the “changing nature” of what is publicly shared about physician services and payment. All this transparency means, HHS concluded, that “the physicians’ privacy interest in payment data is not the same as it was over 30 years ago or even 5 years ago.”

Dataset promotes fraud reporting
CMS’ questions and answers about the Physician and Other Supplier PUF encourage reporting any suspected fraud found in the data. In answer to the question “What do I do if I think I’ve identified fraud in the Physician and Other Supplier PUF?” CMS answers: “CMS is committed to the prevention and detection of fraud and abuse in the Medicare program and partners with numerous entities in this endeavor, including federal and state law enforcement agencies, the HHS Office of Inspector General, and the U.S. Department of Justice, among others. If you suspect a potential case of Medicare fraud or abuse, please visit http://stopmedicarefraud.gov for information on how to report it.” Further evidence that HHS fully encourages users to ferret out fraud using this public dataset is found in the HHS letter to the AMA cited above which emphasizes the ability of such data to reveal fraud as evidence that the public interest in this information outweighs individual physician/provider privacy interests.

Takeaway: CMS continues to promote transparency by setting an example and releasing a public accessible dataset revealing Medicare charges and payments to labs and other providers.