Centers for Medicare & Medicaid Services (CMS), HHS recently issued final rules pursuant to the Patient Protection and Affordable Care Act, (Pub. L. 111-148), enacted on March 23, 2010, and the Health Care and Education Reconciliation Act of 2010, (Pub. L. 111-152), enacted on March 30, 2010 (collectively the “Affordable Care Act.”) Effective January 1, 2012, the Affordable Care Act would amend the Social Security Act (the “Act”) to require standardized extracts of Medicare claims data under parts A, B, and D to be made available to “qualified entities” for the evaluation of the performance of providers and suppliers. Qualified entities may use the information obtained the Act for the purpose of evaluating the performance of providers and suppliers, and to generate public reports regarding such performance (the “Performance Reports”). Qualified entities may receive data for one or more specified geographic areas. Congress also required that qualified entities combine claims data from sources other than Medicare with the Medicare data when evaluating the performance of providers and suppliers.
A. What will be published in the Performance Reports?
Performance Reports generated by the qualified entities may only include information on individual providers and suppliers in aggregate form, that is, at the provider or supplier level, and may not be released to the public until the providers and suppliers have had an opportunity to review them and, if necessary, ask for corrections.
B. How can the qualified entity use of the Medicare Claims Data?
The statute bars the re-use of the Medicare claims data provided to qualified entities under the Act. The qualified entity “shall only use such data, and information derived from such evaluation” for Performance Reports on providers and suppliers. Additionally, the Data Use Agreement between the qualified entity and CMS (the “DUA”), bars re-use of the data for other purposes. The Act does not address the use of the published Performance Report. Subject to any limitations imposed by other applicable laws, the Performance Reports could be used by any party, including the qualified entity, for activities such as internal analyses, pay-for-performance initiatives, or provider tiering.
C. What can Physicians do to correct issues with Performance Reports?
The Act requires the Performance Reports to be made available to the public after they are made available to providers and suppliers for review and requests for corrections. Each provider or supplier will confidentially receive any Performance Report where they are identified. It is the responsibility of the qualified entity to ensure that the data is delivered using a secure method to the appropriate provider or supplier.
D. How long do physicians have to review and provide comments before the Performance Report is published?
CMS requires that qualified entities publicly report measure results on the date specified to the provider or supplier when the report is sent for review (at least 60 days after the date on which the confidential reports are sent to a provider or supplier), regardless of the status of a request for error correction.
E. How many Performance Reports will Physicians have to deal with?
CMS does not intend to limit the number of qualified entities accepted for participation into the program, and therefore, it is possible that there will be more than one qualified entity working in the same geographic area and publish Performance Reports for that geographic area.
F. How much will it cost a Physician to review a Performance Report and provide comments?
Physicians who receive the Performance Reports have no obligation to review them. CMS assumes that those who do review the Performance Reports would devote and average of five hours to reviewing them at an average cost of $214.00 for physician offices. For those who appeal CMS assumes that preparing the appeal would involve an average of ten hours of effort on the part of a physician at an average cost of $429 for physician offices. The latter amount includes CMS’ assumption that 50 percent of the providers and suppliers who decide to appeal would hire consultants to assist with the appeals process.
G. Will the Performance Reports be published in standard formats?
CMS does not intend to standardize the Performance Reports, so each qualified entity will be able to publish Performance Reports in different formats.
H. Must the Performance Reports be published? How frequently will the reports be published?
Qualified entities are not allowed to produce Performance Reports for confidential use only, thus the reports must be published. There is no requirement in the Act on the frequency of public reporting, so CMS adopted a rule of once per year. Reporting once per year is the minimum requirement. A qualified entity may choose to report more frequently than once per year, as long as it is still able to meet the requirement of allowing providers and suppliers the opportunity to review and request error correction in the Performance Reports.
I. How fresh will be the Medicare claims data that CMS provides?
CMS will provide qualified entities with the most recent available historical data, which, for qualified entities approved at the beginning of the program, CMS expects to include data for CY2009, CY2010, and the first two quarters of 2011. Then, CMS would provide quarterly data updates on a rolling basis.
J. Will the qualified entity have all of the claims for a physician?
CMS will release claims based on the location of the beneficiary residence, not the location of the provider or supplier rendering the services. This will mean the qualified entity might not receive all of the Medicare claims for a given provider or supplier.
This is the the link to the release of the final rule by CMS: http://www.ofr.gov/OFRUpload/OFRData/2011-31232_PI.pdf