2 more senators introduce bills to publish Medicare claims data

Washington -- Two additional senators have proposed separate bills to open Medicare claims data to the public, a move that doctors organizations have opposed on privacy and anti-fraud grounds.

Sens. Dick Durbin (D, Ill.) and John Cornyn (R, Texas) introduced their versions of Medicare transparency bills on April 14. Sens. Charles Grassley (R, Iowa) and Ron Wyden (D, Ore.) introduced a joint transparency bill earlier in the month. Even though the three bills are different, all would accomplish the same goal of opening billions of claims filed by health professionals every year to public scrutiny.

"While the federal government has stepped up fraud detection and enforcement, allowing nongovernmental groups access to data can also play a role in detecting fraud," Durbin said. "My legislation would bring transparency to the Medicare program by providing basic information about how taxpayer dollars are being spent in order to shine a light on any abuse within the system."

The Durbin bill, the Medicare Spending Transparency Act of 2011, would publish summary-level claims data on individual physicians and other health professionals annually. Information would include the amount paid, number of unique patients seen, total number of patient visits, and a list of the top 50 diagnosis and service procedure codes claimed.

Qualified individuals and groups would gain full access to Medicare's billing data. These groups would need to show that they have the technical ability to analyze the data and that they would use it productively, the Durbin bill states. Also, qualified entities would need to demonstrate knowledge and expertise in medicine, statistics, health care billing and health care fraud detection.

Cornyn's Consumer Information Enhancement Act of 2011 calls for Medicare claims data, starting with the 2005 billing year, to be made available within six months of the legislation's passage. The Dept. of Health and Human Services would be required to contract with three consumer information organizations to store data and release reports on Medicare billing.

The American Medical Association, as well as other members of organized medicine, have opposed releasing raw physician claims data to the public. Such a release violates a doctor's privacy and further places physicians at risk of identity theft, said AMA President Cecil B. Wilson, MD. Access to the claims databases should be restricted to federal agencies and law enforcement entities, he said.

"The Dept. of Justice, HHS Office of Inspector General and others have access to the data they need to aggressively find and prosecute this fraud," Dr. Wilson said. "The AMA opposes any public release of these numbers because of the danger for increased fraud."

Keeping context in mind

In general, transparency in how the government spends money is healthy, said Louis Saccoccio, executive director of the National Health Care Anti-Fraud Assn. based in Washington, D.C. That includes disclosure of the amount physicians receive from the Medicare program, he said.

However, Saccoccio warned against releasing physician billing information without proper context. The public could misinterpret data if they are not framed properly.

For instance, the public might believe a physician or group practice receiving $600,000 in Medicare payments is taking in a lot of money, he said. However, office space, staffing and other practice expenses need to be considered.

"There would have to be context around it," Saccoccio said. "There are bills he has to pay to run his business and his practice."

Saccoccio's organization would not examine Medicare data, but he anticipates that other groups, including the media, would mine the data for fraud. For example, The Wall Street Journal has used a negotiated limited access to Medicare data to write about questionable billing practices and potentially fraudulent activity by doctors and others. Local newspapers and media organizations could follow the newspaper's lead by researching Medicare billing in their areas, Saccoccio said.

"It would add a certain level of deterrence" to those who might commit Medicare fraud, he said. "The data would not be sitting in a repository."