CMS Proposed Rule Would Allow Access to Medicare Data for Reports on Providers

The Centers for Medicare and Medicaid Services (CMS) today released a proposed rule regarding the release and use of Medicare claims data to measure and produce public reports on physicians, hospitals, and other health care providers. CMS explains that these reports will combine private sector claims data with Medicare claims data to identify which hospitals and doctors provide the highest quality, cost-effective care.

The rule allows qualified entities to receive standardized extracts of claims data under Medicare Parts A, B, and D. A qualified entity is defined as a public or private entity that: (1) is qualified, as determined by HHS, to use claims data to evaluate the performance of providers of services and suppliers on measures of quality, efficiency, effectiveness, and resource use; and (2) agrees to meet the requirements of certain eligibility requirements detailed in the proposed rule.

Under the proposed rule, CMS will evaluate an organization’s qualifications across three areas:

1. Organizational and governance capabilities
2. Addition of claims data from other sources
3. Data privacy and security

Organizations will be evaluated individually, and the number of qualified entities would not be limited. Any entity that meets the eligibility criteria would be able to become a qualified entity. CMS suggests that a successful applicant should have an established track record of profiling providers of services and suppliers as well as demonstrated expertise in handling claims data and calculating performance measures for a period of at least three years. In addition, a successful applicant must have thoroughly documented data privacy and security practices, including enforcement mechanisms.

Applicants should submit the following information as part of their application for qualified entity status:

1. The measures the applicant intends to use, including the methods of creating and disseminating reports;
2. The report review process the applicant would use to afford providers of services and suppliers with reports confidentially prior to public release, including addressing requests for data and error correction; and
3. A prototype for the required reports, including any narrative language, and dissemination plans for providing reports to the public.

The proposed rule is scheduled for publication in the Federal Register on June 8^th. CMS seeks public comment on this proposed rule.