[Federal Register: April 5, 2004 (Volume 69, Number 65)]
[Notices]
[Page 17679-17680]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr05ap04-76]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
Privacy Act of 1974; Computer Matching Program (Match No. 2003-
04)
AGENCY: Department of Health and Human Services (HHS), Centers for
Medicare & Medicaid Services (CMS).
ACTION: Notice of Computer Matching Program (CMP).
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SUMMARY: In accordance with the requirements of the Privacy Act of
1974, as amended, this notice announces the establishment of a CMP that
CMS plans to conduct with the Pennsylvania Department of Public Welfare
(DPW). We have provided background information about the proposed
Matching Program in the SUPPLEMENTARY INFORMATION section below.
Although the Privacy Act requires only that CMS provide an opportunity
for interested persons to comment on the proposed Matching Program, CMS
invites comments on all portions of this notice. See EFFECTIVE DATES
section below for comment period.
EFFECTIVE DATES: CMS filed a report of the CMP with the Chair of the
House Committee on Government Reform and Oversight, the Chair of the
Senate Committee on Governmental Affairs, and the Administrator, Office
of Information and Regulatory Affairs, Office of Management and Budget
(OMB) on March 23, 2004. We will not disclose any information under a
Matching Agreement until 40 days after filing a report to OMB and
Congress or 30 days after publication. We may defer implementation of
this Matching Program if we receive comments that persuade us to defer
implementation.
ADDRESSES: The public should address comments to: Director, Division of
Privacy Compliance Data Development (DPCDD), Enterprise Databases
Group, Office of Information Services, CMS, Mailstop N2-04-27, 7500
Security Boulevard, Baltimore, Maryland 21244-1850. Comments received
will be available for review at this location, by appointment, during
regular business hours, Monday through Friday from 9 a.m.-3 p.m.,
eastern daylight time.
FOR FURTHER INFORMATION CONTACT: Phillip Kauzlarich, Health Insurance
Specialist, Centers for Medicare & Medicaid Services, Office of
Financial Management, Program Integrity Group, Mail-stop C3-02-16, 7500
Security Boulevard, Baltimore Maryland 21244-1850. The telephone number
is (410) 786-7170 and e-mail is pkauzlarich@cms.hhs.gov.
SUPPLEMENTARY INFORMATION:
I. Description of the Matching Program
A. General
The Computer Matching and Privacy Protection Act of 1988 (Pub. L.
100-503), amended the Privacy Act (5 U.S.C. 552a) by describing the
manner in which computer matching involving Federal agencies could be
performed and adding certain protections for individuals applying for
and receiving Federal benefits. Section 7201 of the Omnibus Budget
Reconciliation Act of 1990 (Pub. L. 100-508) further amended the
Privacy Act regarding protections for such individuals. The Privacy
Act, as amended, regulates the use of computer matching by Federal
agencies when records in a system of records are matched with other
Federal, state, or local government records. It requires Federal
agencies involved in computer matching programs to:
1. Negotiate written agreements with the other agencies
participating in the matching programs;
2. Obtain the Data Integrity Board approval of the match
agreements;
3. Furnish detailed reports about matching programs to Congress and
OMB;
4. Notify applicants and beneficiaries that the records are subject
to matching; and,
5. Verify match findings before reducing, suspending, terminating,
or denying an individual's benefits or payments.
B. CMS Computer Matches Subject to the Privacy Act
CMS has taken action to ensure that all CMPs that this Agency
participates in comply with the requirements of the Privacy Act of
1974, as amended.
Dated: March 23, 2004.
Dennis Smith,
Acting Administrator, Centers for Medicare & Medicaid Services.
Computer Match No. 2003-04
NAME:
``Computer Matching Agreement Between the Centers for Medicare &
Medicaid Services (CMS) and the Commonwealth of Pennsylvania,
Department of Public Welfare (DPW) for Disclosure of Medicare and
Medicaid Information.''
SECURITY CLASSIFICATION:
Level Three Privacy Act Sensitive
PARTICIPATING AGENCIES:
The Centers for Medicare & Medicaid Services, and Commonwealth of
Pennsylvania, Department of Public Welfare
AUTHORITY FOR CONDUCTING MATCHING PROGRAM:
This CMA is executed to comply with the Privacy Act of 1974 5
U.S.C. 552a, (as amended by Pub. L. 100-503, the Computer Matching and
Privacy Protection Act (CMPPA) of 1988), the Office of Management and
Budget (OMB) Circular A-130, titled ``Management of Federal Information
Resources'' at 65 FR 77677 (December 12, 2000), and OMB guidelines
pertaining to computer matching at 54 FR 25818 (June 19, 1989).
This Agreement provides for information matching fully consistent
with the authority of the Secretary of the Department of Health and
Human Services (Secretary). Section 1816 of the Social Security Act
(the Act) permits the Secretary to contract with fiscal intermediaries
``to make such audits of the records of providers as may be necessary
to insure that proper payments are made under this part,'' and ``to
perform such other functions as are necessary to carry out this
subsection.'' (42 U.S.C. 1395h(a)).
Section 1842 of the Act provides that the Secretary may contract
with entities known as carriers to ``make such audits of the records of
providers of services as may be necessary to assure that proper
payments are made'' (42 U.S.C. 1395u(a)(1)(C)); ``assist in the
application of safeguards against unnecessary utilization of services
furnished by providers of services and other persons to individuals
entitled to benefits'' (42 U.S.C. 1395u(a)(2)(B)); and ``otherwise
assist * * * in discharging administrative duties necessary to carry
out the purposes of this part'' (42 U.S.C. 1395u(a)(4)).
[[Page 17680]]
Furthermore, section 1874(b) of the Act authorizes the Secretary to
``contract with any person, agency, or institution to secure on a
reimbursable basis such special data, actuarial information, and other
information as may be necessary in the carrying out of his functions''
under this title (42 U.S.C. 1395kk(b)).
Section 1893 of the Act establishes the Medicare Integrity Program,
under which the Secretary may contract with eligible entities to
conduct a variety of program safeguard activities, including fraud
review employing equipment and software technologies that surpass the
existing capabilities of Fiscal Intermediaries and carriers (42 U.S.C.
1395ddd). The contracting entities are called Program Safeguards
Contractors (PSC).
DPW is charged with the administration of the Medicaid program in
Pennsylvania and is the single state agency for such purpose. 62
Purdon's Statutes (P.S.) Sec. 201(1); 55 Pennsylvania (Pa.) Code Sec.
101.1(e). In Pennsylvania, DPW provides qualifying individuals with
health care and related remedial or preventive services, including both
Medicaid services and services authorized under state law that are not
provided under Federal law. The program to provide all such services is
known as the Medical Assistance (MA) Program.
DPW's disclosure of the MA Program data pursuant to this Agreement
is for purposes directly connected with the administration of the MA
Program, in compliance with 62 P.S. Sec. 404, 55 Pa. Code Sec. Sec.
105.1 et seq., 42 U.S.C. 1396a(a)(7), 42 CFR 431.300 et seq., and 45
CFR 205.50-205.60. Those purposes include the investigation,
prosecution or criminal or civil proceeding conducted in connection
with the administration of the MA Program. (55 Pa. Code Sec.
105.3(b)(2)).
PURPOSE(S) OF THE MATCHING PROGRAM:
The purpose of this Agreement is to establish the conditions,
safeguards, and procedures under which the Centers for Medicare &
Medicaid Services (CMS) will conduct a computer matching program with
the Commonwealth of Pennsylvania, Department of Public Welfare (DPW),
to study claims, billing, and eligibility information to detect
suspected instances of Medicare and Medicaid fraud and abuse (F&A) in
the Commonwealth of Pennsylvania. CMS and DPW will provide Electronic
Data Systems (EDS), a CMS contractor (hereinafter referred to as the
``Custodian''), with Medicare and Medicaid records pertaining to
eligibility, claims, and billing which the Custodian will match in
order to merge the information into a single database. Utilizing fraud
detection software, the information will then be used to identify
patterns of aberrant practices requiring further investigation. The
following are examples of the type of aberrant practices that may
constitute F&A by practitioners, providers, and suppliers in the
Commonwealth of Pennsylvania expected to be identified in this matching
program: (1) Billing for provision of more than 24 hours of services in
one day; (2) providing treatment and services in ways more
statistically significant than similar practitioner groups; and (3) up-
coding and billing for services more expensive than those actually
performed.
CATEGORIES OF RECORDS AND INDIVIDUALS COVERED BY THE MATCH:
This CMP will enhance the ability of CMS and DPW to detect F&A by
matching claims data, eligibility, and practitioner, provider, and
supplier enrollment records of Medicare beneficiaries, practitioners,
providers, and suppliers in the Commonwealth of Pennsylvania against
records of Pennsylvania Medicaid beneficiaries, practitioners,
providers, and suppliers in the Commonwealth of Pennsylvania.
Description of RecordS TO BE USED IN THE MATCHING PROGRAM:
The data for DPW are maintained in the following data files:
The data the Pennsylvania Fraud and Abuse Detection System (FADS)
receives consists of a number of data tables that contain the different
data element requirements for the operation of the system. These tables
are grouped into ``universes'' of data. In Phase I the FADS universes
are: Claims Analysis, Provider, Recipient, Reference, and Code Tables.
In Phase II they are: Claims Analysis, Provider, Recipient, Reference,
Financial, and Managed Care.
INCLUSIVE DATES OF THE MATCH:
The CMP shall become effective no sooner than 40 days after the
report of the Matching Program is sent to OMB and Congress, or 30 days
after publication in the Federal Register, whichever is later. The
matching program will continue for 18 months from the effective date
and may be extended for an additional 12 months thereafter, if certain
conditions are met.
[FR Doc. 04-7633 Filed 4-2-04; 8:45 am]
BILLING CODE 4120-03-P