[Federal Register: July 25, 2005 (Volume 70, Number 141)]
[Notices]
[Page 42558-42560]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr25jy05-49]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
Privacy Act of 1974; Computer Match No. 2005-02
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 establishes a CMP that CMS plans to
conduct with the Ohio Department of Jobs & Family Services (ODJFS). We
have provided background information about the proposed matching
program in the SUPPLEMENTARY INFORMATION section below. The Privacy Act
requires that CMS provide an opportunity for interested persons to
comment on the proposed matching program. We may defer implementation
of this matching program if we receive comments that persuade us to
defer implementation. See DATES section below for comment period.
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 July 14, 2005. 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.
ADDRESSES: The public should address comments to: CMS Privacy Officer,
Division of Privacy Compliance Data Development (DPCDD), Enterprise
Databases Group, Office of Information Services, CMS, Mail-stop 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: Linda Guenin, Government Task Leader,
Centers for Medicare & Medicaid Services, Division of Medicare
Financial Management, Program Integrity Branch, 233 N. Michigan Avenue,
6th Floor, Chicago, Illinois 60601. The telephone number is (312) 353-
1279 and e-mail is Linda.Guenin@cms.hhs.gov.
SUPPLEMENTARY INFORMATION: Description of the Matching Program
A. General
The Computer Matching and Privacy Protection Act of 1988 (Public
Law (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. 101-508)
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.
[[Page 42559]]
Dated: July 12, 2005.
John R. Dyer,
Chief Operating Officer, Centers for Medicare & Medicaid Services.
Computer Match No. 2005-02
Name
``Computer Matching Agreement (CMA) Between the Centers for
Medicare & Medicaid Services (CMS) and the State of Ohio Department of
Job & Family Services (ODJFS) for Disclosure of Medicare and Medicaid
Information''.
Security Classification
Level Three Privacy Act Sensitive.
Participating Agencies
The Centers for Medicare & Medicaid Services, and State of Ohio
Department of Job & Family Services.
Authority for Conducting Matching Program
This CMA is executed to comply with the Privacy Act of 1974 (Title
5 United States Code (U.S.C.) 552a), as amended, (as amended by Public
Law (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
Federal Register (FR) 77677 (December 12, 2000), 61 FR 6435 (February
20, 1996), 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
(FI) 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 ``to otherwise
assist * * * in discharging administrative duties necessary to carry
out the purposes of this part'' (42 U.S.C. 1395u(a)(4)).
Furthermore, Sec. 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 FIs and Carriers (42 U.S.C. Sec. 1395ddd)).
The contracting entities are called Program Safeguards Contractors.
Authority for ODJFS to participate in this computer-matching
program is given under the provisions of Sec. Sec. 5101.27-30 of the
Ohio Revised Code, and 42 CFR 431.300 through 431.307. ODJFS is charged
with administration of the Medicaid program in Ohio and is the single
state agency for such purpose. ODJFS may act as an agent or
representative of the Federal Government for any purpose in furtherance
of ODJFS's functions or administration of the Federal funds granted to
the state. In Ohio, the Medicaid program 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.
Purpose(s) of the Matching Program
The purpose of this agreement is to establish the conditions,
safeguards, and procedures under which CMS will conduct a computer
matching program with ODJFS to study claims, billing, and eligibility
information to detect suspected instances of fraud and abuse (F&A) in
the State of Ohio. CMS and ODJFS will provide 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 State of Ohio expected to be identified in this
matching program: (1) Billing for provisions 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 ODJFS 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 State of Ohio against records of
Medicaid beneficiaries, practitioners, providers, and suppliers in the
State of Ohio.
Description of Records To Be Used in the Matching Program
The data for CMS are maintained in the following Systems of Records
(SOR): National Claims History (NCH), System No. 09-70-0005 was most
recently published in the Federal Register, at 67 FR 57015 (September
6, 2002). NCH contains records needed to facilitate obtaining Medicare
utilization review data that can be used to study the operation and
effectiveness of the Medicare program. Matched data will be released to
ODJFS pursuant to the routine use as set forth in the system notice.
Carrier Medicare Claims Record, System No. 09-70-0501 was published
in the Federal Register at 67 FR 54428 (August 22, 2002). Matched data
will be released to ODJFS pursuant to the routine use as set forth in
the system notice.
Enrollment Database, System No. 09-70-0502 was published in the
Federal Register at 67 FR 3203 (January 23, 2002). Matched data will be
released to ODJFS pursuant to the routine use set forth in the system
notice.
Intermediary Medicare Claims Record, System No. 09-70-0503 was
published in the Federal Register at 67 FR 65982 (October 29, 2002).
Matched data will be released to ODJFS pursuant to the routine use as
set forth in the system notice.
Unique Physician/Provider Identification Number, System No. 09-70-
0525, was most recently published in the Federal Register at 69 FR
75316 (December 16, 2004). Matched data will be released to ODJFS
pursuant to the routine use as set forth in the system notice.
Medicare Supplier Identification File, System No. 09-70-0530 was
most recently published in the Federal Register, at 67 FR 48184 (July
23, 2002). Matched data will be released to ODJFS
[[Page 42560]]
pursuant to the routine use as set forth in the system notice.
Medicare Beneficiary Database, System No. 09-70-0536 was published
in the Federal Register at 66 FR 63392 (December 6, 2001). Matched data
will be released to ODJFS pursuant to the routine use as set forth in
the system notice.
The data for ODJFS are/is maintained in the following Medical Data
Warehouse Files:
DRUGOUT.txt DRUG pre-convert layout
EDRUGOUT.txt Encounter Drug extract layout (no pre-convert)
EFACOUT.txt Encounter Facility extract layouts (no pre-convert and
there are 4 extract files)
ELIGOUT.txt Eligibility pre-convert layout
EPROFOUT.txt Encounter Prof. extract layout (no pre-convert)
FACOUT.txt Facility pre-convert layout
GROSSOUT.txt Gross financial extract (no pre-convert)
PROFOUT.txt Professional pre-convert layout
PROVOUT.txt Provider pre-convert layout.
ODJFS may change files maintained in the Medical Data Warehouse
after giving reasonable notice to CMS and the Custodian.
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, which ever 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. 05-14562 Filed 7-22-05; 8:45 am]
BILLING CODE 4120-03-P