[Federal Register: December 10, 2007 (Volume 72, Number 236)]
[Notices]
[Page 69691-69696]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr10de07-82]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
Privacy Act of 1974; Report of a Modified or Altered System
AGENCY: Department of Health and Human Services (HHS), Centers for
Medicare & Medicaid Services (CMS).
ACTION: Notice of a Modified or Altered System of Records (SOR).
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SUMMARY: In accordance with the requirements of the Privacy Act of
1974, we are proposing to modify or alter an existing SOR, ``Intern and
Resident Information System (IRIS), System No. 09-70-0524, last
published at 67 Federal Register 48189 (July 23, 2002). We propose to
modify existing routine use number 1 that permits disclosure to agency
contractors and consultants to include disclosure to CMS grantees who
[[Page 69692]]
perform a task for the agency. CMS grantees, charged with completing
projects or activities that require CMS data to carry out that
activity, are classified separate from CMS contractors and/or
consultants. The modified routine use will remain as routine use number
1. We will delete routine use number 5 authorizing disclosure to
support constituent requests made to a congressional representative. If
an authorization for the disclosure has been obtained from the data
subject, then no routine use is needed. The Privacy Act allows for
disclosures with the ``prior written consent'' of the data subject. We
will broaden the scope of published routine uses number 7 and 8,
authorizing disclosures to combat fraud and abuse in the Medicare and
Medicaid programs to include combating ``waste'' which refers
increasingly more to specific beneficiary or recipient practices that
result in unnecessary cost to Federally-funded health benefit programs.
We will delete the section titled ``Additional Circumstances
Affecting Routine Use Disclosures,'' that addresses ``Protected Health
Information (PHI)'' and ``small cell size.'' The requirement for
compliance with HHS regulation ``Standards for Privacy of Individually
Identifiable Health Information'' does not apply because this system
does not collect or maintain PHI. In addition, our policy to prohibit
release if there is a possibility that an individual can be identified
through ``small cell size'' is not applicable to the data maintained in
this system.
We are modifying the language in the remaining routine uses to
provide a proper explanation as to the need for the routine use and to
provide clarity to CMS' intention to disclose individual-specific
information contained in this system. The routine uses will then be
prioritized and reordered according to their usage. We will also take
the opportunity to update any sections of the system that were affected
by the recent reorganization or by Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 (Pub. L. 108-173) provisions
and to update language in the administrative sections to correspond
with language used in other CMS SORs.
The primary purpose of the SOR is to ensure that no interns and
residents (IRs) are counted by the Medicare program as more than one
full-time equivalent (FTE) employee in the calculation of payments for
the costs of direct graduate medical education (GME) and indirect
medical education (IME). Information retrieved from this SOR will also
be disclosed to: (1) Support regulatory, reimbursement, and policy
functions performed within the Agency or by a contractor or consultant,
(2) assist another Federal and/or state agency, agency of a state
government, an agency established by state law, or its fiscal agent,
(3) support providers and suppliers of services, (4) assist third-party
contacts where necessary to establish or verify information, (5)
support litigation involving the Agency, and (6) combat fraud, waste,
and abuse in certain health benefits programs. We have provided
background information about the modified system in the ``Supplementary
Information'' section below. Although the Privacy Act requires only
that CMS provide an opportunity for interested persons to comment on
the routine uses, CMS invites comments on all portions of this notice.
See ``Effective Dates'' section for comment period.
DATES: Effective Dates: CMS filed a modified or altered system report
with the Chair of the House Committee on Government Reform and
Oversight, the Chair of the Senate Committee on Homeland Security and
Governmental Affairs, and the Administrator, Office of Information and
Regulatory Affairs, Office of Management and Budget (OMB) on December
4, 2007. To ensure that all parties have adequate time in which to
comment, the modified system, including routine uses, will become
effective 30 days from the publication of the notice, or 40 days from
the date it was submitted to OMB and Congress, whichever is later,
unless CMS receives comments that require alterations to this notice.
ADDRESSES: The public should address comments to: CMS Privacy Officer,
Division of Privacy Compliance, Enterprise Architecture and Strategy
Group, Office of Information Services, CMS, Room 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 Time Zone.
FOR FURTHER INFORMATION CONTACT: Milton Jacobson, Division of Provider
Audit Operations, Financial Services Group, Office of Financial
Management, CMS, Room C3-14-00, 7500 Security Boulevard, Baltimore,
Maryland 21244-1850. Mr. Jacobson can be reached by telephone at 410-
786-7553 or via e-mail at Milton.Jacobson@cms.hhs.gov.
SUPPLEMENTARY INFORMATION:
I. Description of the Modified or Altered System of Records
A. Statutory and Regulatory Basis for System
Authority for maintenance of the system is given under the
provisions of Sec. Sec. 1886(d)(5)(B) and 1886(h) of the Social
Security Act (Title 42 United States Code (U.S.C.) 1395ww(d)(5)(B) and
1395ww(h)).
B. Collection and Maintenance of Data in the System
The system collects and maintains information interns and residents
in programs approved under 42 CFR 413.75, working in all areas of the
hospital complex, or other freestanding providers, as well as non-
hospital or non-provider settings on or after July 1, 1985. The system
includes the following information for each IR: name, social security
number; name of medical, osteopathic, dental, or podiatric school
graduated from and date of graduation, type of residency program for
the medical specialty, number of years completed in all types of
residency programs, foreign medical school graduation date and
certification date, name of employer (e.g., hospital, university,
corporation) paying the salary, the percentage of time spent working in
either the inpatient areas of the hospital subject to the Prospective
Payment System or in the outpatient areas of the hospital or in a non-
hospital setting under agreement with the hospital for IME, the
percentage of time spent working in any area of the hospital complex or
in a non-provider setting under agreement with the hospital for GME,
the start and end dates assigned to the hospital and any hospital-based
providers (assignment periods) during the hospital's cost reporting
period, the start and end dates assigned to any non-hospital or non-
provider setting in connection with approved residency programs
(assignment periods) during the hospital's cost reporting period, and
the full-time or part-time percentage during each assignment period.
II. Agency Policies, Procedures, and Restrictions on the Routine Use
A. The Privacy Act permits us to disclose information without an
individual's consent if the information is to be used for a purpose
that is compatible with the purpose(s) for which the information was
collected. Any such disclosure of data is known as a ``routine use.''
The government will only release IRIS information that can be
associated with an individual as provided for under ``Section III.
[[Page 69693]]
Proposed Routine Use Disclosures of Data in the System.'' Both
identifiable and non-identifiable data may be disclosed under a routine
use.
We will only collect the minimum personal data necessary to achieve
the purpose of IRIS. CMS has the following policies and procedures
concerning disclosures of information that will be maintained in the
system. Disclosure of information from this system will be approved
only to the extent necessary to accomplish the purpose of the
disclosure and only after CMS:
1. Determines that the use or disclosure is consistent with the
reason that the data is being collected, e.g., to ensure that no
interns and residents (IR) are counted by the Medicare program as more
than one full-time equivalent (FTE) employee in the calculation of
payments for the costs of GME and IME.
2. Determines:
a. That the purpose for which the disclosure is to be made can only
be accomplished if the record is provided in individually identifiable
form;
b. That the purpose for which the disclosure is to be made is of
sufficient importance to warrant the potential effect and/or risk on
the privacy of the individual that additional exposure of the record
might bring; and
c. That there is a strong probability that the proposed use of the
data would in fact accomplish the stated purpose(s).
3. Requires the information recipient to:
a. Establish administrative, technical, and physical safeguards to
prevent unauthorized use of disclosure of the record; and
b. Remove or destroy at the earliest time all patient-identifiable
information.
4. Determines that the data are valid and reliable.
III. Proposed Routine Use Disclosures of Data in the System
A. Entities Who May Receive Disclosures Under Routine Use
These routine uses specify circumstances, in addition to those
provided by statute in the Privacy Act of 1974, under which CMS may
release information from the IRIS without the consent of the individual
to whom such information pertains. Each proposed disclosure of
information under these routine uses will be evaluated to ensure that
the disclosure is legally permissible, including but not limited to
ensuring that the purpose of the disclosure is compatible with the
purpose for which the information was collected. We are proposing to
establish or modify the following routine use disclosures of
information maintained in the system:
1. To support agency contractors, consultants, or grantees, who
have been engaged by the agency to assist in the performance of a
service related to this collection and who need to have access to the
records in order to perform the activity.
We contemplate disclosing information under this routine use only
in situations in which CMS may enter into a contractual or similar
agreement with a third party to assist in accomplishing CMS function
relating to purposes for this system.
CMS occasionally contracts out certain of its functions when doing
so would contribute to effective and efficient operations. CMS must be
able to give a contractor, consultant or grantee whatever information
is necessary for the contractor or consultant to fulfill its duties. In
these situations, safeguards are provided in the contract prohibiting
the contractor, consultant or grantee from using or disclosing the
information for any purpose other than that described in the contract
and requires the contractor, consultant or grantee to return or destroy
all information at the completion of the contract.
2. To another Federal or state agency, agency of a state
government, an agency established by state law, or its fiscal agent:
a. To contribute to the accuracy of CMS' proper payment of Medicare
benefits,
b. To enable such agency to administer a Federal health benefits
program, or as necessary to enable such agency to fulfill a requirement
of a Federal statute or regulation that implements a health benefits
program funded in whole or in part with federal funds.
Other Federal or state agencies in their administration of a
Federal health program may require IRIS information in order to support
evaluations and monitoring of reimbursement for services provided.
SSA may require IRIS data to enable it to assist in the
implementation and maintenance of the Medicare program.
State licensing boards may require IRIS data to enable them to
assist in the review of activities related to IRs in their state.
The Medicare Payment Advisory Commission and Congressional Budget
Office may require IRIS data to assist in certain budgetary and
planning activities related to IR status.
3. To providers and suppliers of services (and their authorized
billing agents) directly or dealing through fiscal intermediaries or
carriers, for administration of provisions of Title XVIII of the Social
Security Act.
We contemplate disclosing information under this routine use only
in situations in which CMS may enter into a contractual agreement with
providers and suppliers of services to assist in accomplishing CMS
functions relating to purposes for this SOR.
4. To third-party contacts where necessary to establish or verify
information provided on or by IR.
We contemplate disclosing information under this routine use only
in situations in which CMS may enter into a contractual or similar
agreement with a third party to assist in accomplishing CMS functions
relating to purposes for this system of records.
5. To the Department of Justice (DOJ), court or adjudicatory body
when:
a. The agency or any component thereof, or
b. Any employee of the agency in his or her official capacity, or
c. Any employee of the agency in his or her individual capacity
where the DOJ has agreed to represent the employee, or
d. The United States Government
Is a party to litigation or has an interest in such litigation, and by
careful review, CMS determines that the records are both relevant and
necessary to the litigation and that the use of such records by the
DOJ, court or adjudicatory body is compatible with the purpose for
which the agency collected the records.
Whenever CMS is involved in litigation, or occasionally when
another party is involved in litigation and CMS' policies or operations
could be affected by the outcome of the litigation, CMS would be able
to disclose information to the DOJ, court or adjudicatory body
involved.
6. To a CMS contractor (including, but not limited to FIs and
carriers) that assists in the administration of a CMS-administered
health benefits program, or to a grantee of a CMS-administered grant
program, when disclosure is deemed reasonably necessary by CMS to
prevent, deter, discover, detect, investigate, examine, prosecute, sue
with respect to, defend against, correct, remedy, or otherwise combat
fraud, waste, or abuse in such program.
We contemplate disclosing information under this routine use only
in situations in which CMS may enter into a contract or grant with a
third party to assist in accomplishing CMS functions relating to the
purpose of combating fraud, waste, and abuse.
CMS occasionally contracts out certain of its functions when doing
so
[[Page 69694]]
would contribute to effective and efficient operations. CMS must be
able to give a contractor or grantee whatever information is necessary
for the contractor or grantee to fulfill its duties. In these
situations, safeguards are provided in the contract prohibiting the
contractor or grantee from using or disclosing the information for any
purpose other than that described in the contract and requiring the
contractor or grantee to return or destroy all information.
7. To another Federal agency or to an instrumentality of any
governmental jurisdiction within or under the control of the United
States (including any state or local governmental agency), that
administers, or that has the authority to investigate potential fraud
or abuse in a health benefits program funded in whole or in part by
Federal funds, when disclosure is deemed reasonably necessary by CMS to
prevent, deter, discover, detect, investigate, examine, prosecute, sue
with respect to, defend against, correct, remedy, or otherwise combat
fraud, waste, or abuse in such programs.
Other agencies may require IRIS information for the purpose of
combating fraud, waste, and abuse in such Federally funded programs.
IV. Safeguards
CMS has safeguards in place for authorized users and monitors such
users to ensure against excessive or unauthorized use. Personnel having
access to the system have been trained in the Privacy Act and
information security requirements. Employees who maintain records in
this system are instructed not to release data until the intended
recipient agrees to implement appropriate management, operational and
technical safeguards sufficient to protect the confidentiality,
integrity and availability of the information and information systems
and to prevent unauthorized access.
This system will conform to all applicable Federal laws and
regulations and Federal, HHS, and CMS policies and standards as they
relate to information security and data privacy. These laws and
regulations may apply but are not limited to: the Privacy Act of 1974;
the Federal Information Security Management Act of 2002; the Computer
Fraud and Abuse Act of 1986; the Health Insurance Portability and
Accountability Act of 1996; the E-Government Act of 2002, the Clinger-
Cohen Act of 1996; the Medicare Modernization Act of 2003, and the
corresponding implementing regulations. OMB Circular A-130, Management
of Federal Resources, Appendix III, Security of Federal Automated
Information Resources also applies. Federal, HHS, and CMS policies and
standards include but are not limited to: all pertinent National
Institute of Standards and Technology publications; the HHS Information
Systems Program Handbook and the CMS Information Security Handbook.
V. Effects of the Modified or Altered System of Records on Individual
Rights
CMS proposes to modify this system in accordance with the
principles and requirements of the Privacy Act and will collect, use,
and disseminate information only as prescribed therein. Data in this
system will be subject to the authorized releases in accordance with
the routine uses identified in this system of records.
CMS will take precautionary measures to minimize the risks of
unauthorized access to the records and the potential harm to individual
privacy or other personal or property rights of patients whose data are
maintained in the system. CMS will collect only that information
necessary to perform the system's functions. In addition, CMS will make
disclosure from the proposed system only with consent of the subject
individual, or his/her legal representative, or in accordance with an
applicable exception provision of the Privacy Act. CMS, therefore, does
not anticipate an unfavorable effect on individual privacy as a result
of information relating to individuals.
Dated: November 28, 2007.
Charlene Frizzera,
Chief Operating Officer, Centers for Medicare & Medicaid Services.
SYSTEM NO. 09-70-0524
SYSTEM NAME:
``Intern and Resident Information System (IRIS), HHS/CMS/OFM''
SECURITY CLASSIFICATION:
Level Three Privacy Act Sensitive Data
SYSTEM LOCATION:
The Centers for Medicare & Medicaid Services (CMS) Data Center,
7500 Security Boulevard, North Building, First Floor, Baltimore,
Maryland 21244-1850 and South Building, Baltimore, Maryland 21244-1850.
CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:
Interns and residents (IR) in medical residency programs approved
under 42 CFR Sec. 413.75, working in all areas of the hospital
complex, or other freestanding providers, as well as non-hospital or
non-provider settings on or after July 1, 1985.
CATEGORIES OF RECORDS IN THE SYSTEM:
The system includes the following information for each IR: name,
social security number; name of medical, osteopathic, dental, or
podiatric school graduated from and date of graduation, type of
residency program for the medical specialty, number of years completed
in all types of residency programs, foreign medical school graduation
date and certification date, name of employer (e.g., hospital,
university, corporation) paying the salary, the percentage of time
spent working in either the inpatient areas of the hospital subject to
the Prospective Payment System or in the outpatient areas of the
hospital or in a non-hospital setting under agreement with the hospital
for indirect medical education (IME), the percentage of time spent
working in any area of the hospital complex or in a non-provider
setting under agreement with the hospital for graduate medical
education (GME), the start and end dates assigned to the hospital and
any hospital-based providers (assignment periods) during the hospital's
cost reporting period, the start and end dates assigned to any non-
hospital or non-provider setting in connection with approved residency
programs (assignment periods) during the hospital's cost reporting
period, and the full-time or part-time percentage during each
assignment period.
AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
Authority for maintenance of the system is given under the
provisions of Sec. Sec. 1886(d)(5)(B) and 1886(h) of the Social
Security Act (Title 42 United States Code (U.S.C.) Sec. Sec.
1395ww(d)(5)(B) and 1395ww (h)).
PURPOSE(S) OF THE SYSTEM:
The primary purpose of the SOR is to ensure that no interns and
residents (IRs) are counted by the Medicare program as more than one
full-time equivalent (FTE) employee in the calculation of payments for
the costs of direct graduate medical education (GME) and indirect
medical education (IME). Information retrieved from this SOR will also
be disclosed to: (1) Support regulatory, reimbursement, and policy
functions performed within the Agency or by a contractor or consultant,
(2) assist another Federal and/or state agency, agency of a state
government, an agency established by state law, or its fiscal agent,
(3) support providers and suppliers of services, (4) assist third-party
contacts where necessary to establish or verify information, (5)
[[Page 69695]]
support litigation involving the Agency, and (6) combat fraud, waste,
and abuse in certain health benefits programs.
ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES
OR USERS AND THE PURPOSES OF SUCH USES:
A. Entities Who May Receive Disclosures Under Routine Use
These routine uses specify circumstances, in addition to those
provided by statute in the Privacy Act of 1974, under which CMS may
release information from the IRIS without the consent of the individual
to whom such information pertains. Each proposed disclosure of
information under these routine uses will be evaluated to ensure that
the disclosure is legally permissible, including but not limited to
ensuring that the purpose of the disclosure is compatible with the
purpose for which the information was collected. We are proposing to
establish or modify the following routine use disclosures of
information maintained in the system:
1. To support agency contractors, consultants, or grantees, who
have been engaged by the agency to assist in the performance of a
service related to this collection and who need to have access to the
records in order to perform the activity.
2. To another Federal or state agency, agency of a state
government, an agency established by state law, or its fiscal agent:
a. To contribute to the accuracy of CMS' proper payment of Medicare
benefits,
b. To enable such agency to administer a Federal health benefits
program, or as necessary to enable such agency to fulfill a requirement
of a Federal statute or regulation that implements a health benefits
program funded in whole or in part with federal funds.
3. To providers and suppliers of services (and their authorized
billing agents) directly or dealing through fiscal intermediaries or
carriers, for administration of provisions of Title XVIII of the Social
Security Act.
4. To third-party contacts where necessary to establish or verify
information provided on or by IR.
5. To the Department of Justice (DOJ), court or adjudicatory body
when:
a. The agency or any component thereof, or
b. Any employee of the agency in his or her official capacity, or
c. Any employee of the agency in his or her individual capacity
where the DOJ has agreed to represent the employee, or
d. The United States Government
Is a party to litigation or has an interest in such litigation, and
by careful review, CMS determines that the records are both relevant
and necessary to the litigation and that the use of such records by the
DOJ, court or adjudicatory body is compatible with the purpose for
which the agency collected the records.
6. To a CMS contractor (including, but not limited to FIs and
carriers) that assists in the administration of a CMS-administered
health benefits program, or to a grantee of a CMS-administered grant
program, when disclosure is deemed reasonably necessary by CMS to
prevent, deter, discover, detect, investigate, examine, prosecute, sue
with respect to, defend against, correct, remedy, or otherwise combat
fraud, waste, or abuse in such program.
7. To another Federal agency or to an instrumentality of any
governmental jurisdiction within or under the control of the United
States (including any state or local governmental agency), that
administers, or that has the authority to investigate potential fraud
or abuse in a health benefits program funded in whole or in part by
Federal funds, when disclosure is deemed reasonably necessary by CMS to
prevent, deter, discover, detect, investigate, examine, prosecute, sue
with respect to, defend against, correct, remedy, or otherwise combat
fraud, waste, or abuse in such programs.
POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING,
AND DISPOSING OF RECORDS IN THE SYSTEM:
STORAGE:
All records are stored on paper and magnetic disk.
RETRIEVABILITY:
Magnetic media records are retrieved by the name of the employees
or other authorized individual and/or card key number. Paper records
are retrieved alphabetically by name.
SAFEGUARDS:
CMS has safeguards in place for authorized users and monitors such
users to ensure against excessive or unauthorized use. Personnel having
access to the system have been trained in the Privacy Act and
information security requirements. Employees who maintain records in
this system are instructed not to release data until the intended
recipient agrees to implement appropriate management, operational and
technical safeguards sufficient to protect the confidentiality,
integrity and availability of the information and information systems
and to prevent unauthorized access.
This system will conform to all applicable Federal laws and
regulations and Federal, HHS, and CMS policies and standards as they
relate to information security and data privacy. These laws and
regulations may apply but are not limited to: the Privacy Act of 1974;
the Federal Information Security Management Act of 2002; the Computer
Fraud and Abuse Act of 1986; the Health Insurance Portability and
Accountability Act of 1996; the E-Government Act of 2002, the Clinger-
Cohen Act of 1996; the Medicare Modernization Act of 2003, and the
corresponding implementing regulations. OMB Circular A-130, Management
of Federal Resources, Appendix III, Security of Federal Automated
Information Resources also applies. Federal, HHS, and CMS policies and
standards include but are not limited to: all pertinent National
Institute of Standards and Technology publications; the HHS Information
Systems Program Handbook and the CMS Information Security Handbook.
RETENTION AND DISPOSAL:
Records are maintained in a secure storage area with identifiers.
Disposal occurs three years from the last action on the hospital's cost
report, and should be coordinated with disposal of the reports.
SYSTEM MANAGER AND ADDRESS:
Director, Division of Provider Audit Operations, Financial Services
Group, Office of Financial Management, CMS, 7500 Security Boulevard,
C3-14-00, Baltimore, Maryland 21244-1850.
NOTIFICATION PROCEDURE:
For purpose of access, the subject individual should write to the
systems manager who will require the system name, SSN, address, date of
birth, sex, and for verification purposes, the subject individual's
name (woman's maiden name, if applicable). Furnishing the SSN is
voluntary, but it may make searching for a record easier and prevent
delay.
RECORD ACCESS PROCEDURE:
For purpose of access, use the same procedures outlined in
Notification Procedures above. Requestors should also reasonably
specify the record contents being sought. (These procedures are in
accordance with Department regulation 45 CFR 5b.5(a)(2).)
CONTESTING RECORD PROCEDURES:
The subject individual should contact the system manager named
above, and reasonably identify the record and specify the information
to be contested.
[[Page 69696]]
State the corrective action sought and the reasons for the correction
with supporting justification. (These procedures are in accordance with
Department regulation 45 CFR 5b.7.)
RECORD SOURCE CATEGORIES:
Data for this system is collected from IRIS diskettes/CDs as
transmitted by the hospitals.
SYSTEMS EXEMPTED FROM CERTAIN PROVISIONS OF THE ACT:
None.
[FR Doc. E7-23877 Filed 12-7-07; 8:45 am]
BILLING CODE 4120-03-P