Health care providers across the country are still adapting to the unprecedented disclosure of health care information that is associated with the government’s effort create a more transparent health care system. As many providers recall, in April, 2014, the Centers for Medicare & Medicaid Services (“CMS”), which administers the Medicare program, publicly released detailed data itemizing and summarizing health care providers’ and suppliers’ charges and payment, based on National Provider Number (“NPI”). The data was readily available, for full searching and analysis, to any individual or entity that wanted to see how individuals and entities were billing Medicare.

Physicians should be mindful that their claim information will likely continue to be made publically available on a going-forward basis. Unfortunately for the provider community, the future disclosure of CMS’ data will continue to allow scrutiny of the provider’s claim information, and will continue to permit the public at large, news sources, competitors, and others to shed light on generalized data and allege that such data supports fraud, waste and abuse. Unfortunately, due to the release of such partial data without explanation, it forces physicians to defend their billings, even when such billings are otherwise appropriate. In fact, even CMS’ website for disclosing the information notes the associated challenges with the pooled data: “While the Physician and Other Supplier PUF has a wealth of information on payment and utilization for Medicare Part B services, the dataset has a number of limitations. Of particular importance is the fact that the data may not be representative of a physician’s entire practice as it only includes information on Medicare fee-for-service beneficiaries. In addition, the data are not intended to indicate the quality of care provided and are not risk-adjusted to account for differences in underlying severity of disease of patient populations.”

Although the recent trend toward transparency–and the specific disclosure of data–is viewed with unease by many in the physician community, health care providers nonetheless should recognize that CMS and other private payors have always had this information at their disposal and were able to run internal analytics. The distinction, however, was that such information was not public. Given the future of health care, physicians should operate with the foreknowledge that each claim that they submit potentially is subject to scrutiny; however, in the future, it seems that providers will also be subject to scrutiny in the public arena.

For more information about this topic, please contact Adrienne Dresevic, Esq., or Carey Kalmowitz, Esq., at (248) 996-8510 or (212) 734-0128.

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