02-1524. Privacy Act of 1974; Report of New Computer Matching Agreement

AGENCY:

Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS) (formerly the Health Care Financing Administration).

ACTION:

Notice of a New Computer Matching Agreement (CMA).

SUMMARY:

In accordance with the requirements of the Privacy Act of 1974, we are proposing to establish a CMA between CMS and the State of California Department of Health Services (DHS) titled “Disclosure of Medicare and Medicaid Information.”

EFFECTIVE DATES:

CMS filed a CMA report 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 January 15, 2002. To ensure that all parties have adequate time in which to comment, the modified or altered system of records, including routine uses, will become effective 40 days from the publication of the notice, or from the date it was submitted to OMB and the Congress, whichever is later, unless CMS receives comments that require alterations to this notice.

ADDRESSES:

The public should address comments to: Director, Division of Data Liaison and Distribution, 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 standard time.

FOR FURTHER INFORMATION CONTACT:

Howard Cohen, Health Insurance Specialist, Program Integrity Group, Office of Financial Affairs, CMS, Room C3-02-16, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. The telephone number is 410-786-9537.

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 Computer Matching Programs that this Agency participates in comply with the requirements of the Privacy Act of 1974, as amended.

Dated: January 14, 2002.

Thomas A. Scully,

Administrator, Centers for Medicare & Medicaid Services.

CMA No. 2001-06

Name:

Computer Matching Agreement between the Centers for Medicare & Medicaid Services and the State of California Department of Health Services entitled Disclosure of Medicare and Medicaid Information.

Security Classification:

Level Three Privacy Act Sensitive.

Participating Agencies:

The Centers for Medicare & Medicaid Services (CMS), and State of California Department of Health Services (DHS).

Authority for Conducting Matching Program:

This Computer Matching Program (CMP) is executed to comply with the Privacy Act of 1974 (Title 5 United States Code (U.S.C.) sec. 552a), as amended, the Office of Management and Budget (OMB) Circular A-130, titled “Management of Federal Information Resources” published at 65 FR 77677 (December 12, 2000), and OMB guidelines pertaining to computer matching (54 FR 25818 (June 19, 1989)).

Authority for this matching program is given under the matching provisions of sections 1816, 1842, and 1874(b) of the Social Security Act (42 U.S.C. 1395h, 1395u, and 1395kk(b)).

Authority for DHS to participate in this computer-matching program is given under the provisions of sections 10740, 10748, 10750, 14000, 14000.3. 14000.4, 14005, 14005.4, 14100.1, 14200 of the California Welfare and Institutions Code, and 42 CFR 431.300 through 431.307. DHS is charged with administration of the Medicaid program in California and is the single state agency for such purpose. DHS may act as an agent or representative of the Federal government for any purpose in furtherance of DHS's functions or administration of the Federal funds granted to the state. In California, the Medi-Cal Act 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 Medi-Cal program.

Purpose (S) of the Matching Program:

The purpose of this agreement is to establish the conditions, safeguards, and procedures under which the CMS will conduct a computer matching program with DHS to study claims, billing, and eligibility information to detect suspected instances of fraud and abuse (F&A) in the State of California. CMS and DHS will provide a CMS contractor (hereinafter referred to as the “Custodian”) with Medicare and Medicaid/Medi-Cal 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 California 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 DHS 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 California against records of Medicaid/Medi-Cal beneficiaries, practitioners, providers, and suppliers in the State of California.

Description of Records to be Used in the Matching Program:

A. Systems of Records.

The data for CMS are maintained in the following Systems:

National Claims History (NCH), System No. 09-70-0005, was most recently published at 59 FR 19181 (April 22, 1994). 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 DHS pursuant to the routine use as set forth in the system notice.

Enrollment Database, System No. 09-70-0502 (formerly known as the Health Insurance Master Record) published at 55 FR 37547 (September 12, 1990). Matched data will be released to DHS pursuant to the routine use set forth in the system notice.

Medicare Supplier Identification File, System No. 09-70-0530 published at 57 FR 23420 (June 3, 1992). Matched data will be released to DHS pursuant to the routine use as set forth in the system notice.

Unique Physician/Provider Identification Number (formerly known as the Medicare Physician Identification and Eligibility System), System No. 09-70-0525, published at 53 FR 50584 (Dec 16, 1988). Matched data will be released to DHS pursuant to the routine use as set forth in the system notice.

Carrier Medicare Claims Record, System No. 09-70-0501 published at 59 FR 37243 (July 21, 1994). Matched data will be released to DHS pursuant to the routine use as set forth in the system notice.

B. The data for DHS are maintained in the following data files:

“Medi-Cal RFF035 File Paid Claims,” “Medi-Cal Combined Provider Master File;” and “Medi-Cal Eligibility File.

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.