05-14563. Privacy Act of 1974; Computer Match No. 2005-03

AGENCY:

Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS).

ACTION:

Notice of Computer Matching Program (CMP).

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 Washington Department of Social and Health Services (DSHS). 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, 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 [e-mail].

SUPPLEMENTARY INFORMATION:

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. 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.

Dated: July 12, 2005.

John R. Dyer,

Chief Operating Officer, Centers for Medicare & Medicaid Services.

Computer Match No. 2005-03

Name

“Computer Matching Agreement Between the Centers for Medicare & Medicaid Services (CMS) and the State of Washington Department of Social and Health Services 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 Washington Department of Social and Health 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 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 “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)).

Furthermore, § 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).

DSHS is charged with the administration of the Medicaid program in Washington and is the single state agency for such purpose. The Revised Code of Washington (RCW) 74.09.500 established the Medical Assistance Program and authorized DSHS to comply with Federal requirements for the medical assistance program provided in the Social Security Act and Title XIX of Public Law (89-97) in order to secure Federal matching funds for the program. DSHS provides eligible individuals with health care and remedial or preventive services, including both Medicaid services and Medical Care Services defined in RCW 74.09.035 and authorized for payment solely from State funds.

DSHS' disclosure of the Medicaid data pursuant to this Agreement is for purposes directly connected with the administration of the Medicaid Program, in compliance with 42 CFR 431.300 through 431.307 and RCW 74.09.200, 74.09.210 and 74.09.290. Those purposes include the detection, prosecution and deterrence of fraud and abuse (F&A) in the Medicaid Program.

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 State of Washington Department of Social and Health Services (DSHS), to study claims, billing, and eligibility information to detect suspected instances of Medicare and Medicaid fraud and abuse (F&A) in the State of Washington. CMS and DSHS will provide Computer Services Corporation, 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 Washington 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 DSHS 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 Washington against records of Washington Medicaid beneficiaries, practitioners, providers, and suppliers in the State of Washington.

Description of Records to be Used in the Matching Program

The data for CMS are maintained in the following Systems of Records:

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 DSHS 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 DSHS 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 DSHS pursuant to the routine use 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 DSHS 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 DSHS 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 DSHS pursuant to the routine use as 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 DSHS pursuant to the routine use as set forth in the system notice.

The data for DSHS are maintained in the Washington Medicaid Management Information System (MMIS). In 2001, DSHS procured the development and operation of a Decision Support System by DSHS' contractor HWT, Inc. The MMIS provides an electronic data feed to the HWT-DSS on a weekly basis. The DSS will be used to extract data for purposes of this computer matching agreement. The following HWT-DSS tables will be utilized:

—Washington Medicaid Management Information System (MMIS) Paid Claims Table;

—Washington MMIS Provider Master Table; and

—Washington MMIS Eligibility Table.

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.