II 112th CONGRESS 1st Session S. 856 IN THE SENATE OF THE UNITED STATES April 14, 2011 Mr. Durbin introduced the following bill; which was read twice and referred to the Committee on Finance A BILL To amend title XI of the Social Security Act to make available to the public aggregate data on providers of services and suppliers under the Medicare program and to allow qualified individuals and groups access to claims and payment data under the Medicare program for purposes of conducting health research and detecting fraud.

1.

Short title

This Act may be cited as the Medicare Spending Transparency Act of 2011.

2.

Public availability of aggregate data on Medicare providers of services and suppliers

(a)

Purpose

The purpose of this section is to make aggregate information about providers of services and suppliers under the Medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) publicly available and to provide a new level of transparency in such program. (b)

Public availability

Section 1128J of the Social Security Act (42 U.S.C. 1320a–7k) is amended by adding at the end the following new subsection: (f)

Public availability of certain medicare data

(1)

In general

The Secretary shall, to the extent consistent with applicable information, privacy, security, and disclosure laws, including the regulations promulgated under the Health Insurance Portability and Accountability Act of 1996 and section 552a of title 5, United States Code, make available to the public on the Internet website of the Centers for Medicare & Medicaid Services the following data with respect to title XVIII: (A)A complete list of the providers of services and suppliers participating in the program under such title, including the business address of such providers of services and suppliers. (B)Aggregate information about each such provider of services and supplier, including— (i)the total number of individuals furnished items or services by the provider of services or supplier for which payment was made under such title during the preceding year; (ii)the number of unique patient encounters conducted by the provider of services or supplier for which payment was made under such title during the preceding year; (iii)the average number of codes billed under such title by the provider of services of supplier per patient encounter during the preceding year; (iv)the total amount paid to such provider of services or supplier under such title during the preceding year; (v)the top 50 billing codes on claims paid under such title to the provider of services or supplier during the preceding year, as determined by volume, including a description of such codes; (vi)the top 50 billing codes on such claims paid during such year, as determined by dollar amount, including a description of such codes; and (vii)the top 50 diagnosis and procedure code pairs on such claims paid during such year, as determined by volume, including a description of such codes. (2)

Implementation

Not later than 1 year after the date of enactment of the Medicare Spending Transparency Act of 2011, the Secretary shall promulgate regulations to carry out this subsection. .

3.

Access to Medicare claims and payment data by qualified individuals and groups

(a)

Purpose

The purpose of this section is to allow qualified individuals and groups access to information on claims and payment data under the Medicare program for purposes of conducting health research and detecting fraud under such program. (b)

Access to medicare claims and payment data by qualified individuals and groups

Section 1128J of the Social Security Act (42 U.S.C. 1320a–7k), as amended by section 2, is amended by adding at the end the following new subsection: (g)

Access to Medicare claims and payment data by qualified individuals and groups

(1)

In general

For purposes of conducting health research and detecting fraud under title XVIII, and to the extent consistent with applicable information, privacy, security, and disclosure laws, including the regulations promulgated under the Health Insurance Portability and Accountability Act of 1996 and section 552a of title 5, United States Code, and subject to any information systems security requirements under such laws or otherwise required by the Secretary, a qualified individual or group shall have access to claims and payment data of the Department of Health and Human Services and its contractors related to title XVIII. Notwithstanding any other provision of law, such data shall include the identity of individual providers of services and suppliers under such title. (2)

Definition of qualified individual or group

(A)

In general

In this subsection, the term qualified individual or group means an individual or entity that the Secretary has determined, in accordance with subparagraph (B), has relevant experience, knowledge, and technical expertise in medicine, statistics, health care billing, practice patterns, health care fraud detection, and analysis to use data provided to the individual or the entity under this subsection in an appropriate, responsible, and ethical manner and for the purposes described in paragraph (1). (B)

Procedures

The Secretary shall establish procedures for determining, in a timely manner, whether an individual or entity is a qualified individual or group. (3)

Procedures

The Secretary shall establish procedures for the storage and use of data provided to a qualified individual or group under this subsection. Such procedures shall ensure that, in the case where the qualified individual or group publishes an analysis of such data (or any analysis using such data), the qualified individual or group discloses the following information (in a form and manner, and at a time, specified by the Secretary): (A)The name of the qualified individual or group. (B)The sources of any funding for the qualified individual or group. (C)Any employer or other relevant affiliations of the qualified individual or group. (D)The data analysis methods used by the qualified individual or group in the analysis involved. .