[Congressional Record Volume 157, Number 55 (Thursday, April 14, 2011)]
[Senate]
[Pages S2531-S2532]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. DURBIN:
  S. 856. 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; to the 
Committee on Finance.
  Mr. DURBIN. Mr. President, Congress will soon debate the budget 
resolution for fiscal year 2012, and one of the issues under 
consideration is how to contain the cost of the Medicare program. While 
there is significant disagreement about some of the proposals already 
put forward, one part of the solution that members on both sides of the 
aisle agree on is cracking down on waste, fraud, and abuse.
  For several years, the Government Accountability Office has 
designated Medicare as a high risk program because its size and 
complexity make it a target for waste, fraud and abuse. Medicare pays 
4.5 million claims per work day, so catching false or inflated claims 
is a challenge. As a result, every year an estimated $30-60 billion in 
Medicare spending is wasted on fraud and abuse.
  Under President Obama, the Executive branch has stepped up its 
enforcement activities. The Department of Health and Human Services and 
Department of Justice joined together to form Health Care Fraud 
Prevention and Enforcement Action Teams to combat Medicare fraud. These 
strike forces have netted hundreds of potential criminals in the past 
couple of years.
  Nongovernmental groups can also play a role in detecting fraud. 
Normally, individual Medicare providers' billing data is not available 
to the public as a result of a 1979 lawsuit that blocked disclosure of 
this information. But under a special arrangement, The Wall Street 
Journal and Center for Public Integrity were allowed access to a 5 
percent sample of the Medicare payment data.
  Even using just this small sliver of the data, the newspaper was able 
to identify suspicious billing and potential abuses of the Medicare 
system. However, based on the agreement with CMS, the paper could not 
name individual physicians.
  I think that the exercise by the Wall Street Journal shows that 
outside group provide a valuable complement to the government's own 
fraud detection research. That is why I am introducing the Medicare 
Spending Transparency Act today.
  The legislation would increase transparency of the Medicare program 
by providing two things.
  First, it would provide access to aggregated claims data.
  It would require CMS to annually publish on its website summary level 
information about how and what Medicare is paying to individual 
Medicare providers such as hospitals, physicians and home health 
agencies.
  Information would the include the total amount paid, number of unique 
patients seen, total number of patient visits, and a summary of the 
services provided. This will provide a snapshot of Medicare spending to 
interested groups. It will also discourage fraudulent providers from 
overbilling Medicare.
  Secondly, a complete set of Medicare data would be made available to 
qualified groups or individuals for the purposes of fraud detection and 
research. All patient identifying information would be protected, 
consistent with HIPAA and other privacy laws.
  To access this information, the individual or group would have to 
demonstrate technical capacity to make prudent and productive use of 
the data. Any published analysis of the data must disclose the names, 
funding sources, employer or other relevant affiliations, and data 
analysis methods of the researchers.
  This legislation would bring transparency to the Medicare program by 
providing basic information about how taxpayer dollars are being spent. 
If nongovernmental groups want to dedicate their own resources to 
rooting out fraud, we should welcome those efforts. I encourage my 
colleagues to support this common sense legislation.
  Mr. President, I ask unanimous consent that the text of the bill be 
printed in the Record.
  There being no objection, the text of the bill was ordered to be 
printed in the Record, as follows:

                                 S. 856

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE.

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

     SEC. 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;

[[Page S2532]]

       ``(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; and
       ``(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.''.

     SEC. 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.''.
                                 ______