[Federal Register Volume 69, Number 65 (Monday, April 5, 2004)]
[Notices]
[Pages 17679-17680]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-7633]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services


Privacy Act of 1974; Computer Matching Program (Match No. 2003-
04)

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

ACTION: Notice of Computer Matching Program (CMP).

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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 Pennsylvania Department of Public Welfare 
(DPW). We have provided background information about the proposed 
Matching Program in the SUPPLEMENTARY INFORMATION section below. 
Although the Privacy Act requires only that CMS provide an opportunity 
for interested persons to comment on the proposed Matching Program, CMS 
invites comments on all portions of this notice. See EFFECTIVE DATES 
section below for comment period.

EFFECTIVE 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 March 23, 2004. 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. We may defer implementation of 
this Matching Program if we receive comments that persuade us to defer 
implementation.

ADDRESSES: The public should address comments to: Director, 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 [email protected].

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

    Dated: March 23, 2004.
Dennis Smith,
Acting Administrator, Centers for Medicare & Medicaid Services.
Computer Match No. 2003-04

NAME:
    ``Computer Matching Agreement Between the Centers for Medicare & 
Medicaid Services (CMS) and the Commonwealth of Pennsylvania, 
Department of Public Welfare (DPW) for Disclosure of Medicare and 
Medicaid Information.''

SECURITY CLASSIFICATION:
    Level Three Privacy Act Sensitive

PARTICIPATING AGENCIES:
    The Centers for Medicare & Medicaid Services, and Commonwealth of 
Pennsylvania, Department of Public Welfare

AUTHORITY FOR CONDUCTING MATCHING PROGRAM:
    This CMA is executed to comply with the Privacy Act of 1974 5 
U.S.C. 552a, (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 FR 77677 (December 12, 2000), 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)).


[[Page 17680]]

Furthermore, section 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).
    DPW is charged with the administration of the Medicaid program in 
Pennsylvania and is the single state agency for such purpose. 62 
Purdon's Statutes (P.S.) Sec.  201(1); 55 Pennsylvania (Pa.) Code Sec.  
101.1(e). In Pennsylvania, DPW 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 Medical Assistance (MA) Program.
    DPW's disclosure of the MA Program data pursuant to this Agreement 
is for purposes directly connected with the administration of the MA 
Program, in compliance with 62 P.S. Sec.  404, 55 Pa. Code Sec. Sec.  
105.1 et seq., 42 U.S.C. 1396a(a)(7), 42 CFR 431.300 et seq., and 45 
CFR 205.50-205.60. Those purposes include the investigation, 
prosecution or criminal or civil proceeding conducted in connection 
with the administration of the MA Program. (55 Pa. Code Sec.  
105.3(b)(2)).

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 Commonwealth of Pennsylvania, Department of Public Welfare (DPW), 
to study claims, billing, and eligibility information to detect 
suspected instances of Medicare and Medicaid fraud and abuse (F&A) in 
the Commonwealth of Pennsylvania. CMS and DPW will provide Electronic 
Data Systems (EDS), 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 
Commonwealth of Pennsylvania 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 DPW 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 Commonwealth of Pennsylvania against 
records of Pennsylvania Medicaid beneficiaries, practitioners, 
providers, and suppliers in the Commonwealth of Pennsylvania.

Description of RecordS TO BE USED IN THE MATCHING PROGRAM:
    The data for DPW are maintained in the following data files:
    The data the Pennsylvania Fraud and Abuse Detection System (FADS) 
receives consists of a number of data tables that contain the different 
data element requirements for the operation of the system. These tables 
are grouped into ``universes'' of data. In Phase I the FADS universes 
are: Claims Analysis, Provider, Recipient, Reference, and Code Tables. 
In Phase II they are: Claims Analysis, Provider, Recipient, Reference, 
Financial, and Managed Care.

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.

[FR Doc. 04-7633 Filed 4-2-04; 8:45 am]
BILLING CODE 4120-03-P