[Federal Register Volume 69, Number 66 (Tuesday, April 6, 2004)]
[Notices]
[Pages 18083-18085]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-7630]


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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-
02)

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

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 Texas Health and Human Services 
Commission (HHSC). 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,

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Mail stop 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: Lourdes Grindal Miller, 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) 786-1022 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 (Public 
Law (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. 2003-02

NAME:
    ``Computer Matching Agreement Between the Centers for Medicare & 
Medicaid Services (CMS) and the State of Texas Health and Human 
Services Commission (HHSC) 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 Texas 
Health and Human Services Commission

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 by Public Law (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), 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 ``to otherwise 
assist * * * in discharging administrative duties necessary to carry 
out the purposes of this part'' (42 U.S.C. 1395u(a)(4)).
    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).
    HHSC is charged with the administration of the Medicaid program in 
Texas and is the single state agency for such purpose (Texas Government 
Code (TGC) 531.021). HHSC may act as an agent or representative of the 
Federal government for any purpose in furtherance of HHSC's functions 
or administration of the Federal funds granted to the state (TGC 
531.021). In Texas, HHSC 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 Texas Medical Assistance Program. (TGC 531.021).
    HHSC's disclosure of the Texas Medicaid Program (TMP) data pursuant 
to this agreement is for purposes directly connected with the 
administration of the TMP program, in compliance with Texas Human 
Resources Code sections 12.003 and 21.012, and CFR 431.300 through 
431.307. Those purposes are the detection, prosecution and deterrence 
of fraud and abuse (F&A) in the TMP, and the enforcement of state law 
relating to the provisions of program services (TGC 531.102).

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 Texas Health and Human Services Commission (HHSC) to study 
claims, billing, and eligibility information to detect suspected 
instances of Medicare and Medicaid fraud and abuse (F&A) in the State 
of Texas. CMS and HHCS will provide TriCenturion, a CMS contractor 
(hereinafter referred to as the

[[Page 18085]]

``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 Texas 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.

DESCRIPTION OF RECORDS TO BE USED IN THE MATCHING PROGRAM:
    The release of the data for CMS are maintained in the following 
SOR: 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 
HHSC pursuant to the routine use as set forth in the system notice.
    Carrier Medicare Claims Record, System No. 09-70-0501 published in 
the Federal Register at 67 FR 54428 (August 22, 2002). Matched data 
will be released to HHSC 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 67 FR 3203 (January 23, 
2002). Matched data will be released to HHSC pursuant to the routine 
use set forth in the system notice.
    Intermediary Medicare Claims Record, System No. 09-70-0503 
published in the Federal Register at 67 FR 65982 (October 29, 2002). 
Matched data will be released to HHSC 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, was most recently published in the Federal Register at 
53 FR 50584 (Dec 16, 1988). Matched data will be released to HHSC 
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 HHSC pursuant to the 
routine use as set forth in the system notice.
    Medicare Beneficiary Database, System No. 09-70-0536 published in 
the Federal Register at 67 FR 63392 (December 6, 2001). Matched data 
will be released to HHSC pursuant to the routine use as set forth in 
the system notice.
    The data for HHSC are maintained in the following data files: The 
data that the Texas Medicaid Fraud and Abuse Detection System (MFADS) 
receives from the acute care claims processor comprises over 320 files. 
These files include not only the claims data, but also all other data 
necessary to process the claim such as client, provider, and reference 
information. The Texas Medicaid claims administrator vendor utilizes a 
real-time transaction processing system to adjudicate the claims and 
therefore, has organized the data to facilitate efficient transaction 
processing. This data organization results in the data being parsed out 
over a number of data tables. It is these data tables that are 
extracted for processing by the MFADS. As these files are received, 
they are organized or reassembled into an Oracle relational database to 
support access using the MFADS tools.
    In addition to the organization of the data, there are numerous 
updates that take place during the monthly load process. The monthly 
acute extracts that are received contain data that has finalized during 
the month. Therefore, these files must be applied to the multi-year 
database, changing some of the data through an update process as well 
as adding additional records. It is due to these reasons that the data 
will be extracted from the MFADS database rather than from incoming 
data sources. All or part of these elements may be used in this data-
matching program.

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.

[FR Doc. 04-7630 Filed 4-5-04; 8:45 am]
BILLING CODE 4120-03-P