[Federal Register Volume 70, Number 141 (Monday, July 25, 2005)]
[Notices]
[Pages 42560-42562]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 05-14563]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services


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).

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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 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 [email protected].

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

[[Page 42561]]

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, Sec.  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

[[Page 42562]]

--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.
[FR Doc. 05-14563 Filed 7-22-05; 8:45 am]
BILLING CODE 4120-03-P