[Federal Register Volume 70, Number 174 (Friday, September 9, 2005)]
[Notices]
[Pages 53666-53667]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 05-17846]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[HHS Computer Match No. 0508; CMS Computer Match No. 2005-05]


Privacy Act of 1974

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 establishes a CMP that CMS plans to 
conduct with the Florida Agency for Health Care Administration (AHCA). 
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 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 09/01/2005. 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, Enterprise Databases 
Group, Office of Information Services, CMS, 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, Program Integrity Group, Office of Financial 
Management, CMS, 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:

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. 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: August 30, 2005.
John R. Dyer,
Chief Operating Officer, Centers for Medicare & Medicaid Services.
CMS COMPUTER MATCH No. 2005-05

NAME:
    ``Computer Matching Agreement (CMA) Between the Centers for 
Medicare & Medicaid Services (CMS) and the State of Florida Agency for 
Health Care Administration (AHCA) titled ``Disclosure of Medicare and 
Medicaid Information.''

SECURITY CLASSIFICATION:
    Level Three Privacy Act Sensitive.

PARTICIPATING AGENCIES:
    The Centers for Medicare & Medicaid Services, and State of Florida 
Agency for Health Care Administration.

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.) Sec.  552a), as amended, (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), 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 
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 
(FI) 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, 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

[[Page 53667]]

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 FIs and carriers (42 U.S.C. 1395ddd)). The contracting 
entities are called Program Safeguards Contractors.
    Pursuant to Sec.  409.902, Florida Statutes (F.S.), AHCA is charged 
with the administration of the Medicaid program in Florida, and is the 
single state agency for such purpose. AHCA is required to operate a 
program to oversee the activities of Florida Medicaid recipients and 
providers to ensure that fraudulent and abusive behavior occurs to the 
minimum extent possible (Sec.  409.913, F.S.).
    AHCA's 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. 
Those purposes are 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 CMS will conduct a computer 
matching program with AHCA to study claims, billing, and eligibility 
information to detect suspected instances of Medicare and Medicaid F&A 
in the State of Florida. CMS and AHCA will provide 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 State of Florida 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.

CATEGORIES OF RECORDS AND INDIVIDUALS COVERED BY THE MATCH:
    This CMP will enhance the ability of CMS and AHCA 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 Florida against records of 
Florida Medicaid beneficiaries, practitioners, providers, and suppliers 
in the State of Florida.

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 
AHCA 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 AHCA 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 AHCA pursuant to the routine use 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 AHCA pursuant to the routine use as 
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 AHCA 
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 AHCA 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 67 FR 63392 (December 6, 2001). Matched data 
will be released to AHCA pursuant to the routine use as set forth in 
the system notice.
    The data for AHCA are maintained in the following data files: 
Claims File Layouts HIPAA Version, Download File Record File-Claims, 
Recipient File Layout, Provider File Layout.

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. 05-17846 Filed 9-8-05; 8:45 am]
BILLING CODE 4120-03-P