Data Transparency and the Extension of Temporary Provider Enrollment Moratoria (CMS 6059-N4)
By Shantanu Agrawal, M.D., CMS Deputy Administrator and Director, Center for Program Integrity
As part of our efforts to improve care delivery through the sharing and utilization of information, the Centers for Medicare & Medicaid Services (CMS) has released two new public data sets. A new public file provides information on the availability and use of services provided to Medicare beneficiaries by ambulance and home health agencies (HHAs), a second data set provides the list of all approved providers and suppliers in Medicare’s fee-for-service operations. Both data sets are available at https://data.cms.gov
The Affordable Care Act provided CMS with new opportunities and resources to combat fraud, waste, and abuse in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). CMS used authority provided by the Affordable Care Act to impose temporary enrollment moratoria for the first time on July 30, 2013 (Phase I) and for the second time on January 30, 2014 (Phase II). CMS extended these six-month phases of the moratoria on July 29, 2014; January 29, 2015; July 29, 2015 and most recently on January 29, 2016. The moratoria temporarily halted the enrollment of new home health agencies (HHAs) and ground ambulance suppliers in certain geographic areas, and giving CMS the opportunity to analyze and monitor the existing provider and supplier base, as well as further focus additional fraud prevention and detection tools in these areas.
Today, as part of our efforts to share information, CMS released a Moratoria Provider and Supplier Services and Utilization Data Tool. The tool uses ambulance and HHA paid claims data within CMS systems for Medicare fee-for-service beneficiaries. The data, which do not contain any individually identifiable information about Medicare beneficiaries or their providers, cover the period from October 1, 2014 to September 30, 2015, and are updated quarterly. The tool includes interactive maps and a dataset that shows national-, state-, and county-level provider and supplier services and utilization data for selected health service areas. For this first release, the data provide information on the number of Medicare ambulance suppliers and HHAs servicing a geographic region, with moratoria regions at the state and county level clearly indicated, and the number of Medicare beneficiaries who use one of these services. Users of the tool can also find the degree to which use of these services is related to the number of providers and suppliers servicing a geographic region. Provider and supplier services and utilization data by geographic regions are compared easily using the interactive maps. Future releases may include comparable information on additional health service areas.
CMS’ continued commitment to strengthening program integrity also extends to supporting the provider and supplier community through increased transparency about those enrolled in the Medicare program. As part of this effort, CMS is publishing Public Provider Enrollment Files that list all providers and suppliers enrolled in Medicare. The continued growth of programs that require provider and supplier enrollment in Medicare fee-for-service as a prerequisite has steadily increased, as has the demand for information from the healthcare industry. This public provider data allows users, including other health plans, and researchers the ability to access Medicare data.
The Public Provider Enrollment Files consist of individual and organizational enrollment information on all providers and suppliers nationwide who are approved to bill Medicare. This includes key unique identifiers, enrollment type and state, names, National Provider Identifier (NPI), specialty, and limited address information (City, State, Zip code). This data also identifies reassignment relationships between individuals and groups. The information in the file will be updated quarterly and extracted directly from the Provider Enrollment, Chain, and Ownership System (PECOS), which is the official system of record for Medicare fee-for-service enrollment. The information can only be updated through submission of updates to enrollment information via PECOS. Providers and suppliers will need to make enrollment updates by contacting their respective Medicare Administrative Contractor (MAC), or by going to https://pecos.cms.hhs.gov/. Updates will be shown with the next release of the file.
The long-term goal of this initiative is to continue to expand data elements available in the files, and eventually consolidate other existing public lists of provider information, such as the Ordering and Referring File, Part D Prescribing File, and Revalidation Lists. CMS believes the release of the enrollment data provides a clear and transparent way for providers, suppliers, state Medicaid programs, private payers, researchers, and other interested individuals or organizations to leverage Medicare Provider Enrollment information.
To view a fact sheet on the Ambulance and HHA data set, visit: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-02-22.html The utilization tool is available through the CMS website at: https://data.cms.gov/moratoria-data
To view a fact sheet on the Public Provider Enrollment file, visit: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-02-22-2.html This data set is available through a series of .csv files that will be updated quarterly and published at https://data.cms.gov/public-provider-enrollment.
Questions regarding the Public Provider and Supplier Enrollment files or the Ambulance and HHA data set should be sent to the Office of Communications at the Office of Communication, 7500 Security Blvd., Baltimore, MD 21244-1850.