Durbin Introduces Legislation to Reduce Medicare Fraud

U.S. Senator Dick Durbin (D-IL) today introduced legislation to crack down on Medicare fraud by increasing the access to information that will allow for better oversight and accountability of the program. The Medicare Spending Transparency Act would make summary level Medicare data publicly available and enhance the ability of qualified outside organizations to access more detailed data.

"Every year, between $30 and $60 billion in Medicare spending is wasted on fraud and abuse," said Durbin. "While the federal government has stepped up fraud detection and enforcement, allowing nongovernmental groups access to data can also play a role in detecting fraud. My legislation would bring transparency to the Medicare program by providing basic information about how taxpayer dollars are being spent in order to shine a light on any abuse within the system."

For several years, the Government Accountability Office has designated Medicare as a high risk program because its size and complexity make it a target for waste, fraud and abuse. Medicare pays 4.5 million claims per work day, so catching false or inflated claims is a challenge.

A recent investigation illustrates how outside groups can provide a valuable complement to the government's own fraud detection research. Under a special arrangement, The Wall Street Journal and Center for Public Integrity were allowed access to a 5% sample of the Medicare payment data which, because of a 1979 lawsuit, is not currently available to the public. Based on just this sliver of information, the newspaper was able to identify physicians who were billing large amounts to Medicare and who may be engaged in fraud or abuse. Because of the agreement that allowed The Wall Street Journal and Center for Public Integrity to access this information, the paper could not name individual physicians.

Durbin's Medicare Spending Transparency Act will enable access to data -- like what was used by The Wall Street Journal and the Center for Public Integrity -- and lift the restriction on releasing a fraudulent provider's name. Specifically, the legislation would increase transparency of the Medicare program by:

Providing access to summary claims data -- The Centers for Medicare & Medicaid Services (CMS) would be required to annually publish, on its website, summary level information about how and what Medicare is paying to individual providers including: amount paid, number of unique patients seen, total number of patient visits and a summary of the services provided. This will provide a snapshot of spending to interested groups and discourage fraudulent providers from overbilling Medicare.

Qualified groups would be eligible for access to complete data -- A complete set of Medicare data would be made available to qualified groups or individuals for the purposes of fraud detection and research. To access this information, the individual our group would have to demonstrate technical capacity to make prudent and productive use of the data. Any published analysis of the data must disclose the names, funding sources, employer or other relevant affiliations, and data analysis methods of the researchers. All patient identifying information would be protected, consistent with HIPAA and other privacy laws.

Source