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CMS publishes Medicare fee-for-service provider and supplier lists

As part of our efforts to improve care delivery, data sharing, and transparency, the Centers for Medicare & Medicaid Services (CMS) is releasing two public data sets regarding the availability and use of services provided to Medicare beneficiaries by ground ambulance suppliers and home health agencies, as well as a list of Medicare fee-for-service (FFS) providers and suppliers currently approved to bill Medicare. The data sets are accessible at https://data.cms.gov.

CMS recently published a Federal Register notice on February 2, 2016 (effective January 29, 2016) extending the temporary enrollment moratoria on new ground ambulance suppliers and home health agencies sub-units, and branch locations in the Medicare, Medicaid, and the Children’s Health Insurance Programs (CHIP) for an additional six months in seven geographic areas.  Such moratoria provisions were authorized by the Affordable Care Act and serve to reduce fraud, waste, and abuse while ensuring that patient access to care is not interrupted.

The enrollment moratoria extension, coupled with these new provider and supplier data tools, signal that the potential for fraud, waste, and abuse that continues to exist in these areas. “CMS has used this powerful monitoring tool several times before to fight fraud, safeguard taxpayer dollars, and protect beneficiaries. By introducing data mapping for these specific, high-risk providers and suppliers in the moratoria areas and, for the first time, making service area data on all other FFS providers and suppliers publicly available, analyses of the data offers additional insight for CMS and its stakeholders,” said CMS Deputy Administrator and Center for Program Integrity Director Shantanu Agrawal, M.D.  “Use of these tools gives us evidence of the use, disproportion, and saturation of certain services within Medicare, Medicaid, and CHIP coverage and provides insight beneficial to reducing program threats, assisting law enforcement, and averting harm to patients and the public.”

Future data releases may include comparable information on additional health services outside the seven moratoria areas.

The Moratoria Provider Services and Utilization Data Tool includes interactive maps and a dataset that shows national-, state-, and county-level provider and supplier services and utilization data that can be used by CMS to determine which geographic and health service areas might be considered for a moratorium on new provider and supplier enrollments. The data provides the number of Medicare providers and suppliers servicing a geographic region, identifies moratoria regions at the state and county levels, and identifies the number of people with Medicare benefits who use a specific health service in that region. The data can also be used to reveal service levels related to the number of providers and suppliers in a geographic region. Utilization data and geographic regions for these services can be easily compared using interactive maps.

CMS’ ongoing program integrity work has inspired growing stakeholder interest in Medicare provider and supplier enrollment information, Agrawal said. The Public Provider data allow users, including other health plans, to easily access and validate provider and supplier information against Medicare data. Public Provider Enrollment file sets include information on providers and suppliers, nationwide, who are approved to bill Medicare. The data is extracted directly from the Provider Enrollment, Chain and Ownership System (PECOS) and is updated quarterly.

The Moratoria Provider Services and Utilization Data Tool was created using ground ambulance and home health agency paid claims data that reside in CMS systems for Medicare FFS beneficiaries. The data in this release cover the period from October 1, 2014 to September 30, 2015 and will continue to be updated quarterly.  Data are available for each of the 50 states, their counties, and the District of Columbia. The data set does not contain any individually identifiable information about Medicare beneficiaries.

The public provider data consist of individual and organizational provider and supplier enrollment information and includes names, National Provider Identifier and other unique identifiers, enrollment type, specialty, and limited address information (City, State, ZIP Code).

For more information on the recent temporary enrollment moratoria extension please see the Federal Register posting at: http://federalregister.gov/a/2016-01835.  

To view the Ambulance and Home Health Agency data set and a related fact sheet, visit: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-02-22.html.

To view the Public Provider Enrollment data set and a related fact sheet, visit: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-02-22-2.html.

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