CMS plans to expand access to Medicare, private claims data

Under new proposed federal rules, the government will expand provider and employer access to Medicare and private insurance claims data in an effort to drive quality improvement in healthcare.

"Qualified entities" will be able to provide or sell Medicare and private-sector claims data to providers, as well as confidentially share or sell analyses of claims data in order to support improved care, according to the Centers for Medicare & Medicaid Services (CMS). The new rules are part of the Medicare Access and CHIP Reauthorization Act.

"Increasing access to analyses and data that include Medicare data will make it easier for stakeholders throughout the healthcare system to make smarter and more informed healthcare decisions," CMS Acting Administrator Andy Slavitt said in the announcement.

So far, 13 organizations have applied and been approved for designation as a qualified entity--two of which have already completed their public reporting. Under the federal rules, qualified entities are required to combine Medicare data and other claims data to produce "quality reports that are representative of how providers and suppliers are performing across multiple payers, for example Medicare, Medicaid or various commercial payers," CMS says.

The announcement also notes that the regulations include strict privacy and security requirements for entities that receive claims data, and these entities are also subject to new annual reporting requirements.

Stakeholders throughout the healthcare sector are increasingly embracing the potential of harnessing claims data to improve quality and lower costs. Private insurers mine their own members' data to craft health-promoting interventions, and the Blue Cross Blue Shield Association announced last fall that its 36 member companies will contribute information to a massive database known as Axis.  

Attempts by states to create all-payer claims databases, however, have met some resistance. In fact, an insurance company is challenging the legality of Vermont's database in a case set to be decided by the Supreme Court.  

To learn more:
- read the announcement

Related Articles:
Blue Cross Blue Shield Association launches massive database
Insurers mine data for information on members
Supreme Court hears all-payer claims database case
Insurers' support for HIEs driven by value-based payment

Free Webinar

Take Control of Your Escalating Claim Costs through a Comprehensive Pre-payment Hospital Bill Review Solution

Today managing high dollar claim spend is more important than ever for Health Plans, TPAs, Employers, and Reinsurers, and can pose significant financial risks. How can these costs be managed without being a constant financial drain on your company resources? Our combination of the right people and the right technology provides an approach that ensures claims are paid right, the first time. Register Now!

Suggested Articles

A new Aetna pilot program aims to harness its parent company's pharmacy reach to help address members' social needs.

A three-way deal between UpHealth, Cloudbreak, and a blank check company has created a new public digital health company valued at $1.35 billion.

Operation Warp Speed plans to distribute 6.4 million doses of a COVID-19 vaccine 24 hours after it receives emergency approval, officials said.