Database of Medicare Claims Made Public - Healthcare | Financial Buzz

Database of Medicare Claims Made Public

Injuction, Doctors, PublicIt will finally be possible to see how much a doctor earns from Medicare. The big revelation is that about 15 percent of total billings originate from just one percent of doctors.

Removal of injunction

This was not possible earlier as an injunction was placed on CMS by American Medical Association in 1979. This injunction was removed in 2013 after the Wall Street Journal , through Down Jones, its parent company, contested the injunction.

Openness means faster detection

A Medicare claims database available in the public domain would greatly simplify and raise the possibility of detection of fraud. However, fraud detection is not enough, the actual misdemeanor must be first investigated and then prosecuted. If journalists, data analysts and private companies all can access a public database, then there is a strong possibility of the fraud getting detected faster.

The process

This public disclosure will have considerable implications. If the data were first analyzed and then published by researchers or news media, the public and the government, including the employees of the providers, would notice the providers linked to wrong billing data. This would, on one hand, reduce the number of relators who make frivolous fraud accusations, as such accusations can be easily checked against the existing database. On the hand, if anomalous patterns related to billing are detected for a few particular providers, there can be more relators who come forward in regard to those providers. If these relators try to constitute the “original source” and avoid the prohibition to public disclosure, more information than suspicious billing patterns will be required. Relators must come forward with specific evidence which must explain anomalous billing patterns already publicly disclosed. Realtors could make increased usage of pre-filing disclosures to help the government understands that the relator is not exploiting data that is already disclosed publicly, but offering original information.

The prohibition of public disclosure is a characteristic of the False Claims Act that has survived a number of legislative revisions and judicial interpretations in the recent years.  The FCA amendments to the Affordable Care Act altered the jurisprudence slightly.

The phrase “allegations or transactions” has been interpreted differently by different courts. The United States Court of Appeals for First Circuit has ruled that the public disclosure of a fraud is said to occur when the principal factors which exposed the specific transaction as fraudulent navigate to the public domain.