CMS Releases Medicare Payment Data to the Public after 35 Years

by | Last updated May 17, 2023 | Published on Apr 29, 2014 | Healthcare News

Medicare Payment
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CMS posted Medicare physician payment data online on April 9, 2014 for the first time to the public after 35 years. The release of Medicare payment records that involves doctors has been legally blocked since 1979. In May 2013, a federal judge lifted the injunction that prevented the government from allowing public access to the confidential database of Medicare insurance claims. This database is known as the Standard Analytic File which contains the details of physicians and other healthcare providers that participate in Medicare and are paid on a fee-for-service basis. All the physicians’ claims for which Medicare pays directly are incorporated in this database.

Specifically, Medicare payment data includes the names and addresses of physicians, summaries of healthcare services provided and the amount paid for the services. This data does not include any information regarding patients. Overall, the payment data shows that Medicare paid $77.4 billion to more than 880,000 healthcare providers in 2012. The highest rate of reimbursement went to public health welfare agencies (94%) while anesthesiologists and anesthesiology assistants were at the bottom with reimbursement rates 15% and 13% respectively. You can find more details on CMS’ website under ‘Research, Statistics, Data & Systems’.

In the opinion of CMS officials, the payment data was released in order to enhance transparency. Consumers can compare the services provided and the payments made to individual healthcare providers. This data can thus be used to drive decision making and reward cost-effective, quality care.

The data shows broad variances in reimbursements, procedure costs and services provided to Medicare patients. Experts see the following benefits in releasing Medicare payment data.

  • Consumers can have a better understanding about healthcare costs
  • Help healthcare providers give quality care
  • Enable advocacy groups to find clues about medical billing frauds

The American Medical Association (AMA) is not happy with this as they argue CMS did not provide reasonable safeguards along with the payment data so as to help people understand the limitations of this data. The broad data dump by CMS has crucial shortcomings regarding the accuracy and value of the healthcare services provided by the physicians. Making the payment data publicly available without context may lead to inaccuracies, false conclusions, misinterpretations and other unintentional consequences. The AMA feels that this data release may “mislead the public” and requested that doctors must be allowed to review and correct any misleading information before the data was made publicly available.

Here are some of the limitations cited by various healthcare experts on the release of payment data, which fortifies what the AMA meant.

  • The payment data does not necessarily reflect the full scope or complete revenue of an individual practice since most of the consumers with a provider are not covered under Medicare.
  • Payments may vary according to the cost of living of a region or whether other services were rendered during a visit
  • Since the payment records do not follow doctors or their patients over time, they do not capture the intricacies of increasingly complicated healthcare practices which may require housing multiple providers in a wide range of arrangements.
  • The figures listed in the payment records do not reflect the variations in overhead costs for doctors. If we take the case of radiology oncology, which produces highest per-doctor payments of any specialty, only a small percentage (18%) of payments represent physician work. The rest is overhead costs for equipment and other expenses.
  • Sometimes, the physicians may bill certain procedures under a personal provider number while others may bill under the number of an organization. The physician’s total would not include the payments to the organization in such cases.

The AMA also says that payments or costs are not the only metric to evaluate medical care, but quality, value and outcomes are among the critical yardsticks for patients. They added that Medicare payment data released by CMS will not present meaningful conclusions regarding the value or quality of care to patients or payers.

Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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