Medicare Hospital Payment Data Could Bolster Whistleblower Cases

January 8, 2015 in News

Experts say 2012 Medicare hospital payment data made public last year by CMS could bolster whistleblower cases alleging Medicare fraud and encourage additional cases, although the data alone are not sufficient to bring a case forward, Modern Healthcare reports (Schencker, Modern Healthcare, 6/2).


The information — released by CMS in June 2014 — was the agency’s first annual update to Medicare hospital charge data, which compare the average amount a hospital charges for services provided with a similar inpatient stay or outpatient visit (iHealthBeat, 6/2/14).

The policy change to release the payment data came after a federal judge in May 2013 lifted a 33-year-old injunction that barred the government from giving the public access to a confidential database of Medicare insurance claims (iHealthBeat, 4/3/14).

The data include payment information for more than 3,000 hospitals across the U.S., including:

  • The 100 most common Medicare procedures; and
  • The 30 most common outpatient procedures (iHealthBeat, 6/2/14).

The data represents $77 billion in 2012 Medicare hospital payments.

Some stakeholders, including the American Medical Association, criticized the data release, arguing that the data could be misinterpreted. Others praised the release and said that data could enhance patients’ and insurers’ ability to identify high-quality care.

Limits of Public Data

According to Modern Healthcare, the False Claims Act requires a whistleblower to have independent knowledge of illegal activity in order to file a claim.

Pam Brecht — a partner at Pietragallo Gordon Alfano Bosick Raspanti and an attorney for some whistleblowers — said that data included on the CMS site alone cannot initiate a case, and data indicating that a physician has received a high amount of Medicare reimbursements does not necessarily indicate fraud.

For example, data showing that certain physicians have received high amounts of payments could be the result of an entire practice’s payment being submitted to Medicare through that physician’s Medicare number, according to Modern Healthcare.

Potential Use of Data

However, stakeholders said that public payment data could:

  • Assist journalists and others with identifying fraud;
  • Be employed to test fraud allegations, such as analyzing whether a physician changed his or her prescribing behavior after receiving benefits from a drugmaker;
  • Enhance existing whistleblower cases by identifying claims that require additional analysis or research, or information that backs up whistleblowers’ allegations;
  • Incentivize attorneys to pursue False Claims Act cases because of the amount of funds that could be at stake; or
  • Spur whistleblowers to further analyze physicians if the data show they have received a suspicious amount of Medicare payments (Modern Healthcare, 6/2).
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