Provider Data Sources Reference

Last week (May 3, 2024) CarePrecise published a dynamic new healthcare data resource, entitled the Provider Data Sources Reference Guide (or just "PDS" for short). By "dynamic" we mean that it will be continually updated, and it will grow with new entries relating to free and fee-based provider data sources.

Navigating public and private data sources is challenging and time consuming, and it's something that the CarePrecise resources team has been doing for decades. Opening our expertise to the public is built into the DNA of our company. We take pride in being the most open and transparent healthcare provider data vendor, and the Provider Data Sources Reference Guide is just the logical next step.

The PDS is free and publicly available, with listings of data sources, both public and proprietary. It's a great place to find clues about the data sources needed across the healthcare industry. Included are sources that we use to build our authoritative provider data packages, as well as others that can be integrated with data packages from CarePrecise and other vendors using the NPI, CCN and PAC ID unique identifiers, to augment and enhance value for our customers, the industry at large.

Our resources team accepts submissions for entries in the PDS, which are reviewed for quality, pertinence, and value of content. Direct links to the sources are included on the page, where possible.

Using the on-screen tools, listings can be sorted and filtered by Category (such as Physicians, Hospital/Medical Facility, Mental Health, etc.), and by Free, Fee-based, or Limited use sources.

The PDS is a companion to the CarePrecise U.S. Healthcare Administration and Information (USHAI) resources guide, which contains links to medical associations, healthcare IT, cost reduction, patient guidance information, and much more. Both public and proprietary sources are included, and the USHAI guide also accepts submissions from the industry. Note that submissions must come from the source of the information; submissions that come from a public relations agency or other third party are not considered for publication. Both the USHAI and the PDS consider limited commercial content of high quality, with inclusion at the discretion of CarePrecise.

Go here to submit a provider data source for the PDS reference guide. Go here for commercial submissions to the companion USHAI guide.

The Power of Physician Databases

In the ever-evolving landscape of healthcare in the United States, access to accurate and comprehensive provider data is crucial for improving patient outcomes, optimizing resource allocation, advancing medical research, and communication between providers and innovators. Clinician data stands at the forefront of this revolution, offering a treasure trove of information that empowers stakeholders across the healthcare ecosystem. From pharmaceutical companies seeking to collaborate with key opinion leaders to healthcare organizations aiming to enhance their referral networks, the value of physician and other prescribing clinician data cannot be overstated.

The Backbone of Healthcare Insights

Physician data serves as the backbone of healthcare insights, providing centralized repositories of information on medical professionals, including their specialties, affiliations, contact details including email addresses, and clinical interests and treatment patterns. These databases are meticulously curated, drawing from authoritative sources such as federal provider data maintained by the Centers for Medicare and Medicaid Services (CMS), medical licensing boards, professional associations, and healthcare institutions. Good physician databases can offer a comprehensive view of the healthcare landscape, enabling stakeholders to make informed decisions and to reach out for strategic partnerships.

Driving Medical Innovation

Innovation in healthcare relies heavily on collaboration and knowledge sharing among medical professionals. Authoritative physician data fosters these connections by facilitating networking opportunities and identifying experts in specific fields. Pharmaceutical companies, for instance, leverage physician databases to identify potential investigators for clinical trials, gather insights on prescribing patterns, and engage with thought leaders to advance their research agendas. By streamlining the process of connecting with relevant healthcare providers, these databases accelerate the pace of medical innovation and drug development.

Enhancing Patient Care

Effective patient care hinges on seamless coordination among healthcare providers and access to timely, relevant information. Physician databases enable healthcare organizations to build robust referral networks, ensuring that patients receive the specialized care they need. Primary care physicians can quickly identify specialists based on their expertise and proximity, leading to shorter wait times and improved patient satisfaction. Access to comprehensive physician profiles allows clinicians to make well-informed referrals, resulting in better treatment outcomes and continuity of care. 

Accurate fax numbers for pharmacies facilitate delivery of prescriptions where prescribers do not subscribe to an ePresciption system, and contact information for the prescribers is crucial when a pharmacist needs clarification, or has potentially life-saving information on a drug interaction that may have escaped a prescriber's notice.

Communicating Vital Information to Doctors

The process of updating physicians on advances in their areas of practice relies heavily on good physician contact information. Up-to-date, accurate physician databases, with practice addresses, phone and fax numbers, and email addresses, from a reliable vendor are the basis for communication. Companies use authoritative these data resources to update their own in-house databases, keeping the lines f communication open and effective.

Informing Healthcare Policy

In an era of evidence-based medicine, data-driven insights are indispensable for shaping healthcare policy and regulation. Physician databases provide policymakers with valuable information on physician demographics, practice patterns, and geographic distribution, enabling them to identify areas of need and allocate resources effectively. By analyzing trends in physician workforce dynamics, policymakers can develop strategies to address shortages in underserved areas, promote diversity in healthcare, and support initiatives aimed at improving access to care for underserved populations.

Ensuring Data Accuracy and Privacy

While physician databases offer immense benefits, ensuring data accuracy and privacy is paramount. To maintain the integrity of these databases, data providers employ rigorous validation processes and adhere to strict privacy regulations such as HIPAA (Health Insurance Portability and Accountability Act) in the United States. Additionally, data anonymization techniques are often employed to protect sensitive information and preserve patient confidentiality. By prioritizing data quality and security, stakeholders can harness the full potential of physician databases while safeguarding patient privacy.

Looking Ahead: The Future of Physician Databases

As technology continues to evolve, the future of physician databases holds tremendous promise. Advancements in artificial intelligence and machine learning are poised to revolutionize data analytics, enabling stakeholders to extract deeper insights and predictive analytics from vast datasets. Integration with electronic health records (EHRs) and interoperability standards will further enhance the value of physician databases by providing real-time access to patient information and care coordination tools. With data coming in from so many sources in government and the healthcare industry, intelligent tools for merging information into a “single source of truth,” such as the CarePrecise Collection™ healthcare provider dataset, are key. CarePrecise developed its QoRelate™ record collection and linkage intelligence to build a range of data modules that can be used in any relational database environment across the industry.

Effects on Data of a Government Shutdown

UPDATE: An agreement reached for continuing funding has ensured that normal collection and dissemination of federal healthcare data will continue through at least the upcoming October update of CarePrecise data packages.

Discussion of a government shutdown that could affect the Centers for Medicare and Medicaid Services (CMS) – a primary source for U.S. healthcare data – has raised concerns that the regular updates of CarePrecise datasets may be impacted. Our pledge is to provide the most recent data as released from our sources, which are largely within The U.S. Department of Health and Human Services (HHS), the U.S. Department of Commerce, and the U.S. Postal Service, among other government agencies. Should a government shutdown occur, it was announced a few days ago that a large portion – perhaps 42% – of personnel in the HHS will be furloughed. In this event, Medicare, Medicaid, and Obamacare are not expected to be impacted from the perspectives of most patients, providers, and payers, beyond brief delays in reimbursements. However, it is not known at this time how the furloughs will affect processes related to delivery of healthcare data updates. Should any delays occur, CarePrecise will alert all of our data subscribers with what we know.

It is important to point out that there have been 21 government shutdowns since the days of the Ford Administration, and four of these have taken place since CarePrecise began leveraging federal data for the benefit of our customers. The longest, and perhaps most dramatic of these, was the seventeen-day shutdown that occurred in October 2013. No impact on CarePrecise data delivery was felt during any of these previous shutdowns. We note also that much of the responsibility for data production within the federal government falls to contractors. In many, if not most, cases, contractor agreements will not immediately be affected, and work may be expected to continue.

The criticality of current, accurate, standardized data in healthcare has sustained strong bipartisan support since the leadership of HHS Secretary Louis W. Sullivan in the administration of President George H.W. Bush.

It is also noteworthy that, since its founding in the 2008/2009 federal fiscal year, CarePrecise has never missed a data distribution. Whatever happens, CarePrecise will distribute the data as soon as digitally possible.

HIPAA Prevents State LEOs from Grazing for PHI -- Doesn't It?

h/t to Samantha Holvey's concise and timely weekly Whealth Care newsletter for addressing a question that is probably on every HIPAA-savvy reader's mind of late: "Can State Attorneys General just randomly scan out of state health records to see whether one of their residents may have committed a health care 'crime'?" This might apply to potentially pregnant patients seeking reproductive diagnosis and treatment, or parents of transgender minors seeking gender-affirming care not available at home.

Having been engaged with HIPAA since its earliest days, I was prepared to repeat my customary, reassuring, "HIPAA is better privacy protection than we had before" speech, but I quickly realized that this time, I was not so sure. See, when we were implementing the three pillars of HIPAA (Privacy | Security | Transactions and Code Sets), back in the aughts, people were most concerned about organizations within the industry misusing the data, or letting it leak out for commercial exploitation.

Very few were worried about a malevolent government. The pre-HIPAA government guardrails that had been erected were still in place, and HIPAA itself was relatively neutral on the matter. Or at least, we implementers were relatively complacent. We thought that, occasional abuse aside, law enforcement organizations would go through existing legal channels to obtain patient records in pursuit of fraud, theft, controlled substance misappropriation, or malpractice.

Now, state after state is passing laws that not only criminalize healthcare procedures that have been common practice for decades, they extend that criminality to procedures performed in states whose own laws preserves their legality. Private citizens can earn bounties by revealing someone has crossed a state line to pursue such treatment. Or even helped fund such an excursion.

And while CMS has published regulatory guidance that explains what sorts of inquiries are already unacceptable under HIPAA, they have also released a Notice of Proposed Rulemaking (NPRM) to tighten the federal regulations against potential state governmental fishing expeditions. The comment period on the NPRM has closed. Can federal regulations be far behind? HIPAA history says not to be too confidents. Some NPRMs were allowed to languish for years. Other draft regulations were never formalized into a Final Rule.

How To Complain, Revisited

Today, CMS reminds us that we can use their ASETT HIPAA Compliance site (Administrative Simplification Enforcement and Testing Tool) if you think a trading partner is forcing you to accept (or send) non-standard administrative transactions, such as ASC X12N 837 Claims or 835 Remittance Advice. The tool also validates against 60-plus clinical and non-clinical code sets, including ICD 10 diagnosis and procedure codes. Best of all, you can file a complaint directly with the CMS National Standards Group (NSG), whose job it is to police HIPAA Transaction and Code Sets violations.

CMS is not trumpeting this capability, but it looks like they also have an option to test your own EDI files (or perhaps ones you've received) without necessarily filing a complaint.

Back in the day, word on the street was that the ASETT tool's foundational architecture was based on the Edifecs validation engine technology. I can't confirm or deny that, but if you are using a different translation/validation technology, it might be a good idea to see if your streams are clean, as it were.

A Word from Our Sponsor: CarePrecise offers the sharpest healthcare provider tools in the shed. At CarePrecise, we are all about data integrity and validation. 

CCN and PAC ID to NPI: Crosswalk between the NPI Registry and Hospital and Group Records

The federal Centers for Medicare and Medicaid Services (CMS) publishes a wide range of information on U.S. hospitals, which all carry the unique identifier, the CCN number (CMS Certification Number)*. On the other hand (which often seems to not know what its counterpart is doing), CMS also publishes the frequently updated NPPES database (National Plan and Provider Enumeration System), commonly known as the NPI Registry, which uses the NPI number (National Provider Identifier) as its unique identifier. While hospitals and other medical organizations will have only one CCN Number, they are required to have at least one NPI number, and they're permitted to have as many as they like (and they do seem to like quite a few). 

And, between these two ID systems, the CCN and the NPI, ne'er the twain shall meet.

CarePrecise has developed a sophisticated system to "roll up" an organization's NPI-numbered records with its CCN number (and with the PAC ID for practice groups, which stands for "PECOS Associate Control ID"). This mighty trick produces some eye-opening data, such as contact names and titles, license information, specializations, market data added by CarePrecise to NPI records, and the ability to crossmatch groups to their members and hospital affiliations, directly from their NPI numbers. It also permits integration across the complete line of CarePrecise provider data packages, and all of the information that CarePrecise collects or creates and then merges to the NPI records.

Currently, these CarePrecise rollups (or "crosswalks" if you prefer) are the only available such thing in a relatively comprehensive dataset. The full rollup of all medical facility NPI numbers is available for hospitals, and a single "priority" NPI number is currently available for practice groups, with a full rollup of all PAC ID-to-NPI linkages in development with a tentative release date in May 2023.

The hospital CCN-to-NPI crosswalk is part of the Authoritative Hospital Database (APD), and the Group PAC ID-to-NPI link is part of the Authoritative Physician Database (APD) and CarePrecise Platinum.

The "rolling up" is made possible by several CarePrecise innovations, starting with the CoLoCode (co-location code) affixed to almost every provider in the 7 million+ record CarePrecise master reference database. To fill in additional linkages, The CarePrecise HealthGeo geocode dataset, containing latitude and longitude for all 8.5 million+ provider records, which can readily be used to link data between data suppliers for a variety of purposes.

* The CMS Certification Number has replaced the term Medicare Provider Number, Medicare Identification Number or OSCAR Number. The CCN is used to verify Medicare/Medicaid providers for survey and certification, assessment-related activities and communications. Note that CarePrecise includes the old OSCAR Number in its CarePrecise Complete and CarePrecise Advanced/Platinum datasets, if reported by the provider in their NPI record(s) or available through third-parties, but this is a small fraction of records, and the OSCAR numbers have changed, hence the need for a CCN-to-NPI crosswalk.

CMS Pushes Connectivity Supports for Better Health

Citing research that associates internet connectivity with better health outcomes, the Centers for Medicare and Medicaid Services (CMS) is asking people who know elders with no or limited internet connectivity to share the news about a new benefit.

"If you or someone you know needs help paying for internet service, you may qualify for a monthly discount on a new or existing internet service plan through a government program called the Affordable Connectivity Program (ACP).

"You may also qualify for a one-time device discount of up to $100, to buy a laptop, desktop computer, or tablet from participating providers."

The program supports the whole household, so if you have a qualifying individual in your home, you should be able to obtain services on their behalf.

Benefits include:

• Up to a $30/month discount on your internet service
• Up to a $75/month discount if your household is on qualifying Tribal lands
• A one-time discount of up to $100 for a laptop, tablet, or desktop computer (with a co-payment of more than $10 but less than $50)
• A low cost service plan that may be fully covered through the ACP

People can apply by pulling up AffordableConnectivity.gov or calling 1-877-384-2575. On the site, you can download a PDF application form that lists the various criteria, though we recommend using the online application process once you've reviewed it.

Notably, even if you are already enrolled in the FCC's Lifeline program, you may still be able to qualify and receive the ACP supplements. 

Rather than requiring a new, complex set of qualification criteria, your enrollment in one or more other federal programs (SNAP. WIC, SSI, Medicaid, and numerous others, including VA benefits) provides the necessary hoop-jumping by proxy. It's great to see the government offering new benefits without inventing a whole new system of red tape to support it. 

DISCLAIMER: CarePrecise uses data provided by CMS develop and refine its products.

How to Save Money on Healthcare Provider Data

It might seem like this is a shameless, self-serving promo for CarePrecise provider data packages. Unsurprisingly, our name does come up a lot when companies stagger away in shock from the prices our competitors charge. But that's not what this post is about. We're going to talk about (mostly) free data.

Hopefully this post will help you find provider data that's available for free from the U.S. government. Using free data you can boost the information value in any provider contact list. If you're working with a helpful data vendor, chances are they'll help you find where you can download particular kinds of data you're looking for. For instance, we have a lot of customers who use our basic hospital database who need additional components that we don't package with the product, but we know where to find them and we're glad to share our knowledge. 

Of course, we could pull all of that data into our hospital dataset, but there's SO much out there, and if we did that the product would be very expensive indeed. That database sells for $939 but would be a couple of orders of magnitude pricier with all of just the 70 U.S. hospital data files listed in just one spot on the Centers for Medicare and Medicaid Services (CMS) website.

So, instead of trying to pack everything in, we bring together the hard-to-find/basic-necessity data, and assist customers in finding additional information specific to their particular need. Here are some of our more common recommendations.

When on the hunt for data gold, it can be painfully difficult to locate that needle in the haystack. The screenshot shows the count of the results of a search on the federal data website, data.gov, for "healthcare provider data." 127,500 datasets would be a daunting place to start digging. It's like, "Go get the gold! It's somewhere in that there mountain." Fortunately, we have had some experience with healthcare data excavation, and can often point our customers to pay dirt.

If you have talented data people, a good starting place is the NPPES dataset (National Plan and Provider Enumeration System), which contains about 7.4 million NPI records for individuals and organizations. The download file is much to large to use in ordinary office software, so your team will have to cut it into pieces. Or you can get the full NPPES already processed into a form to be used with Microsoft Office programs from CarePrecise. The CarePrecise product also contains additional data, such as sanctions, and whether or not a practitioner is enrolled to bill Medicare.

Once you have basic data on the providers, you'll want to add linkages between the clinicians and their practice groups and hospital affiliations. You can download the free Physician Compare database and have your tech team work its magic here, too, to make it useable on ordinary office computers. This used to be easier back when CMS included hospital information in the database, but now just to get all the hospital names and basic info you have to ingest ten additional datasets. The list is too big to include here, but highlights include the Licensed and Certified Healthcare Facility Listing where you'll find hospitals' CCN numbers matched to their names and addresses, and Medicare Inpatient Hospitals where you'll find some payment information. You'll want to head on back to CMS to pick up outpatient hospital info. These are just a few of the dozens of datasets we ingest on an ongoing basis to produce our monthly updates. For the datasets we monitor but don't regularly ingest, we're more than happy to help customers dig it up.

Hospital data is a bit easier to find and work with than practitioner data. For instance, the list of U.S. physicians is about 1.1 million doctors long, and that's too big to open in Excel. You'll need to get the physician files into a relational database for them to be very useful. If you're starting from the provider data catalog, you'll see the datasets for hospitals, home health agencies and other kinds of healthcare providers, as well as those doctors and other clinicians. You can also find physicians' CAHPS (patient experience metrics), as well as many of the types of procedures physicians perform.

Perhaps the best advice we find ourselves giving our customers who want to go it alone is to have a crackerjack tech team, or at least one person with a lot of database savvy, and start with buying a basic provider data product that you can use as a data structure template. Most federal data on clinicians is linked to their NPI number, so that's where you'll start building your relational database. Your next step is to talk with whoever sold you your basic data, and ask for help finding any missing components. CarePrecise prides itself on offering most of these, all ready to use, but some customers just enjoy the hunt, and even our most comprehensive data package can't contain everything you might want.

We don't shy away from telling our customers where they can find what they're looking for, even if the only place happens to be one of our competitors. In fact, CarePrecise data is compatible with data structures used across the industry. We even provide the Placekey for almost every record in our products, which connects our data with visitor traffic data and other Point of Interest (POI) products offered by other companies.

Many CarePrecise customers get our extended provider data package. CarePrecise Platinum has those elusive practice group and hospital affiliations, and software that makes it possible to get at exactly what you need without knowing anything about databases. It makes a great starting place for building your own bespoke database. 

About Updates

When you're finding and ingesting data, it's important to plan for updates. Some data sources are updated weekly, others monthly or quarterly, and some only on an annual basis. Create a table listing the resources and their update frequency, and build in the necessary automation to re-ingest them regularly.  This is especially important if your use case requires up-to-date information. This often overlooked step of building-in updates can be costly to do later on. Best if it's baked-in from the beginning. This includes your ingestion process for data you get from us, which you can automate to import the monthly or quarterly updates. We offer FTP delivery as an option, which can put the data directly onto your server, ready to be ingested by stored procedures that are triggered by the upload of the data, or by the modified date on the files.

If you want some help finding data sources, just speak with your CarePrecise representative. We may already have an affordable solution that will save you many hours of understanding an unfamiliar and often cryptic dataset. If we don't have it, your representative will help you find it.

One quick note... We offer these sourcing services to current CarePrecise subscribers. It would be great if we could open it up to everyone, but we have to keep our focus on our customers.

Two Decades Later, CMS Releases Draft Rule on Claims Attachments

More than twenty years after the original HIPAA Transactions and Code Sets Final Rule established mandatory standards to simplify and expand the use of electronic data interchange (EDI) to transmit administrative healthcare messages electronically between providers and payers, CMS has finally released the Electronic Claims Attachment standard promised in that regulation.

More specifically, the draft regulation provides specifications for documents necessary to support both healthcare claims and prior authorizations. Also included are specifications for electronic signatures needed in association with these transmissions, and a version upgrade for some existing transactions already in use.

At a tidy 31 pages, the title is exuberantly verbose: Administrative Simplification: Adoption of Standards for Health Care Attachments Transactions and Electronic Signatures, and Modification to Referral Certification and Authorization Transaction Standard. The first pages of the narrative are both a history lesson and a reference library tracing the development and evolution of the industry wide collaboration known as Administrative Simplification or, to participants, portmanteaued as "AdminSimp." I say "library," because as the authors, in explaining how we got to this point, generously footnoted -- and linked -- the key documents that mapped that progress.

For example:

9 CAQH CORE Report on Attachments: ‘‘A Bridge to a Fully Automated Future to Share Medical Documentation’’, CAQH CORE, May 9, 2019: https://www.caqh.org/about/press-release/caqh-core-study-reveals-five-opportunities-increase-electronic-exchange-medical.

That press release then points to the white paper: CAQH CORE Report on Attachments: A Bridge to a Fully Automated Future to Share Medical Documentation.

The comment period on the new regulation is open until 5 p.m. on March 21, 2023.  CMS will be hosting two informational calls with Q&A over the next few weeks. I'll be attending the one on January 25.

Physician Quality Grading for Consumers

Update March 2023: Physician Compare data is available as part of a rich physician database compiled from Physician Compare and numerous other sources. All reported physician/facility affiliations are included, with more than 50,000 medical facilities covered. 

Columbia University Medical Center has just this week [week of 4/12/2016] published a guide to the Physician Compare quality data. While the release of physician quality data has been delayed, expectations are that it will appear in 2017.

CMS will generate star ratings based on data drawn from the Consumer Assessment of Healthcare Providers and Systems (CAHPS), the Physician Quality Reporting System (PQRS), as well as Accountable Care Organization (ACO) and claims data. CMS will set benchmarks based on the Achievable Benchmark of Care (ABC) methodology.

The data will be made available with the intent to help consumers to make informed decisions and to encourage physicians to improve performance, leading to more efficient and healthful outcomes.

CarePrecise will continue to monitor the project, and will begin including physician quality data in an upcoming product, The Authoritative Physician Database™, as it currently does with its product The Authoritative Hospital database™. CarePrecise is a leading supplier of healthcare provider data used in consumer-facing web and mobile applications, through special licensing arrangements.

Medicare Fraud Steals $60 Billion a Year

Six months after a provider performs a particular medical procedure, they can bill it again. And, exactly six months to the day, the provider photocopies the original claim, changes the date, and sends the scammed claim it off to Medicare.

$60 billion worth of fraud is roughly 10% of the total amount Medicare pays out every year on healthcare for 54 million people. According to a March 7 WIRED article, "Since 2007 more than 2,300 providers have been charged with fleecing Medicare, and more than 1800 defendants have been convicted of felony offences, ranging from claiming phantom services to performing unnecessary surgeries."

Among CarePrecise Clients are the Federal Bureau of Investigation and state anti-fraud law enforcement bodies. CarePrecise provides comprehensive data on healthcare providers.

How will ever stop these scams? There are just too many of them for CMS' dedicated investigators to keep up. But the government is getting help from hundreds of citizens: whistle-blower lawsuits allow any medical office staff or other insider to sue their employer and collect 15% to 30% of the settlement. The number of bounty hunters is growing; in 2014 there were 469 such settlements resulting in $2.2 billion in fines.

Professional whistle-blower lawyers can help skittish employees to rat correctly, but they may not have the investigative chops. Now one clever business has begun to turn medical office whistle-blowing into a growth industry. National Healthcare Analysis Group may do more to help recover this money than has been possible in the past by organizing the process and "packaging" it. Read more about it...

COMING: Standard Quality Measures

The Obama administration, acting in concert with the health insurance trade group America's Health Insurance Plans (AHIP), announced today an agreement to develop a standardized set of healthcare quality measures for physicians. In particular, the new quality measurement system will track care given by accountable care organizations, patient-centered medical homes, primary care physicians, cardiologists, gastroenterologists, HIV and hepatitis C care providers, medical oncologists, orthopedists, obstetricians and gynecologists.

As physician's pay from insurance plans is more and more tied to quality outcomes - did the patient get well, or will there be additional claims down the road? - a system for measuring outcomes has become necessary. In recent years, government and private health plans have been working separately, and a confusing array of different measures for different companies has been growing. The CMS/AHIP agreement will seek to create a single standard system of measurement, relieving much of the burden caused by separate systems. In their news release, acting CMS administrator Andy Slavitt stated that "this agreement today will reduce unnecessary burdens for physicians and accelerate the country's movement to better quality." Representatives of the American Medical Association and the Americal Academy of Family Physicians praised the effort.

Sunshine Thursday Morning

Open Payments, also known as the "Sunshine Act," relationship-data-collecting-period starts August 1, 2013, bright and early. Some of our customers are using CarePrecise data as the basis for the physician database underlying their Open Payments tracking process.

Starting August 1, manufacturers and suppliers have to start tracking payments and other transfers of value made to physicians and teaching hospitals, an certain ownership or investment interests held by physicians or their family members. Names, dates, values and other data must be captured, and will be required to be submitted to Centers for Medicare and Medicaid Services in early 2014. Submission files specifications are available for review.

Two New Beta Provider Data Releases

This summer has seen one spectacular new release of healthcare provider data from CarePrecise already, and a second is on the way. The first one, released just a week ago, is already finding its way into EMR pre-population, new web apps, OpenPayments and HIE applications.

The Extended Professional, Group & Hospital(TM) dataset extends CarePrecise's flagship master database, CarePrecise Access Complete (CPAC), with verified group practice data for physicians and other providers, their hospital affiliations, medical schools and graduation years. The EPGH's Extended Hospital table provides an unduplicated list of all U.S. acute care, VA, children's and critical access hospitals that bill Medicare (essentially all of these hospital types bill Medicare, so this list is nearly complete; link it to hospital data in the CPAC, and you've got everything -- a more complete, up-to-date and verified database of physicians than the American Medical Association's list at a small fraction of the cost... plus more than 3 million other healthcare providers not included in the AMA data.

The EPGH has only been released in beta so far, and in beta it is being distributed to all current CPAC subscribers free of charge through September 2013. The EPGH/CPAC bundle is the only commercially available merged database of NPPES, LEIE, PECOS, PhysicianCompare and HospitalCompare data, and it contains all of the "hooks" necessary to link to CMS hospital quality data and forthcoming physician quality data.

Coming next is the beta release of CP ProCase(TM), a proper-case version of the name, mailing address and practice address in CPAC, for all approximately 4 million records. Using CPAC data for marketing and other communications will be easier and more professional looking. As with the EPGH dataset, the ProCase add-on will be available bundled with CPAC, and not separately.

Planned beta release of CP ProCase will coincide with the August 2013 CPAC update release. As with EPGH, ProCase will be distributed as a free beta for evaluation to all current CPAC subscribers. (Betas are not available on single download purchasers.)

And, as if that weren't enough, our popular software, CP ListMaker, is undergoing a rebuild to add EPGH functionality. (Proper casing is already a feature of CP ListMaker.) The new version -- 4.01 -- will sport new output queries that include the new extended data linked to list outputs, completely configurable to use the new information. Release date for CP ListMaker v4.01 is scheduled to coincide with the August CPAC data release.

Questions about the new products? Call your CarePrecise sales representative at (877) 782-2294.

Doctors: Will Patients Misread Sunshine Info?

The Centers for Medicare and Medicaid Services (CMS) is reassuring physicians about Physician Payment Sunshine Act reporting, saying that reporting efforts involving connections between physicians and vendors will fall largely on the shoulders of the vendors, rather than on physicians. But that's not the only issue that worries docs. Once the Sunshine data becomes public, they are concerned that it may be incorrectly interpreted by consumers and the media, leading to unwarranted witch hunts. At the AMA's House of Delegates meeting in Chicago, pediatrician Lynda Young said "The media can really sensationalize this," worrying that when information goes public, "the media jumps on it."

The Sunshine Act (Section 6002 of the Patient Protection and Affordable Care Act) is being rebranded by CMS as the "Open Payment Program," according to a June 20 article in Modern Healthcare. Quoting Dr. Shantanu Agrawal, director of the CMS data-sharing and partnership group, the agency wants to create a national transparency program for payments to physicians and teaching hospitals by drug and medical-device manufacturers and group purchasing organizations. According to Agrawal, pharmaceutical companies spent $15.7 billion in 2011 on face-to-face sales and promotional activities. But companies like Pfizer and GlaxoSmithKline have reported reductions in spending to attract doctors.

The law kicks in August 1, requiring drug and device companies to start tracking transfers of anything valued at more than $10. Physicians will be able to see what has been reported about them in the second quarter of 2014, and reports will become public on Septenver 30 of that year.

CarePrecise.com supplies accurate physician databases used by drug and device manufacturers in their Sunshine Act tracking programs.

Healthcare IT Spending Optimism

As federal support for EHR implementation ebbs, other HIT projects are crowding in to keep spending strong. Aging financial management systems will need to be replaced as pay-for-performance ramps up as a result of the Patient Protection and Affordable Care Act. The mandated switch to the ICD-10 diagnostic and procedural code set, requiring updates in IT systems, as well as more advanced coding systems to handle the vastly increased code granularity, not to mention the new technical complexities felt by state Medicaids and CMS itself, is already making good business for firms like Cognosante, a brain trust of some of the most talented healthcare IT people in the country.

BCC Research recently predicted that total spending on clinical health IT would soar to $26.1 billion a year in five years, up from $9.5 billion in 2011 and $11.2 billion in 2012. CarePrecise builds provider databases targeting various applications within the healthcare industry, including EHR, HIE, HIX and Sunshine Law (Open Payments) applications.

Joseph Conn has an excellent article in Modern Healthcare will more details.

Free Webinar on Sunshine Law

The federal National Physician Payment Transparency Program, variously know as NPPTP, Open Payments, and Sunshine Law, requires collection of information by the healthcare industry as of August 1, 2013. Getting ready for that yet? How about some help?

A free webinar is being offered by the Centers for Medicare and Medicaid Services (CMS) on Wednesday, May 22, 2013 titled "National Provider Call: National Physician Payment Transparency Program (OPEN PAYMENTS) - What You Need To Know."

Topics include:

• Overview of final rule
• Review key program dates
• Your role
• Resources available to you

Speakers will be Dr. Shantanu Agrawal, Director, Data Sharing & Partnership Group, and Anita Griner, Deputy Director, Data Sharing & Partnership Group.

Healthcare Fraud Recovery $4.2B for 2012

Attorney General Eric Holder and HHS Secretary Kathleen Sebelius released a report today indicating that for every $1 spent on healthcare fraud and abuse recovery, $7.90 has been returned to the treasury over the past three years. With the Obama administration making recovery a top priority, this is the highest level of return in the 16-year history of the program.

Health Care Fraud Prevention and Enforcement Action Team (HEAT) was created in 2009 to reduce fraud, waste and abuse in the Medicare and Medicaid programs and to crack down on individuals and organizations that are bleeding the system. Last year, the Justice Department opened 1,131 new criminal fraud investigations involving as many as 2,148 defendants. Convictions have been achieved on 826 defendants in fraud-related crimes during the year. In the same year, the department opened 885 new civil investigations.

In 2012, CMS began screening all 1.5 million Medicare-enrolled providers through the new Automated Provider Screening system. APS fingers ineligible and potentially fraudulent providers and suppliers prior to enrollment or revalidation. Nearly 150,000 ineligible providers have been eliminated from Medicare’s billing system so far. 

CarePrecise's standard database of healthcare providers includes a field that indicates providers who may still be active, but have been added to the federal List of Excluded Individuals and Entities, tying excluded providers to their NPI numbers.

15 Types of Medical Billing Fraud & Abuse

Estimates of U.S. medical fraud and abuse go as high as $80 billion. It contributes significantly to rising healthcare and insurance costs.  The complexity and fragmentation of the American healthcare billing landscape is frequently a culprit makes fraud and abuse easier to commit and more difficult to detect.

One of our long-time clients, PayerFusion, has just published an article on its blog highlighting fifteen different forms of fraud and abuse, including upcoding, cloning, phantom billing, and a dozen more. Read the article for useful and timely information on this important subject.

CarePrecise provides software, data and services employed by law enforcement, including the Federal Bureau of Investigation, in ongoing investigations. To report fraud or abuse, go to http://oig.hhs.gov/fraud/hotline/
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CarePrecise encourages you to attend the Big Data for Healthcare Forum, April 29 - May 1, 2013.

Surprise: You May Now Be Liable Under HIPAA

When the HIPAA privacy rule first went into effect, business associates of hospitals, physicians, etc. didn't have to worry about getting in trouble for releasing data in ways that violate patients' privacy.

No more.

In light of several years of clumsy handling of patient data by contractors and employees, it's perhaps not surprising that HHS is changing the rules to extend the strict HIPAA privacy rules -- and penalties for violations -- to external vendors and IT communities.

If you work in any way with patients' medical data -- whether as a data processor, consultant, IT contractor, EHR installer, whatever -- you'd better get familiar with the new rule that goes into effect March 26. It clarifies when breaches need to be reported to the Office for Civil Rights, scraps the old standards for the use of patient-identifiable data for marketing and fundraising purposes, and expands direct liability under the law to so-called “business associates” of HIPAA-covered entities.

Perhaps equally interesting is that patients once again will have the right to limit release of treatment records to insurance companies if they paid out-of-pocket on that treatment. Look out for problems and potential fines related to goof-ups related to granting access to the wrong business partners on the wrong data. Greatly increased penalties for privacy and security violations under the ARRA are explained in the new ruling.

Read the HHS news release.
Read the rule in the federal register (you've still got time to comment).