Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
Problems Pervade the Renal Beneficiary 
and Utilization System 
JANET REHNQUIST 
Inspector General 
FEBRUARY 2002 
OEI-07-01-00250  OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG) mandated by Public Law 95-452, as amended 
by Public Law 100-504, is to protect the integrity of the Department of Health and Human Services 
programs as well as the health and welfare of beneficiaries served by them. This statutory mission is 
carried out through a nationwide program of audits, investigations, inspections, sanctions, and fraud 
alerts.  The Inspector General informs the Secretary of program and management problems and 
recommends legislative, regulatory, and operational approaches to correct them. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) is one of several components of the Office of Inspector 
General. It conducts short-term management and program evaluations (called inspections) that focus 
on issues of concern to the Department, the Congress, and the public. The inspection reports provide 
findings and recommendations on the efficiency, vulnerability, and effectiveness of departmental 
programs. 
OEI's Kansas City office prepared this report under the direction of Brian T. Pattison, Regional 
Inspector General.  Principal OEI staff included: 
Region  Headquarters 
Madeline Carpinelli, Chicago, Program Analyst  Bambi Straw, Program Specialist 
Brian T. Whitley, Kansas City, Program Analyst 
To obtain copies of this report, please call the Kansas City Regional Office at (816) 426-3697. 
Reports are also available on the World Wide Web at our home page address: 
http://oig.hhs.gov/oei/  E X E C U T I V E   S U M M A R Y  
PURPOSE 
To describe the state of the Renal Beneficiary and Utilization System and to evaluate how the 
system and resulting data are used. 
BACKGROUND 
End Stage Renal Disease (ESRD), characterized by a permanent loss of kidney function, is the 
only basis for entitlement to Medicare based on the presence of a specific medical diagnosis. 
The ESRD beneficiaries are entitled to full Medicare benefits as well as the services Congress 
specifically allows for these beneficiaries (e.g., dialysis, transplant procedures, selected 
pharmaceuticals, and nutrition supplies). At the end of 1999, the ESRD population in the 
United States had climbed to approximately 329,000, with Medicare expenditures of $11.3 
billion. In the next 10 years, the number of individuals with ESRD, as well as Medicare 
expenditures, is projected to double. 
The Centers for Medicare & Medicaid Services (CMS) is charged with the administration of 
the ESRD Program. Within CMS, the Information Systems Group manages the operation of 
the legislatively mandated system covering medical and demographic information for the 
Medicare ESRD population, the Renal Beneficiary and Utilization System (REBUS). 
The REBUS is intended to serve as a source of ESRD information, consolidated from various 
data providers.  The main function of REBUS is to maintain data used in the determination of 
Medicare entitlement, including disenrollment, death, transplant, and dialysis treatment data. 
The REBUS also supports program analysis, policy development, program operations, and 
epidemiologic research. We were alerted to problems with REBUS when we experienced 
complications attempting to access data from the system for another inspection.  Given the 
critical nature of the system, we examined the status of REBUS and evaluated the effects that 
data and communication problems have on data providers and end users. 
FINDINGS 
Datasets Within the Renal Beneficiary and Utilization System are Out-of-date, 
Incomplete, and Inaccurate 
Problems existed with 9 of the 12 REBUS datasets within the 12 months prior to the 
completion of our fieldwork (August 2001).  Although CMS has taken steps to update some 
datasets, problems continue.  The most common problem with REBUS datasets is that they are 
out-of-date, thus leading to incomplete and inaccurate data. 
i 
Renal Beneficiary and Utilization System Review  OEI-07-01-00250  Data Problems Result in Duplication of Effort, Delays, and Program Vulnerabilities 
Due to data problems with REBUS, some groups are requesting data already provided to 
CMS directly from the data providers.  Representatives from the United States Renal Data 
System (USRDS) reported that their 2001 annual report, which presents national ESRD data, 
was delayed due to shortcomings in the REBUS data. Representatives from both CMS and 
the USRDS stated that when the dataset regarding Transplant Follow-up was not current, 
CMS did not have the information needed to terminate beneficiaries who had undergone 
successful transplants, thus resulting in an estimated 50,000 individuals continuing to receive 
Medicare benefits beyond their period of eligibility. In addition, incomplete Patient Status data 
has led to termination of ESRD benefits for beneficiaries enrolled in managed care plans. 
Data Problems are the Result of Historical Complications, a Lack of Resources, 
and an Outdated Database 
Data problems have plagued the ESRD Program since its inception in 1973.  The CMS has 
reorganized several times, resulting in changes in the components responsible for operation and 
oversight of REBUS. During these reorganizations, key staff members were reassigned, 
including the two original architects of REBUS. In addition, the REBUS uses an outdated 
programming language, and there are few programmers who have the expertise to work with 
such a system.  Due to its age and programming language, REBUS is incompatible with the 
modernized systems with which it is supposed to exchange data. 
Lack of Defined Roles and Relationships Leads to Poor Communication 
Representatives from the primary organizations providing data for or using data from REBUS 
(e.g., the ESRD Networks, United Network for Organ Sharing, and the United States Renal 
Data System) noted long standing communication problems with CMS. Representatives said 
that few meetings are held to discuss data quality issues. The CMS representatives agreed that 
communication with some groups may be lacking. 
RECOMMENDATIONS 
The CMS is well aware of problems within REBUS.  The CMS has expended considerable 
effort maintaining and updating REBUS, and steps have been underway for some time to 
develop a replacement system. Considering the history of data problems with REBUS and the 
various delays that have stalled the implementation of the replacement system, we recommend 
that CMS: 
Develop a Strategic Plan for Addressing ESRD Data Management 
The strategic plan should build on CMSs current efforts to address data shortcomings. At a 
minimum, the plan should address the following four areas: 
ii 
Renal Beneficiary and Utilization System Review  OEI-07-01-00250  <  Short and Long-Term Targets 
The CMSs strategic plan should address target dates for updating REBUS and restoring out-
of-date datasets. In addition, the plan should establish realistic target dates for the completion 
of the replacement system and the transfer of data from REBUS into this system. 
<  Data Needs 
Problems with the timeliness, completeness, and accuracy of some datasets within REBUS 
raise questions as to the importance of these datasets to the operation of CMSs ESRD 
program.  The CMS should assess internal data needs and the needs of external data users to 
determine the appropriateness of CMS maintaining these data. 
<  Efficiency of Data Distribution 
Within the constraints of the Privacy Act and other applicable laws and regulations, CMS 
should reassess where and how ESRD users obtain needed data.  If CMS decides that it is 
most appropriate for end users to obtain data directly from the source, it should factor in this 
decision when determining which datasets should be retained. 
<  On-going Communication 
The CMS should establish regular, periodic meetings to discuss ESRD data management issues 
with internal and external data providers and end users. 
Coordinate with the Social Security Administration to Address Errors in Basic 
Beneficiary Information 
According to CMS representatives, SSA has given low priority to correcting errors in ESRD 
beneficiary records. The CMS may want to consider holding high-level meetings with SSA to 
develop a mutually acceptable solution for addressing problems with basic beneficiary 
information. 
AGENCY COMMENTS 
In its written response to our report, CMS acknowledged limitations with REBUS and 
concurred with our recommendations. The CMS highlighted various actions taken since 
completion of our draft report, including devising short and long-term strategic plans, initiating 
meetings with data providers and users, and reaching agreements to reduce or eliminate non-
essential data transfers. In addition, CMS is now encouraging various data users to seek 
information directly from the source rather than relying on CMSs system. 
We made minor changes to reflect technical comments received from CMS. The full text of 
CMSs comments are included in Appendix A. 
iii 
Renal Beneficiary and Utilization System Review  OEI-07-01-00250  T A B L E   O F   C O N T E N T S  
PAGE

EXECUTIVE SUMMARY ...................................................... i

INTRODUCTION .............................................................1

FINDINGS 
Out-of-date, Incomplete, and Inaccurate Datasets  ......................................8

Duplication of Effort, Delays, and Program Vulnerabilities ................................10

Historical Complications, Lack of Resources, and an Outdated Database  .................... 11

Poor Communication ...........................................................12

RECOMMENDATIONS ...................................................... 14

AGENCY COMMENTS  ...................................................... 16

APPENDIX A ............................................................... 17
 I N T R O D U C T I O N  
PURPOSE 
To describe the state of the Renal Beneficiary and Utilization System and to evaluate how the 
system and resulting data are used. 
BACKGROUND 
This inspection topic stems from complications faced while attempting to access data from the 
Renal Beneficiary and Utilization System (REBUS), the critical End Stage Renal Disease 
(ESRD) data system, for the planned inspection entitled End Stage Renal Disease:  Method 
Election Vulnerabilities.  Efforts to select a universe of beneficiaries for that inspection were 
compromised by problems encountered with a particular dataset within REBUS.  Inquiries to 
the Centers for Medicare & Medicaid Services (CMS) revealed that some datasets in REBUS 
had not been updated in more than 2 years. Concerns about the entire data system developed 
as we were informed that data in other datasets may have been similarly out-of-date and 
incomplete. 
End Stage Renal Disease 
End Stage Renal Disease is characterized by a permanent and irreversible loss of kidney 
function requiring either kidney transplantation or regular dialysis treatments in order to survive. 
In 1972, amendments to Title XVIII of the Social Security Act extended Medicare Part A and 
Part B benefits to virtually all individuals with ESRD regardless of age.1 The ESRD program is 
the only Medicare program for which entitlement is based on the presence of a specific medical 
diagnosis. 
The ESRD beneficiaries are entitled to full Medicare benefits as well as services Congress 
specifically allows for these beneficiaries (e.g., dialysis, transplant procedures, selected 
pharmaceuticals, and nutrition supplies).  In 1973, the year in which the program was initiated, 
the number of eligible ESRD beneficiaries totaled 10,000. By the end of 1999, the ESRD 
population in the United States had climbed to approximately 329,000, with Medicare 
expenditures of $11.3 billion.2 The number of individuals with ESRD is 
1 
Individuals who suffer from ESRD and are under age 65 may experience a 3-month waiting period prior to 
Medicare coverage. In addition, individuals who have coverage under an Employers Group Health Plan may 
undergo a 30-month period in which Medicare acts as a secondary payer to the Group Health Plan. 
2 
United States Renal Data System, retrieved from the World Wide Web: http://www.usrds.org/atlas.htm 
(August 30, 2001). 
1 
Renal Beneficiary and Utilization System Review  OEI-07-01-00250  projected to double by 2010, surpassing 660,000 individuals, with projected Medicare 
expenditures in excess of $28 billion.3 
The CMS is charged with the administration of Medicare benefits to eligible persons with 
ESRD. Integral to the effective administration and management of this program is the effective 
operation of REBUS, the comprehensive database covering medical and demographic 
information for the Medicare ESRD population. 
ESRD Information System 
In 1978, Public Law 95-292, section (c)(1)(A), mandated the Secretary of the Department of 
Health, Education and Welfare to establish a renal disease medical information system. This 
legislation stemmed from the need to calculate utilization rates and serve the administrative 
needs of the expanding program.  The resulting system merged data from an existing patient 
dialysis registry, a transplant registry, and Medicare eligibility and claims data from the Social 
Security Administration (SSA). 
The technical design and operation of this data merger proved difficult. An agency report from 
the then Health Care Financing Administration noted that poor contract management, inter-
office miscommunication, and staff turnover slowed the implementation of the system.4 After an 
internal reorganization, the ESRD program staff began publishing the first series of regular 
reports using the ESRD medical information system in mid-1979. The system was fully 
operational by July 1980. 
The Renal Beneficiary and Utilization System 
The REBUS is the interactive tool used to access data within the Program Management and 
Medical Information System, the actual repository for the ESRD program data. This repository 
contains data covering the medical and demographic information for the ESRD population. 
Both CMS and the end users of data commonly refer to both the tool and the repository as 
REBUS, as will we throughout this report. The main function of REBUS is to maintain data 
used in the determination of Medicare ESRD entitlement, including disenrollment, death, 
transplant, and dialysis treatment data.  The REBUS also supports program analysis, policy 
development, program operations, and epidemiologic research. 
3 
United States Renal Data System, retrieved from the World Wide Web: http://www.usrds.org/ 
atlas_2000.htm (August 30, 2001). 
4 
Implementing the End Stage Renal Program of Medicare, Richard Rettig, R-2505 HCFA/HEW, September 
1980. 
2 
Renal Beneficiary and Utilization System Review  OEI-07-01-00250  The CMS describes REBUS as: 
. . . a mission critical system that is used by CMS and the renal community to 
perform their duties and responsibilities in monitoring the Medicare status, 
transplant activities, dialysis activities, and Medicare utilization (inpatient and 
physician-supplier bills) of ESRD patients and their Medicare providers, as well 
as in calculating the Medicare-covered period of ESRD. 
The REBUS data are used for payment decisions and actuarial projections, as well as serving 
the needs of the research and planning divisions within CMS, including the Center for 
Beneficiary Choices, the Office of Clinical Standards and Quality, The Center for Medicaid and 
State Operations, and the Office of Strategic Planning. 
REBUS Structure 
The REBUS is composed of twelve datasets. The information contained within those datasets 
is derived from data exchanges between groups as indicated below.  The providers for this data 
are further described on the following page. 
Dataset  Data Description  Data Source 
Death Notice  Date, place, and cause of death  ESRD Networks 
Facility Certification  Annual provider-specific treatment and transplant data  ESRD Networks 
Identification  Basic beneficiary, entitlement, and ESRD termination data  Social Security Administration 
Inpatient Stay  Hospital stay dates, provider number, surgery information  National Claims History 
Medical Evidence  Medical conditions, lab results  ESRD Networks 
Method Selection  ESRD payment method chosen by home dialysis patients  Common Working File 
Patient Status  Verified renal status, dialysis type, most recent treatment  ESRD Networks 
setting 
Quarterly Dialysis  Aggregated information for all dialysis claims in the quarter  National Claims History 
SSA District Office  Addresses of local Social Security Administration offices  Social Security Administration 
Transplant  Date of transplant; organ donor data  United Network for Organ 
Sharing 
Transplant Follow-up  Tracks the status of the beneficiaries transplant  United Network for Organ 
Sharing 
Wait List  Potential kidney transplant recipients awaiting transplantation  United Network for Organ 
Sharing 
Source: CMS Data Users Guide 
3 
Renal Beneficiary and Utilization System Review  OEI-07-01-00250  REBUS Data Exchanges and Usage
The REBUS data mostly are created and maintained in other systems, and then periodically
uploaded into REBUS.  Below are descriptions of the various data providers for REBUS,
followed by descriptions of common users of REBUS.  The primary sources of data for
REBUS and the users of the resulting REBUS data are illustrated below in Diagram 1.  A
discussion of the data sources and external data users follows the diagram.
Diagram 1: REBUS Data Providers and Users
Data Providers (Internal)
Enrollment Database -- This database contains information on all Medicare beneficiaries from
the beginning of the Medicare program in 1966 to the present.
Common Working File -- Fiscal intermediaries and carriers, which work under contract for
CMS, use the Common Working File to process claims.  The file contains edits to screen
claims, helping to ensure proper claims processing.  These edits, for example, would help
ensure that ESRD-related claims are supported by a diagnosis of ESRD for the beneficiary or
that the type of treatment being claimed corresponds with the method of treatment the
beneficiary selected.
National Claims History -- This file serves as a single repository for both Medicare Part A
and Part B claims, which would include 100 percent of ESRD claims.  The National 
4
Renal Beneficiary and Utilization System Review                                                                                          OEI-07-01-00250 Claims History contains every claim submitted since 1991 along with all adjustment claims. 
Data Providers (External) 
ESRD Networks -- In 1987, Congress mandated the formation of 18 ESRD Networks to 
assist in the collection and verification of patient, facility, and provider data. Dialysis treatment 
facilities complete required HCFA forms, including the HCFA-2728 Medical Evidence, 
HCFA-2746 Death Notification, and HCFA-2744 Annual Facility Survey.  These forms are 
then forwarded to the regional Networks for data entry into the Standard Information 
Management System (SIMS), an electronic database implemented in January 2000. This 
system enables all 18 Networks to maintain uniform beneficiary and provider data from their 
respective regions, which are to be periodically uploaded into REBUS. 
Social Security Administration -- The primary source for beneficiary information in CMSs 
Enrollment Database is SSA, which supplies information for updating the database daily. 
The United Network for Organ Sharing (UNOS) -- The UNOS maintains the nations organ 
transplant wait list under contract with the Health Resources and Services Administration 
(HRSA). This data is instrumental in developing organ transplantation policy as well as 
maintaining effective operation of the Organ Procurement and Transplantation Network. The 
Network maintains a national electronic list of patients waiting for organ transplantation and is 
responsible for matching donors and recipients. The UNOS sends their data to CMS, which is 
then loaded into REBUS.  The data includes information regarding the donor and recipient, the 
date of the organ transplant, and routine follow-up information on the patient and transplanted 
kidney. 
Data Users (External) 
United States Renal Data System (USRDS) --In 1986, Public Law 99-509 mandated the 
establishment of a national ESRD patient registry. This registry, the USRDS, formerly operated 
through the University of Michigan and currently operates through the Minneapolis Medical 
Research Foundation, University of Minnesota Twin Cities under contract with the National 
Institutes of Health. The USRDS relies on REBUS as its major source of data on the incidence 
and prevalence of kidney failure, the rates of hospitalization and transplantation, the rates and 
causes of death, and the costs of associated medical care.  The USRDS distributes information 
to Congress, several Federal agencies, and the ESRD community through its annual reports. 
Independent Researchers -- The CMS creates Public Use Files used for independent and 
organizational research.  The REBUS has been used in a number of ways, including basic 
descriptive epidemiology, analysis of mortality rates, and assessments of programmatic issues, 
such as reimbursement and clinical practice. 
5 
Renal Beneficiary and Utilization System Review  OEI-07-01-00250  University of Michigan Kidney Epidemiology and Cost Center (KECC) -- The Center uses 
data from REBUS to create facility specific reports for facilities, Networks, and state agencies. 
The Center also creates state specific reports which are used in program operations and 
oversight. 
Social Security Administration -- The SSA receives ESRD termination data from REBUS so 
that it can correctly terminate beneficiaries as their entitlement expires. 
The Renal Management Information System (REMIS) 
The CMS is developing a modernized information system to replace REBUS. The 
replacement, REMIS, is expected to improve system access and data quality because it will 
integrate better with updated systems of internal and external data providers.  Plans for the 
development of REMIS were announced in December 1999, with the implementation date 
originally set for Spring 2000. Due to delays in the development of REMIS, the current target 
date is Spring 2002. 
Other ESRD Work by the Office of Inspector General 
The Office of Inspector General (OIG) has issued several ESRD-related studies. Most 
recently, the OIG released External Quality Review of Dialysis Facilities: A Call for Greater 
Accountability, OEI-01-99-00050, June 2000. The study found that CMS does not require a 
core set of facility-specific clinical performance measures, limiting its ability in identifying poorly 
performing facilities. The study also found deficiencies in lines of communication between the 
Networks and State agencies. 
In January 2001, the OIG issued Review of Separately Billed End Stage Renal Disease 
Hospital Outpatient Laboratory Tests Included in the Composite Rate, A-01-99-00506, a 
follow-up to the October 1996 report, Review of Separately Billable ESRD Laboratory 
Tests, A-01-96-00513. Both reports found that hospital laboratories were reimbursed 
separately for laboratory services already included in the dialysis facilitys composite rate. 
Based on a statistical sample, the 2001 report estimated that $6.1 million was improperly paid 
to hospital laboratories for services provided to ESRD beneficiaries during calendar years 1995 
through 1997. 
The OIG also released three reports focusing on the appropriateness of payments to Health 
Maintenance Organizations for ESRD-classified beneficiaries. In February 1996, the OIG 
issued Review of Medicare Payments to Health Maintenance Organizations for End Stage 
Renal Disease Beneficiaries, A-04-94-01090.  Later the OIG released End Stage Renal 
Disease Payments to Health Maintenance Organizations (HMOs), A-14-9600203, June 
1997, and Review of HMO Payments-Beneficiaries on Dialysis, A-14-98-00211, July 2000. 
In each of these reports, the OIG found significant overpayments to HMOs for Medicare 
beneficiaries inappropriately identified as having ESRD due to the enhanced rate received for 
patients in that high-cost category. 
6 
Renal Beneficiary and Utilization System Review  OEI-07-01-00250  METHODOLOGY 
As previously stated, this inspection was an outgrowth of complications faced while attempting 
to access data from REBUS for a planned inspection. Based on the data problems we 
identified through our initial inquiry, we gathered additional information from key stakeholders, 
including the Information Systems Group within CMSs Office of Clinical Standards and 
Quality, the ESRD Networks, UNOS, USRDS, and KECC. We were able to identify these 
key stakeholders through a CMS issued Data Users Guide which described each dataset of 
REBUS and how the information was exchanged between REBUS and stakeholders. 
Using structured discussion guides, we collected from the Information Systems Group 
information about the concept and design of REBUS, the causes of current and prior data 
problems, and the phase-in plans for REMIS. We collected from external data providers (e.g., 
UNOS) and data users (e.g., USRDS) their experiences working with REBUS and CMS, the 
challenges they faced accessing and/or submitting data to REBUS, the effect data and system 
problems have had on their operations, and the steps they have taken to overcome these 
problems. 
We analyzed all collected information, comparing the collective experiences of data providers, 
CMS, and data users, along with our own experiences. Our inspection focus was to assess the 
status of the individual REBUS datasets and how problems impact upon the data providers and 
users of the system. We did not test data within REBUS for completeness or accuracy 
because it was not our intent to assess the magnitude of problems so much as to assess the 
nature of the problems. 
We conducted follow-up interviews with CMS regarding the status of REBUS datasets and 
any plans for updating these datasets as a final step in our fieldwork.  Therefore, all statements 
related to status and update plans are current as of August 2001. 
We conducted this inspection in accordance with the Quality Standards for Inspections 
issued by the Presidents Council on Integrity and Efficiency. 
7 
Renal Beneficiary and Utilization System Review  OEI-07-01-00250  F I N D I N G S  
Datasets Within the Renal Beneficiary and Utilization System 
are Out-of-date, Incomplete, and Inaccurate 
Problems existed with 9 of the 12 REBUS datasets within the 12 months prior to our fieldwork 
completion (August 2001). The table below provides the status of all REBUS datasets as of 
August 2001, followed by discussions of problems with selected datasets.5 
Table 2: REBUS Dataset Status 
Dataset  Description  Status  Plans for updating 
Death Notice  Date, place, and cause of death  Current  N/A 
Facility Certification  Annual provider-specific treatment  Current  N/A 
and transplant data 
Identification  Basic beneficiary information,  Not Current  Dependent on other 
entitlement and ESRD termination  datasets 
data 
Inpatient Stay  Hospital stay dates, provider  Not Current  Up-to-date within 1 
number, surgery information  month 
Medical Evidence  Medical conditions, lab results  Current  N/A 
Method Selection  ESRD payment method chosen by  Not Current  Data needs to be 
home dialysis patients  uploaded 
Patient Status  Verified status, dialysis type, most  Not Current  Up-to-date within 3 
recent treatment setting  months 
Quarterly Dialysis  Aggregated information for all  Current 6  N/A 
dialysis claims in quarter 
SSA District Office  Address of local SSA offices  Not Current  No plans to update 
Transplant  Date of transplant, organ donor  Current6  N/A 
data 
Transplant Follow-up  Tracks status of beneficiary  Current6  N/A 
transplant 
Wait List  Potential kidney transplant  Not Current  Up-to-date within 3 
recipients awaiting transplant  months 
5 
The status of REBUS datasets as of December 21, 2001, as reported by CMS, is included in Appendix A. 
6 
These datasets were out-of-date during the prior 12-month period. 
8 
Renal Beneficiary and Utilization System Review  OEI-07-01-00250 The Method Selection dataset is more than 2 years out-of-date 
We found that the Method Selection dataset, which indicates the payment method and the 
source of dialysis supplies for home dialysis beneficiaries, was more than 2 years out-of-date at 
the time of this review. We initially identified problems with this dataset when we attempted to 
select a universe of beneficiaries for the End Stage Renal Disease:  Method Election 
Vulnerabilities inspection. The CMS representatives reported that, although they have since 
collected the historical data needed to update the dataset, they have yet to upload the data to 
bring the dataset up-to-date.  Therefore, in order to obtain the method selection data needed 
for the aforementioned inspection, we have requested data directly from the Common Working 
File, which supplies REBUS with this data. 
Systems incompatibility with the United Network for Organ Sharing has led to out-
of-date and incomplete transplant data in REBUS 
The three datasets pertaining to organ transplantation (Transplant, Transplant Follow-up, and 
Wait List) are further examples of datasets which are out-of-date, leading to incomplete data. 
In January 2000, UNOS changed both the layout within their database and the method they use 
to submit data.  The CMS was unable to upload this reformatted data into REBUS, which led 
to the datasets becoming out-of-date. After rewriting the process of accepting the UNOS 
data, CMS has reported they are now posting data to the Transplant and Transplant Follow-up 
datasets in a timely manner; however, problems still remain with the Wait List dataset. Because 
Medicare beneficiaries with successful transplants are limited by law to 36 months of post-
operative coverage, the data UNOS supplies are essential for determining continued Medicare 
eligibility for patients with transplants. 
Incomplete Patient Status data in REBUS may lead to termination of ESRD 
beneficiaries enrolled in managed care plans 
Representatives from the CMS regional offices alerted us to the potential of ESRD beneficiaries 
enrolled in managed care plans having their benefits inadvertently terminated because of 
incomplete data in the Patient Status dataset. The CMS relies on automated systems to 
determine the continued eligibility of ESRD beneficiaries. These systems rely on both claims 
activity (an estimated 15 percent of the Medicare ESRD beneficiaries are enrolled in managed 
care plans, meaning that these beneficiaries do not have individual dialysis claims filed for their 
treatments) and Patient Status data. The CMS formerly relied on the Networks bi-annual 
facility census to verify the status of patients. However, with the implementation of SIMS, the 
Networks no longer send this information.  The REBUS is supposed to load the information 
continuously from SIMS, but the system is incompatible with SIMS and is unable to upload 
information directly. Therefore, patient status information in REBUS remains incomplete. 
Managed care beneficiaries run the risk of incorrect termination of benefits because CMS will 
terminate eligibility after 12 months of no claims activity and no update in Patient Status 
information. 
9 
Renal Beneficiary and Utilization System Review  OEI-07-01-00250  Basic patient information in the Identification dataset is inaccurate 
The Networks, CMS, and USRDS all acknowledged problems with data in the Identification 
dataset. Information for this dataset is uploaded daily into REBUS based on information 
received from SSA. The ESRD Networks also maintain beneficiary identification information 
derived from the facility and patient forms. For several years, the SSA and Network data have 
not matched. During this time, CMS generated reports of non-matching data and sent these to 
both SSA and the Networks for verification or correction, as appropriate.  The CMS officials 
reported that they have held discussions with various components within SSA regarding data 
errors. In addition, the Networks have and continue to report that they find their information is 
correct.  Because the information in the Identification dataset is overwritten nightly based on 
information received from the SSA Master Beneficiary Record, it is not possible to correct the 
information in the Identification dataset permanently unless the SSA corrects its data.  The SSA 
acknowledges that data corrections are a low priority unless the data directly effects beneficiary 
benefits and so data problems remain unresolved. 
Data Problems Result in Duplication of Effort, Delays, and 
Program Vulnerabilities 
We found that problems with REBUS data have created complications for data users. For 
example, CMS requires the ESRD Networks to produce annual reports.  Sections of these 
reports are based on transplant information.  As previously stated, transplant data from UNOS 
was, for a time, not loaded into REBUS. The Networks had to request the information directly 
from UNOS to complete their annual reports, which resulted in UNOS producing the same 
data twice.  In addition, UNOS representatives reported that such work results in additional 
charges to the HRSA-administered contract. 
The USRDS reported that its 2001 annual report was delayed due to shortcomings in the 
REBUS data.  Representatives stated that some of the datasets they received had not been 
updated for some time.  Because of outdated datasets, the USRDS had to obtain information, 
which should have been maintained in REBUS, from other sources to supplement the missing or 
incomplete data. 
Moreover, problems with specific datasets in REBUS have created program vulnerabilities. 
The CMS reported delays in updating the Transplant Follow-up dataset, which tracks ESRD 
Medicare beneficiaries after transplantation. Beneficiaries who have undergone a kidney 
transplant are eligible for Medicare benefits for a statutorily set period of 36 months.  If the 
transplant is successful, coverage should be terminated after the 36-month period. 
Representatives from both CMS and USRDS estimate that past problems with updating the 
Transplant Follow-up dataset has allowed an estimated 50,000 individuals with successful 
transplants to continue receiving Medicare benefits beyond their period of eligibility.  Now that 
the Transplant Follow-up dataset is current, CMS representatives report that ESRD 
beneficiaries with successful transplants are being terminated properly. (The CMS 
10 
Renal Beneficiary and Utilization System Review  OEI-07-01-00250  representatives stated that their plans are to retroactively adjust all individuals no longer entitled 
to Medicare due to successful transplants coverage, but not to collect any lost funds.) 
Data Problems are the Result of Historical Complications, a 
Lack of Resources, and an Outdated Database 
Data problems have plagued the ESRD Program since its inception in 1973. As previously 
stated, CMS experienced problems in the development of the original ESRD data system. 
While REBUS has centralized much of the data, many of the earlier identified problems remain. 
For example, in a report to the Secretary of Health, Education and Welfare in 1980, the history 
of the original ESRD system is described: 
. . . at no time in the design, development, or operation of the system was sustained, 
informed policy direction given to the system.  Consequently, issues of feasibility, need, 
and cost either went unanalyzed or were poorly investigated. [There was no] sufficient 
authority or power to give policy leadership . . . furthermore, familiar problems of the 
existing Medicare system nourished a belief that a new system could be created which 
would avoid these problems and that awarding an external contract was the means to 
this end.7 
Although this is a description of the complications faced from 1973 to 1979, many of the 
problems are similar to those CMS currently experiences.  The plan for the transfer to  REMIS 
was first announced in the Information Technology Architecture Sketches newsletter in July 
1999, with plans for implementation by Spring 2000. Two years later, the transfer still has not 
occurred. 
The CMS cited various reasons for this delay. In 1997, CMS undertook an agency-wide 
reorganization, which resulted in the operation and oversight of REBUS moving from the Office 
of Information Systems to the Office of Clinical Standards and Quality. In this move, several 
crucial staff members were reassigned, including the two original architects of REBUS.  Since 
this time, there have been numerous staffing changes, with new members frequently lacking 
experience in the ESRD program. Continuous staffing turnover and general lack of expertise 
have contributed to data problems. 
The CMS has made efforts to address some of these shortcomings. The agency has re-hired 
one of the original architects of REBUS and has contracted with a private company to develop 
REMIS. 
7 
Implementing the End Stage Renal Program of Medicare, Richard Rettig, R-2505-HCFA/HEW, 
September 1980. 
11 
Renal Beneficiary and Utilization System Review  OEI-07-01-00250  Obsolete technology renders REBUS incompatible with other systems and makes 
the system difficult to maintain 
The REBUS was created in 1980 to run as a mainframe application.  Now, more than 20 years 
later, individuals with whom we spoke noted problems with the age of the system, its 
incompatibility with other systems, and the difficulty of finding programmers who know the 
programming language used to create the system.  Each of these hinders CMSs ability to keep 
data within the system up-to-date. 
The CMS has had to take special steps to allow data to be updated from several sources. 
Staff reported the three datasets they have been able to fix (Quarterly Dialysis, Transplant, and 
Transplant Follow-up) have all taken extra effort, such as rewriting the program and manual 
uploading.  Staff also stated that the remaining five datasets plan to be up-to-date by the end of 
calendar year 2001.  It is unclear, given competing priorities, if CMS will meet these target 
dates. 
Lack of Defined Roles and Relationships Leads to Poor 
Communication 
Despite CMSs reliance on external providers for REBUS data, representatives from each of 
the external groups with whom we spoke cited long standing communication problems with 
CMS.  For example, even though UNOS is a major supplier of data and USRDS is a major 
user of REBUS data, there are no formalized communications between these two groups with 
CMS. The CMS representatives reported the occurrence of infrequent meetings to discuss 
data quality issues with UNOS or USRDS, but stated the reason for no formal communications 
with either organization is because they are under contract with HRSA and the National 
Institutes of Health, respectively, making regularly scheduled meetings inappropriate. 
The lack of communication with CMS has frustrated representatives of UNOS and USRDS. 
The UNOS representatives reported the inability of CMS to load their transplant and wait list 
data into REBUS. The UNOS representatives believed regular communications could have 
prevented many of these problems. Representatives from the USRDS expressed frustration 
with learning that CMS knew of data problems, but did not share them with data users. The 
USRDS representatives said that they made efforts to verify the accuracy of data, and, after 
identifying the problems, contacted CMS only to learn that CMS was already aware of the 
problems. 
Networks also noted communication problems and stated their desire for more formalized 
contact with CMS. Although CMS representatives reported that they hold quarterly 
conference calls and that individual Networks are welcome to participate, Network 
representatives seemed unaware of these calls. The Networks are looking for a forum to 
express their concerns with their role. For example, CMS is in the testing phase of this new 
data system, the Vital Information System to Improve Outcomes in Nephrology or VISION. 
This system will allow facilities to electronically submit all facility and patient 
12 
Renal Beneficiary and Utilization System Review  OEI-07-01-00250  information, thus replacing the need for the Networks to enter the data from the paper forms. 
Although CMS sees this as a way of streamlining the data entry process, Networks 
representatives with whom we spoke believe VISION will replace their role of editing and 
reconciling the data. 
Staff within the CMS acknowledged the validity of the Networks complaints regarding 
communication, and stated that the group is working to improve communication. The CMS 
representatives reported they are in the process of assembling several workgroups with 
representatives from CMS, both headquarters and regional offices, and the ESRD Networks to 
encourage communication. The workgroups are being formed to address current ESRD 
concerns and functionality of the Standard Information Management System software 
application and to . . . improve communication between CMS and the Networks regarding 
reporting requirements and clarification of policy issues. 
13 
Renal Beneficiary and Utilization System Review  OEI-07-01-00250  R E C O M M E N D A T I O N S  
The CMS is well aware of problems within REBUS.  The CMS has expended considerable 
effort maintaining and updating REBUS, and steps have been underway for some time to 
develop a replacement system (REMIS). Nevertheless, considering the history of data 
problems with REBUS and the various delays that have stalled the implementation of REMIS, 
we recommend that CMS: 
Develop a Strategic Plan for Addressing ESRD Data 
Management 
The strategic plan should build on CMSs current efforts to address data shortcomings. At a 
minimum, the plan should address the following four areas: 
<  Short and Long-Term Targets 
Data providers and end users are currently experiencing problems with REBUS. The CMSs 
strategic plan should address target dates for updating REBUS and restoring out-of-date 
datasets. In addition, the plan should establish realistic target dates for the completion of 
REMIS and the transfer of data from REBUS into REMIS. This plan should be communicated 
to both data providers and end users for use in their planning. 
<  Data Needs 
Although CMS describes REBUS as  . . . a mission critical system . . .  problems with the 
timeliness, completeness, and accuracy of some datasets within REBUS raise questions as to 
the importance of these datasets to the operation of CMSs ESRD program. The CMS should 
assess internal data needs and the needs of external data users to determine the appropriateness 
of CMS maintaining these datasets, whether in REBUS or in REMIS. 
<  Efficiency of Data Distribution 
Within the constraints of the Privacy Act and other applicable laws and regulations, CMS 
should reassess where and how ESRD data users obtain needed data End users have 
expressed a preference for receiving data directly from the source, largely because of problems 
with REBUS. If CMS decides that it is most appropriate for end users to obtain data directly 
from the source, it should factor this decision when determining which datasets should be 
maintained within REBUS and/or REMIS. The CMS also should work with end users to 
develop the most efficient methods for obtaining data from the providers. These efforts should 
improve overall efficiency and reduce duplication of effort and increased costs. 
14 
Renal Beneficiary and Utilization System Review  OEI-07-01-00250  <  On-going Communication 
All groups who interact with REBUS suggested they would benefit from improved 
communication with CMS, and CMS has agreed.  The CMS should establish regular, periodic 
meetings to discuss ESRD data management issues with internal and external data providers 
and end users. 
Coordinate with the Social Security Administration to Address 
Errors in Basic Beneficiary Information 
Efforts to correct errors in the Identification dataset are not effective as information within this 
dataset is overwritten nightly using information received from SSA. The SSA data will 
overwrite any corrections made to the dataset. According to CMS representatives, SSA has 
given low priority to correcting errors in ESRD beneficiary records. The CMS may want to 
consider holding high-level meetings with SSA to develop a mutually acceptable solution for 
addressing problems with basic beneficiary information. 
15 
Renal Beneficiary and Utilization System Review  OEI-07-01-00250  A G E N C Y  C O M M E N T S  
In its written response to our report, CMS acknowledged limitations with REBUS and 
concurred with our recommendations. The CMS highlighted various actions taken since 
completion of our draft report, including devising short and long-term strategic plans, initiating 
meetings with data providers and users, and reaching agreements to reduce or eliminate non-
essential data transfers. In addition, CMS is now encouraging various data users to seek 
information directly from the source rather than relying on CMSs system. 
We made minor changes to reflect technical comments received from CMS. The full text of 
CMSs comments are included in Appendix A. 
16 
Renal Beneficiary and Utilization System Review  OEI-07-01-00250  APPENDIX A 
DEPARTMENT OF HEALTH & HUMAN SERVICES  Centers for Medicare & Medicaid 
Services 
Administrator 
Washington, DC 20201 
DATE:  DEC 21 2001 
TO:  Janet Rehnquist 
Inspector General 
FROM:  Thomas A. Scully 
Administrator 
SUBJECT: Office of Inspector General (OIG) Draft Report: Problems Pervade the Renal 
Beneficiary and Utilization System (REBUS) (OEI-07-01-00250) 
Thank you for the opportunity to review and comment on the above-referenced draft report, 
which examines problems resulting in duplication of effort, delays, and program vulnerabilities 
in end-stage renal disease (ESRD) data management.  The Centers for Medicare & Medicaid 
Services (CMS) acknowledges the many limitations of the existing REBUS operational 
environment.  We have expended considerable resources to address these shortcomings and have 
developed a short- and long-term strategy to correct these problems.  We are confident that our 
efforts have made considerable progress since your work on this OIG draft report was 
completed.  We will continue in our efforts to keep REBUS current and accurate as we redesign 
ESRD systems to better meet our business challenges. 
We appreciate the effort that went into this report and the opportunity to comment on the issues 
it raises.  Our detailed comments on the OIG recommendations follow. 
OIG Recommendation 
The CMS should develop a strategic plan for addressing ESRD data management.  The strategic 
plan should build on CMS' s current efforts to address data shortcomings.  At a minimum, the 
plan should address the following four areas: 1) short- and long-term targets; 2) data needs; 3) 
efficiency of data distribution; and 4) ongoing communication. 
CMS Response 
Short- and Long- Term Targets 
The CMS understands the need for a strategic plan to address the shortcomings outlined in the 
above-referenced report and has begun the development of this plan.  As part of the plan, CMS 
will adopt an integrated approach to ESRD systems development.  Currently, the REBUS and 
Standard Information Management System (SIMS) are independent, stand alone data repositories 
that communicate with each other via a complicated file exchange.  Phase I of the Renal 
Management Information System (REMIS) redesign will concentrate on integrating these 
17 
Renal Beneficiary and Utilization System Review  OEI-07-01-00250  Page 2 -Janet Rehnquist 

systems.  A detailed validation of the current REBUS and SIMS is currently underway.  In Phase 

I, CMS will cleanse the current REBUS and SIMS data and integrate these data into one 

common ESRD data repository (warehouse).  We are also implementing the Vital Information System for

Improved Outcomes in Nephrology (VISION) as a standard, front-end forms 

collection tool for ESRD dialysis centers as part of our Phase I effort.  VISION will greatly 

improve the quality of our ESRD data warehouse.  Phase I of the REMIS redesign is scheduled 

for completion in July 2002.  Phase II will commence in the fall of 2002 and will concentrate on

identification of existing and new requirements.  These additional user requirements will be incorporated

into logical quarterly releases of VISION/SIMS/REMIS software.  Strict 

configuration management, testing procedures, and protocols will be used in this new operational paradigm

to ensure integrity of data and software. 

Data Needs and Improved Efficiency of Data Distribution 
The CMS is addressing its internal data needs for the ESRD program, as well as the needs of 
external customers for ESRD data,as part of its integrated ESRD systems effort.  This effort 
encompasses the following: 
Improved Techniques for Data Transmission and Receipt 
As recently as October 2000, obsolete technology affected essentially all of the processes that supplied

REBUS with data essential to its business purpose.  Even in cases where improved technology was

available to the data source organizations, REBUS accepted data only in the 

modes and formats used when REBUS was developed.  Since November 2000, REBUS/REMIS

developers have been working toward methods requiring less workpower. 

Patient Status Information 
In November 2001, REBUS began drawing information from the ESRD networks' SIMS, whose central

server is located in CMS headquarters.  (Previously, the ESRD networks had been 

required to extract information from the PC-based SIMS system and prepare 18 separate 

sequential datasets on the CMS mainframe.) 

Transplant Information 
Also in November 2001, the data prepared by the United Network for Organ Sharing (UNOS) 
for use in REBUS have drastically reduced in volume, in frequency, and in workpower required 
for processing.  Additional improvements are planned for Phase II of REMIS. 
Consultation with Users of REBUS/REMIS Data 
See Ongoing Communication below.  REBUS/REMIS system representatives attend ongoing meetings 
focusing on the data needs of customers.  REBUS/REMIS managers will present information on the 
integrated ESRD system effort to these audiences. 
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Renal Beneficiary and Utilization System Review  OEI-07-01-00250  Page 3 -Janet Rehnquist 
Consultation with Providers of Data 
REBUS/REMIS is "fed" by transplant and dialysis data from CMS's systems, current ESRD 
patient status data from SIMS, and transplant data from UNOS. 
The CMS initiated regular monthly coordination meetings with UNOS and the Health Resources 
and Services Administration's (HRSA) representatives on November 7. That first conference achieved 
several agreements: 
C  The UNOS may discontinue weekly files for CMS -- monthly files suffice for CMS's needs. 
C  The CMS does not need non-ESRD data from UNOS. 
C  The CMS will not house UNOS's data to meet United States Renal Data System's (USRDS) 
needs. (USRDS will be encouraged to "go to the source" of the data; HRSA 
C  has no objection to this approach.) 
C  Pending consultation with the ESRD networks, CMS will no longer house transplant wait list 
data, since the networks can obtain them from UNOS (and many of them have done so). The 
networks will be encouraged to "go to the source" of the data. 
C	 After confirming specifications, CMS will reinstate REBUS reports that provide information 
requested by UNOS (including information on transplant providers, deaths, and transplants not 
recorded by UNOS). 
The CMS has met regularly with SIMS developers and stakeholders since the start of the SIMS

development effort (frequently through teleconferencing). In recent months, as part of the 

integrated ESRD systems effort, in-person meetings have been held to: 

C  plan the integration of SIMS data into REMIS; and 

C  plan the integration of the VISION system with REMIS and SIMS. 

The integrated ESRD systems effort will result in the use of SIMS data as the "gold standard" for

current ESRD patient status. 

Timeliness, Completion, and Accuracy 
Each dataset used by REBUS is under evaluation as part of the migration to REMIS. This 

evaluation process, known as Data Quality Assurance (DQA), assesses each field within each REBUS

dataset for compliance with the documented standards ("metadata," roughly speaking) 

for that field. While there are no plans to add new functionality to REBUS, the DQA findings identify

REBUS data that are no longer usable and help determine the appropriateness of maintaining datasets

or their individual fields in REBUS/REMIS. This approach allows CMS to focus more narrowly on

information essential to the REBUS/REMIS business purpose. 

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Renal Beneficiary and Utilization System Review  OEI-07-01-00250  Page 4 -Janet Rehnquist 
Phased Approach 
Under the integrated ESRD systems effort, REBUS functionality will be transferred to REMIS. 
Phase I of REMIS calls for the new Oracle-based system to "do what REBUS does" with certain 
exceptions: 1) any processing errors found will be corrected; 2) any unnecessary data or 
functionality will be dropped; and 3) the existing multi-platform feed of patient status 
information from SIMS to REBUS will be replaced by read access to SIMS tables by REMIS. 
(Acquisition activities to strengthen the SIMS hardware platform have been initiated.) The 
resulting system will conform to applicable CMS standards and reasonable expectations for 
modem database application systems. 
Phase II will see a more thorough analysis of data needs, with the expectation of efficiency, 
timeliness, reporting, and reliability improvements.  For example, Phase I of REMIS is expected 
to use essentially the same UNOS data as REBUS uses (although unnecessary elements will be 
dropped as a result of narrowing the focus of REBUS /REMIS to essential data).  However, in 
Phase II, the use of UNOS data in REMIS will be fully reviewed.  It is anticipated that the 
current process (receipt of compact discs (CDs) containing full-file copies prepared by UNOS; 
loading of data from CD to mainframe; unzipping of data on mainframe; use of mainframe 
Statistical Analysis Software to prepare inputs to REBUS; adding records to the REBUS Model 
204 database files via FASTLOAD) will be replaced by a more efficient process, possibly 
involving selection of only the required data by code executing on the UNOS platform. 
As part of the current REMIS phases, ESRD facilities will be able to use VISION to transmit 
forms electronically to CMS.  Information transmitted via VISION will become part of the SIMS 
database.  The SIMS data will in turn be treated as a part of REMIS; i.e., SIMS patient data will 
not be copied into REMIS, but will be read from SIMS. 
Additional activities have been instituted to make the current REBUS system more current 
and accurate during the transition to the new REMIS environment. 
The OIG report states that, Data sets within the Renal Beneficiary and Utilization System are 
out-of-date, incomplete, and inaccurate and that problems existed with 9 of the 12 REBUS 
datasets in the past 12 months. That statement is somewhat misleading.  Two of those datasets, 
the Social Security Administration's (SSA) district office file and the waitlist file, in no way 
impact the REBUS business function.  As a result of our review of the appropriateness of 
maintaining the various data stores in REMIS, we have determined not to maintain these two. 
We are testing new matching and analysis routines in order to better take advantage of the event 
data in SIMS and more accurately update the patient status records in REBUS.  We will be 
loading data directly from the SIMS central repository on a regular basis.  These improvements 
were implemented in early December 2001.  We are working closely with the networks to 
improve the feedback that we give to them as a result of these regular census updates.  We will 
also soon be pulling the monthly medical evidence and death notice accretions directly from 
the SIMS central repository, rather than have each network transmit those files to the CMS 
mainframe. 
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Renal Beneficiary and Utilization System Review  OEI-07-01-00250  Page 5 -Janet Rehnquist 

The table below shows the current status of REBUS datasets and is an update to the same table on

page 8 of the OIG draft report. 
Table 2: REBUS Dataset Status 
Dataset  Description  Status  Plans for updating 
Death Notice  Date, place, and cause of death  Current  N/A 
Facility Certification  Annual provider-specific treatment  Current  N/A 
and transplant data 
Identification  Basic beneficiary information,  99.9 Percent  Dependent on other 
entitlement, and ESRD termination  Current  datasets 
data 
Inpatient Stay  Hospital stay dates, provider  Current  N/A 
number, surgery information 
Medical Evidence  Medical conditions, lab results  Current  N/A 
Method Selection  ESRD payment method chosen by  Current  N/A 
home dialysis patients 
Patient Status  Verified status, dialysis type, most  Current  N/A 
recent treatment setting 
SSA District Office  Address of local SSA offices  Not Current  No plans to maintain/no 
longer review 
Transplant  Date of transplant, organ donor data  Current  N/A 
Transplant Follow-up  Tracks status of beneficiary  Current  N/A 
transplant 
Quarterly Dialysis  Aggregated information for all  Current  N/ A 
dialysis claims in quarter 
Wait List  Potential kidney transplant  Not Current  No plans to maintain/no 
recipients awaiting transplant  longer review 
Ongoing Communication 
The CMS ESRD software development staff currently communicates with several of its data users and 
partners in a variety of ways. 
Annual Managed Care Enrollment and Payment Conference 
The Annual Managed Care Enrollment and Payment Conference serves to assist the managed care 
contractors in their understanding of CMS' s regulations, policies, and program developments that 
affect the operation of managed care enrollment and payment processes. 
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Renal Beneficiary and Utilization System Review  OEI-07-01-00250  Page 6 -Janet Rehnquist 
The ESRD and other similar workshops are conducted to enhance communication and address 
concerns of managed care organizations regarding ESRD data validation processes. 
SIMS/REMIS Task Groups 
The CMS has created a new task group structure, comprised of CMS and network staff, in order  to 
address current ESRD concerns and functionality of the SIMS and REMIS software applications. This 
structure will improve communication between CMS and the networks regarding reporting 
requirements and clarification of policy issues. The SIMS/REMIS task groups will consist of a body of 
individuals tasked to perform set functions such as identifying a need, specifying the functionality needed 
in SIMS and REMIS, and finally testing each new process to ensure it works properly and meets all 
required needs. The groups will have a co-chair from CMS and a co-chair from the ESRD networks. 
The CMS believes it essential that the  task groups be populated with network and CMS staff who are 
knowledgeable about the topic and who can commit the time necessary to do the work. 
WebEx Meeting Center 
To facilitate communication between application developers, task groups, and CMS staff, a new

technology called WebEx Meeting Center will be utilized. WebEx is a service that enables the  easy

sharing of information on the Internet (i.e., the Web) through interactive online meetings. 

Through WebEx the user can: 

C  Give any presentation to anyone, anywhere; 

C  Demonstrate software, live; 

C  Allow anyone in the meeting to view, annotate, and edit any document electronically; .

C  Share an application on your system or share the entire desktop;

C  Use remote control to provide support on the Web; 

C  Take meeting participants on a Web tour; 

C  Integrate teleconferencing into your meeting; and 

C  Add video to personalize your meeting. 

Workgroups can collaborate on any project, at any time, from anywhere; e.g., from sharing

presentations to sharing any type of document, to Web tours, to full application and desktop  remote

control, and provide all the capabilities necessary to support real-time meetings on the  Web.

OIG Recommendation 
The CMS should coordinate with SSA to address errors in basic beneficiary information. 
22 
Renal Beneficiary and Utilization System Review  OEI-07-01-00250  Page 7 -Janet Rehnquist 
CMS Response 
CMS has worked diligently with SSA to try and resolve disagreements between our databases.  More 
work needs to be done on this and we will continue to work with SSA to resolve these issues. 
The first is that identification data on the SSA Numerical Identification (NUMIDENT) record  may 
disagree with data on the SSA Master Beneficiary Record (MBR) that updates the CMS Enrollment 
Database (EDB).  The second is that SSA may have documentation that contradicts information that 
providers of CMS data (the ESRD networks) insist is correct. Below follows a  brief history. 
In 1995, when REBUS was designed, a mechanism was created to enter discrepant patient  identifier 
records (name, claim number, date of birth, and sex) in REBUS.  The CMS would  generate a list on 
an as-needed basis and forward it to SSA for investigation and correction.  In  1996, we realized the 
data that were forwarded to SSA for update were not being changed. The  CMS contacted the Office 
of Disability, SSA, and was told the list may be forwarded to the SSA field offices for resolution.  The 
CMS again contacted SSA concerning the outstanding data correction requests. The CMS was 
informed that its request would be transferred to an area responsible for data corrections. In 1997, 
SSA notified CMS that it reviewed the lists and found written documentation which confirmed that the 
SSA record showed the correct date of birth,  which was different from what the beneficiary reported 
to the network. According to SSA, its NUMIDENT file confirms the beneficiary's name and date of 
birth. The CMS has noted data discrepancies between the NUMIDENT and SSA's MBR, which 
updates CMS's EDB. In these instances and with surname changes, SSA suggested that the 
beneficiary contact his or her local SSA field office. The SSA also noted that data corrections are a 
low workload priority unless  these changes have a direct effect on the beneficiary's benefits.  The 
SSA's average workload backlog is 6 months. 
In addition to the above-described situation, we have also been attempting for the past year to 
coordinate with SSA regarding the VISION project and our ability to send, and SSA's willingness to 
receive, electronic ESRD form data in place of the paper forms it receives today.  As with the errors, 
we have been unsuccessful in obtaining SSA's firm commitment to receive data electronically. 
In our discussions with OIG during the exit conference held for discussing this draft report, we strongly 
suggested that OIG include more detail regarding our efforts with SSA, which we again reiterate. We 
also suggest that this report in final form be sent to SSA. 
Again, we appreciate the effort that went into this report and the opportunity to review and comment 
on the issues it raises. 
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