II 

112TH CONGRESS 

1ST SESSION S. 856 

To amend title XI of the Social Security Act to make available to the 

public aggregate data on providers of services and suppliers under the 

Medicare program and to allow qualified individuals and groups access 

to claims and payment data under the Medicare program for purposes 

of conducting health research and detecting fraud. 

IN THE SENATE OF THE UNITED STATES 

APRIL 14, 2011 

Mr. DURBIN introduced the following bill; which was read twice and referred 

to the Committee on Finance 

A BILL 

To amend title XI of the Social Security Act to make available to the public aggregate data on providers of services 

and suppliers under the Medicare program and to allow 

qualified individuals and groups access to claims and 

payment data under the Medicare program for purposes 

of conducting health research and detecting fraud. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Medicare Spending 

5 Transparency Act of 2011’’. 

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1 SEC. 2. PUBLIC AVAILABILITY OF AGGREGATE DATA ON 

2 MEDICARE PROVIDERS OF SERVICES AND 

3 SUPPLIERS. 

4 (a) PURPOSE.—The purpose of this section is to 

5 make aggregate information about providers of services 

6 and suppliers under the Medicare program under title 

7 XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) 

8 publicly available and to provide a new level of trans9 parency in such program. 

10 (b) PUBLIC AVAILABILITY.—Section 1128J of the 

11 Social Security Act (42 U.S.C. 1320a–7k) is amended by 

12 adding at the end the following new subsection: 

13 ‘‘(f) PUBLIC AVAILABILITY OF CERTAIN MEDICARE

14 DATA.— 

15 ‘‘(1) IN GENERAL.—The Secretary shall, to the 

16 extent consistent with applicable information, pri17 vacy, security, and disclosure laws, including the 

18 regulations promulgated under the Health Insurance 

19 Portability and Accountability Act of 1996 and sec20 tion 552a of title 5, United States Code, make avail21 able to the public on the Internet website of the 

22 Centers for Medicare & Medicaid Services the fol23 lowing data with respect to title XVIII: 

24 ‘‘(A) A complete list of the providers of 

25 services and suppliers participating in the pro26 gram under such title, including the business 

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1 address of such providers of services and sup2 pliers. 

3 ‘‘(B) Aggregate information about each 

4 such provider of services and supplier, includ5 ing— 

6 ‘‘(i) the total number of individuals 

7 furnished items or services by the provider 

8 of services or supplier for which payment 

9 was made under such title during the pre10 ceding year; 

11 ‘‘(ii) the number of unique patient en12 counters conducted by the provider of serv13 ices or supplier for which payment was 

14 made under such title during the preceding 

15 year; 

16 ‘‘(iii) the average number of codes 

17 billed under such title by the provider of 

18 services of supplier per patient encounter 

19 during the preceding year; 

20 ‘‘(iv) the total amount paid to such 

21 provider of services or supplier under such 

22 title during the preceding year; 

23 ‘‘(v) the top 50 billing codes on claims 

24 paid under such title to the provider of 

25 services or supplier during the preceding 

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1 year, as determined by volume, including a 

2 description of such codes; 

3 ‘‘(vi) the top 50 billing codes on such 

4 claims paid during such year, as deter5 mined by dollar amount, including a de6 scription of such codes; and 

7 ‘‘(vii) the top 50 diagnosis and proce8 dure code pairs on such claims paid during 

9 such year, as determined by volume, in10 cluding a description of such codes. 

11 ‘‘(2) IMPLEMENTATION.—Not later than 1 year 

12 after the date of enactment of the Medicare Spend13 ing Transparency Act of 2011, the Secretary shall 

14 promulgate regulations to carry out this sub15 section.’’. 

16 SEC. 3. ACCESS TO MEDICARE CLAIMS AND PAYMENT DATA 

17 BY QUALIFIED INDIVIDUALS AND GROUPS. 

18 (a) PURPOSE.—The purpose of this section is to allow 

19 qualified individuals and groups access to information on 

20 claims and payment data under the Medicare program for 

21 purposes of conducting health research and detecting 

22 fraud under such program. 

23 (b) ACCESS TO MEDICARE CLAIMS AND PAYMENT

24 DATA BY QUALIFIED INDIVIDUALS AND GROUPS.—Sec25 tion 1128J of the Social Security Act (42 U.S.C. 1320a– 

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1 7k), as amended by section 2, is amended by adding at 

2 the end the following new subsection: 

3 ‘‘(g) ACCESS TO MEDICARE CLAIMS AND PAYMENT

4 DATA BY QUALIFIED INDIVIDUALS AND GROUPS.— 

5 ‘‘(1) IN GENERAL.—For purposes of conducting 

6 health research and detecting fraud under title 

7 XVIII, and to the extent consistent with applicable 

8 information, privacy, security, and disclosure laws, 

9 including the regulations promulgated under the 

10 Health Insurance Portability and Accountability Act 

11 of 1996 and section 552a of title 5, United States 

12 Code, and subject to any information systems secu13 rity requirements under such laws or otherwise re14 quired by the Secretary, a qualified individual or 

15 group shall have access to claims and payment data 

16 of the Department of Health and Human Services 

17 and its contractors related to title XVIII. Notwith18 standing any other provision of law, such data shall 

19 include the identity of individual providers of serv20 ices and suppliers under such title. 

21 ‘‘(2) DEFINITION OF QUALIFIED INDIVIDUAL

22 OR GROUP.— 

23 ‘‘(A) IN GENERAL.—In this subsection, the 

24 term ‘qualified individual or group’ means an 

25 individual or entity that the Secretary has demstockstill on DSKH9S0YB1PROD with BILLS

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1 termined, in accordance with subparagraph (B), 

2 has relevant experience, knowledge, and tech3 nical expertise in medicine, statistics, health 

4 care billing, practice patterns, health care fraud 

5 detection, and analysis to use data provided to 

6 the individual or the entity under this sub7 section in an appropriate, responsible, and eth8 ical manner and for the purposes described in 

9 paragraph (1). 

10 ‘‘(B) PROCEDURES.—The Secretary shall 

11 establish procedures for determining, in a time12 ly manner, whether an individual or entity is a 

13 qualified individual or group. 

14 ‘‘(3) PROCEDURES.—The Secretary shall estab15 lish procedures for the storage and use of data pro16 vided to a qualified individual or group under this 

17 subsection. Such procedures shall ensure that, in the 

18 case where the qualified individual or group pub19 lishes an analysis of such data (or any analysis 

20 using such data), the qualified individual or group 

21 discloses the following information (in a form and 

22 manner, and at a time, specified by the Secretary): 

23 ‘‘(A) The name of the qualified individual 

24 or group. 

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1 ‘‘(B) The sources of any funding for the 

2 qualified individual or group. 

3 ‘‘(C) Any employer or other relevant affili4 ations of the qualified individual or group. 

5 ‘‘(D) The data analysis methods used by 

6 the qualified individual or group in the analysis 

7 involved.’’. 

Æ 

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