Medicare Increases Transparency Stakes

Physicians are already preparing for the impact of high deductibles and patient shopping, and now must also be aware that Medicare may begin releasing information about payments made to individual physicians (if requested under the Freedom of Information Act [FOIA]).

Under the policy published January 17, 2014, in the Federal Register and scheduled to take effect March 17, the Centers for Medicare & Medicaid Services (CMS) will determine whether or not to release information on a case-by-case basis. In its determination, CMS will use a “balancing test” which weighs the balance between the privacy interest of the physician and the public disclosure of information.

While this overturns the precedent set by CMS in November 1980 – that public interest in individual physician payments was not sufficient to compel the disclosure of such information – this change of direction is consistent with other industry efforts to improve transparency and access to data so that consumers can make informed choices.

While some argue that this is in the public’s best interest, PYA and other organizations, such as the American Medical Association and the American College of Physicians, are concerned that the data can be misleading and misinterpreted.  For instance, claims payment information alone does not reflect the entire picture since it does not address factors such as location, payer mix, patient social and economic demographics, and practice costs.

While it is likely that payment information would be released in the aggregate to protect patient privacy, physicians should consider the ways that this information might be used and the potential impact on day-to-day operations.  Examples might include:

  • Patient inquiries to compare charges and available self-pay options for certain services as they prepare to pay out-of-pocket.
  • Online tools from Medicare, private insurance companies, and public websites that allow patients to see their provider’s credentials and any sanctions; compare how often the provider performs procedures compared to others in the same specialty; research which medications (name, class, brand name vs. generic) their provider prescribes; identify referral patterns between providers, etc.
  • Patient-originated sites that allow patients to rate their provider in terms of ease of appointment access, customer service of staff and providers, and [perceived] quality of the patient experience.

While the day-to-day impact may be slow in building, physicians should prepare for the unexpected and train themselves and their staff with talking points to address questions that patients may raise.  Additionally, physicians should vigilantly monitor themselves on the Internet to see what is available to the public—both individually and their practice as a whole.  For more information about how your practice can address the changing culture of transparency, contact the experts listed below at PYA, (800) 270-9629.

Lori Foley

Lori Foley


Allison Wilson

Allison Wilson


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