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Qualified Entities

The Centers for Medicare and Medicaid Services (CMS) has released a final rule last month, titled “Expanding Uses of Medicare Data by Qualified Entities,” that describes the situations under which some of the “qualified” entities can exchange their Medicare claims details. This rule is authorized by the Medicare Access and CHIP Reauthorization Act (MACRA) as well.

The main feature of the final rule is that those organizations that are approved as Qualified Entities will be able to “confidentially share or sell analyses of Medicare and private sector claims data to providers, employers, and other groups.” The qualified entity program was made under the Affordable Care Act to enable those organizations that meet the qualifications to access protected Medicare data. The data can be used by the organizations to make public reports that can be shared or sold.

CMS believes that improved data sharing would empower providers to offer successful and efficient care, as they will be having improved access to Medicare data to make well-informed clinical decisions. Qualified Entities need to combine their Medicare data with other claims data to make public quality reports, detailing on how suppliers and providers perform for the different type of payers.

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As per the latest rule, entities also have the ability to make use of their combined public and private data for non-public analyses. Besides that, Qualified Entities can also sell their data to third party authorized users. As per the latest reports, about fifteen organizations have got approval from CMS to become Qualified Entities.

The final rule surely encourages data sharing, but retains stringent patient-privacy requirements of Health Insurance Portability and Accountability Act (HIPAA), both for the selling provider and for the hypothetical purchaser. As per the final rule, if Qualified Entities breach their data use agreement, they will be subject to a fine of up to a hundred dollars per person affected.

There are also new reporting requirements for the Qualified Entities, which CMS can make use of to measure compliance with the program when the entities are selling or buying data. CMS hopes the final rule to expand “access to analyses and data that will help providers, employers, and others make more informed decisions about care delivery and quality improvement.”

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