Health Care Financing Administration Privacy Act of 1974

AGENCY: Health Care Financing Administration (HCFA), Department of Health and
Human Services (HHS).

ACTION: Notice of a matching program between HCFA and the Wisconsin Bureau of
Workers' Compensation HCFA will receive information from the State concerning
work-related injuries and diseases.

SUMMARY: Section 1862(b)(2) of the Social Security Act (42 U.S.C. 1395(b)(2))
prohibits Medicare payment with respect to any item or service to the extent
that payment has been made, or can reasonably be expected to be made promptly,
under a workers' compensation law or plan of the United States or a State.

HCFA has developed a model agreement to be used in negotiating individual
agreements with State Workers' Compensation Boards. The agreement will allow
HCFA to seek recovery of identified mistaken payments that are the liability
of workers' compensation agencies.

The matching report set forth below is in compliance with the Computer
Matching and Privacy Protection Act of 1988 (Pub. L. 100Ä503).

EFFECTIVE DATE: No match will begin sooner than 40 days after the date of
publication in the Federal Register, and a copy of the model Data Match
Agreement will be sent to the Senate Committee on Governmental Affairs, the
House Committee on Government Operations, and the Office of Management and
Budget (OMB). Any individual matching agreement will remain in effect for 18
months from the date a notice is published in the Federal Register.

ADDRESSES: Please address comments to: Richard A. DeMeo, HCFA Privacy Act
Officer, Health Care Financing Administration, Office of Budget and
Administration, room 2ÄHÄ4, East Low Rise Building, 6325 Security Boulevard,
Baltimore, Maryland 21207Ä5187.

FOR FURTHER INFORMATION CONTACT:

Herb Shankroff, Division of Entitlement and Benefit Coordination, Bureau of
Program Operations, HCFA, room 367 Meadows East Building, 6325 Security
Boulevard, Baltimore, Maryland 21207Ä5187. His telephone number is (410)
966Ä7171.

SUPPLEMENTARY INFORMATION: One of the priorities of HCFA is to encourage high
quality and effective health care while pursuing strategies to contain or
moderate health care costs and Medicare program expenditures. As required by
the Social Security Act, one approach that HCFA employees to limit Medicare
expenditures is the implementation of the Medicare Secondary Payer (MSP)
provisions (42 U.S.C. 1395y(b)).

HCFA primarily relies upon providers, physicians, or other suppliers, and
beneficiaries themselves, to identify situations where payment should be made
by workers' compensation. In addition. Medicare contractors are instructed to
identify and investigate claims for which the diagnosis or procedure is
suggestive of accidental injury or of work-related illness. Often, however,
Medicare contractors are unaware of the availability of workers' compensation
and make primary payment by mistake. In these situations, the Medicare
contractors must recover the mistaken primary payments to restore them to the
Medicare Trust Funds. The identification of MSP situations and the recovery of
mistaken Medicare payments frequently entail demonstrating to the other third
party payer, such as a worker's compensation agency, its primary liability
under 42 U.S.C. 1395y(b).

The purpose of this matching program is to allow HCFA to identify workers'
compensation cases that otherwise have gone undetected by the Medicare
contractors. HCFA will receive, on a quarterly basis, computer listings of
approved workers' compensation cases from the State of Wisconsin. These
listings will be matched against the Carrier Medicare Claims Records (System
of Records No. 09Ä70Ä0501) and the Intermediary Claims Records (System of
Records No. 09Ä70Ä0503).

After the match, HCFA will further develop the situation and determine whether
a mistaken payment of Medicare funds has been made. Such determinations
generate demand letters to the identified insurer or payer. If the insurer or
payer proves that it did pay primary, in addition to Medicare's mistaken
primary payment, the beneficiary or provider is contacted by Medicare with a
request for return of the duplicate payment.

At this time, the beneficiary or provider will be provided an opportunity to
respond to HCFA's finding that a mistaken payment was made and will be given
an explanation of appeal rights. The determination that the beneficiary or
provider is responsible to refund Medicare is subject to all the appropriate
Medicare review and due process procedures.

In addition, HCFA will add what is known as an auxiliary record indicating
those beneficiaries identified as being entitled to workers' compensation.
This will prevent future erroneous Medicare payments.

The Privacy Act permits disclosure of information from HCFA's records without
a beneficiary's consent if the information issued for purposes that are
consistent with the purpose for which the information was collected, such as
establishing a beneficiary's claim for Medicare benefits and determining the
correct amount of the Medicare payment. The information must also be collected
and used in a manner consistent with Privacy Act procedures. Disclosure of
information is permitted when the benefit of the use of the information
outweighs the effect, or risk of an effect, on the privacy of individuals.

Set forth below is the information required by the Computer Matching and
Privacy Protection Act of 1988 (Pub. L. 100Ä503). A copy of this notice will
be provided to the Chairman of the Committee on Government Operations of the
House of Representatives, the Chairman of the Committee on Government Affairs
of the Senate, and the Acting Administrator of the Office of Information and
Regulatory Affairs in OMB.

Dated: December 20, 1993.

Bruce C. Vladeck,

Administrator, Health Care Financing Administration.

Computer Matching Notice

A. Name of Participating Agencies

Health Care Financing Administration (HCFA) and the State of Wisconsin Bureau
of Workers' Compensation.

B. Purpose of the Match

The match will allow HCFA to identify claims for which workers' compensation
was the primary payer, but Medicare made primary payments by mistake. It will
also facilitate HCFA's attempts to seek recovery of identified mistaken
Medicare payments that are the primary responsibility of workers'
compensation. It will also assist HCFA from making mistaken primary payments
on future claims.

C. Authority for the Match

The match is required to enable HCFA to implement more fully section
1862(b)(2) of the Social Security Act (42 U.S.C. 1395(b)(2)).

D. Records to be Matched

 The Wisconsin Workers' Compensation Board will disclose to HCFA records of
the identity of individuals who have been approved for workers' compensation
reimbursement.

 HCFA will match information from these records against the Carrier Medicare
Claims Records, HHS/HCFA/BPO No. 09Ä70Ä0501, and the Intermediary Medicare
Claims Records, HHS/HCFA/BPO No. 09Ä70Ä0503, to identify possible erroneous
Medicare payments.

E. Period of the Match

Beginning no sooner than 40 days from the date of this notice and lasting 18
full calendar months from the beginning date.

F. Address of Contact

Herb Shankroff, Division of Entitlement and Benefit Coordination, Bureau of
Program Operations, HCFA, Room 367, Meadows East Building, 6325 Security
Boulevard, Baltimore, Maryland 21207Ä5187. His telephone number is (410)
966Ä7171.

[FR Doc. 93Ä31901 Filed 12Ä29Ä93; 8:45 am]

BILLING CODE 4120Ä03ÄM