Annals of Health Law
READY OR NOT
data as well as claims data. 107 IDR goals of providing greater information
sharing with broader and easier access and enhanced data integration will
serve to facilitate data mining capabilities pursuant to audits and drive
accountability of providers submitting clinical data under VBP. 108
The government employs several auditing programs that capitalize on the
massive databases being developed as well as the capabilities of
increasingly sophisticated data mining technologies. By way of example,
with the installment of the permanent Recovery Audit Contractor program
and the transition to Zone Program Integrity Contractors, 109 methods of
preventing fraud and abuse have become progressively more organized and
also highly reliant on data mining strategies. 110 Data mining is particularly
effective in fraud control and prevention efforts that rely on intra- and interagency collaboration and for whom data sharing is critical to their
mission. 111 The Health Care Fraud and Abuse Control (HCFAC) 112
view of data supporting CMS and its partners in more effective deliver[ing]. . .quality health
care at lower cost to CMS’ beneficiaries through state-of-the-art health informatics.” See
CMS Integrated Data Repository (IDR), CTRS. FOR MEDICARE & MEDICAID SERVS.,
available at http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/IDR/ index.html.
107. See id. IDR is geared for use by multiple stakeholders, including beneficiaries,
providers, and health plans. The IDR is designed to analyze data in place instead of relying
on data extracts and can integrate claims from diverse sources in a meaningful way. Id.
108. See id.
109. Section 302 of Tax Relief and HealthCare Act of 2006 required a permanent RAC
Program and required the Secretary of HHS to expand the program to all fifty states. CMS
now has four RACs in place, each of whom is responsible for identifying overpayment and
underpayment in their approximate one quarter of the country. See Recovery Audit
Program, CTRS. FOR MEDICARE & MEDICAID SERVS., available at
http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/recovery-audit-program/ index.html?redirect=/RAC/; CTRS. FOR MEDICARE & MEDICAID SERVS.,
IMPLEMENTATION OF RECOVERY AUDITING AT THE CENTERS FOR MEDICARE & MEDICAID
SERVICES: FY 2010 REPORT TO CONGRESS AS REQUIRED BY SECTION 6411 OF AFFORDABLE
CARE ACT 6 (2010), available at http://www.cms.gov/Research-Statistics-Data-and-
110. See Walcher & Colagiovanni, supra note 104.
111. See Efforts to Combat Health Care Fraud and Abuse: Testimony Before the
Subcomm. On Labor, Health and Human Servs., Educ., and Related Agencies of the Comm.
on Appropriations, U.S. House of Representatives (Mar. 4, 2010) (testimony of Deputy
Secretary William Corr), available at http://www.hhs.gov/asl/testify/2010/
03/ t20100304a.html (recognizing benefits of data sharing among agencies); see also U.S.
DEP’T OF HEALTH & HUMAN SERVS. & DEP’T OF JUSTICE, HEALTH CARE FRAUD AND ABUSE
CONTROL PROGRAM ANNUAL REPORT FOR FISCAL YEAR 2010 51 (Jan. 2011), available at
http://www.justice.gov/archive/dag/pubdoc/hcfacreport2010.pdf (describing government
investment in data sharing techniques across agencies aimed at fraud detection and
112. Efforts to combat fraud were consolidated and strengthened under Public Law 104-
191, the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Act