Qualified Entity Program

Section 10332 of the Affordable Care Act amends section 1874 of the Social Security Act (the Act) by adding a new subsection (e) requiring standardized extracts of Medicare claims data under parts A, B, and D to be made available to ‘‘qualified entities'' for the evaluation of the performance of providers and suppliers.  Qualified entities may use the information obtained under section 1874(e) of the Act for the purpose of evaluating the performance of providers and suppliers, and to generate public reports regarding such performance.

Potential qualified entities that wish to request data under this provision must submit an application that includes, among other things, a description of the methodologies that the applicant proposes to use to evaluate the performance of providers and suppliers in the geographic area(s) they select.  Once certified, qualified entities:

•  enter into a Data Use Agreement committing the organization to the highest levels of data security and privacy protection;

•  pay a fee equal to the cost of making the data available;

•  receive data for one or more specified geographic areas;

•  combine claims data from sources other than Medicare with the Medicare data. 

•  use valid and reliable measures for evaluating the performance of providers and suppliers; and,

•  produce and make publicly available reports on individual providers and suppliers in aggregate form.

We believe the sharing of Medicare data with qualified entities through this program and the resulting reports produced by qualified entities will be an important driver of improving quality and reducing costs in Medicare, as well as for the health care system in general.  Additionally, we believe this program will increase the transparency of provider and supplier performance, and provide beneficiaries access to information that will help them make more informed decisions about their health care.

For more information on or to apply for the Qualified Entity Program, please visit the links below.