“Questions have been raised about the reliability of states’ Medicaid managed care encounter data, which are often used to set rates paid to MCOs. States collect the data from the Medicaid MCOs they contract with and then submit the data to CMS through T-MSIS. With managed care comprising nearly half of the total federal Medicaid expenditures in 2017, the importance of reliable encounter data is paramount to ensuring that rates are appropriate and beneficiaries in Medicaid managed care are receiving covered services…”
“What GAO Found
The Centers for Medicare & Medicaid Services (CMS) requires states to collect service utilization data—known as encounter data—from Medicaid managed care organizations (MCO). GAO found that, in 2017, all eight selected states it reviewed checked MCO-submitted encounter data for reasonableness—that is, they checked that the data contained valid values, were submitted in a timely manner, and reflected historical trends. Three of the selected states used an additional oversight practice—comparing encounter data with an external data source—which could involve comparing encounter data with a sample of medical records. Such comparisons are recommended by CMS and other experts, such as actuaries, to help ensure data reliability (i.e., accuracy, completeness, and timeliness). Five of the eight selected states reported using mechanisms—such as penalties—to enforce encounter data reporting requirements in 2017…”
“What GAO Recommends
The Administrator of CMS should provide states information on (1) scope and methodology requirements for encounter data audits; (2) required content of the annual assessments; and (3) circumstances for deferring or disallowing matching funds in response to noncompliant T-MSIS data submissions…” Read the full 47-page report here.
Source: Additional CMS Actions Needed to Help Ensure Data Reliability – November 19, 2018. GAO.
