Data lacking to help stem tide of improper Medicaid payments

CMS announces new strategy designed to improve the integrity of program through advanced analytics.

The lack of robust national Medicaid data is preventing the Centers for Medicare and Medicaid Services from preventing, detecting and addressing improper payments, which totaled nearly $37 billion in Fiscal Year 2017.

That was the message delivered to lawmakers on Wednesday by a senior official from the Department of Health and Human Services’ Office of Inspector General, who testified before the Senate Committee on Homeland Security and Government Affairs.

“A consistent impediment to effective prevention, detection and enforcement within the Medicaid program (is the) lack of complete, accurate and timely national Medicaid data,” testified Brian Ritchie, assistant inspector general for audit services at OIG. That shortcoming, hampers CMS in quickly identifying and addressing problems in the program, he adds.

Data from the Transformed Medicaid Statistical Information System (TMSIS) were supposed to help ensure the effective administration and oversight of the Medicaid program, including enhancing the ability to identify potential fraud, waste and abuse. While all states are now reporting to this national repository for Medicaid data, the data are not sufficient to provide effective oversight of the program, according to OIG.

Also See: GAO contends oversight is lacking for national repository of Medicaid data

In his testimony, OIG’s Ritchie said CMS must do a better job of ensuring the completeness and reliability of data in the TMSIS. Specifically, he called on the agency to ensure that states consistently report and uniformly interpret the same data elements.

“We found that states are not consistently submitting the same TMSIS data elements, limiting the ability to make comparisons across all states,” according to Ritchie. “Despite CMS’s attempts to further standardize meaning through a revised standard data dictionary, TMSIS data elements may not mean the same thing across states. Different interpretations across states could result in data that is not comparable across different states.”

Further, OIG found that states’ Medicaid managed care encounter data were incomplete. As a result, in his testimony, Ritchie called on CMS to ensure that states report encounter data for all managed care entities.

According to Ritchie, 80 percent of all Medicaid beneficiaries receive part or all of their services through managed care. “For CMS and states to operate Medicaid effectively at both the federal and state level, it is vital that TMSIS include complete and accurate managed care encounter data,” he testified. “Like fee-for-service Medicaid claims, encounter data are the primary record of services provided to Medicaid beneficiaries enrolled in managed care.”

In an effort to address some of these issues, CMS on Tuesday announced a Medicaid Program Integrity Strategy that seeks to leverage advanced analytics to improve Medicaid eligibility and payment data.

“It is an administration priority for CMS to work closely with states to ensure that CMS and oversight bodies have access to the best, most complete and accurate Medicaid data,” states the agency’s strategy. “For the first time, all 50 states, D.C. and Puerto Rico are now submitting data on their programs to the TMSIS, and over the course of the coming months, CMS will be validating the quality and completeness of the data.”

According to the strategy, the agency’s “ongoing goal is to use advanced analytics and other innovative solutions to both improve TMSIS data and maximize the potential for program integrity purposes,” which “will allow CMS to identify instances like a beneficiary receiving more hours of treatment than hours in a day or other flags that necessitate further investigation.”

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