Data lacking for national review of Medicaid opioid prescribing

The lack of robust Medicaid data is preventing the Centers for Medicare and Medicaid Services from conducting a national analysis to identify beneficiaries potentially at risk of opioid misuse or overdose.

In particular, an audit by the Department of Health and Human Services’ Office of Inspector General found limitations in data from the national Medicaid claims database—the Transformed Medicaid Statistical Information System (T-MSIS).

While all states are reporting to the T-MSIS repository, the data are not sufficient for the identification of individual beneficiaries for a national review of opioid prescribing in Medicaid, according to OIG.

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“Until T-MSIS data are complete in all states and limitations across states are addressed, it will not be possible to conduct a national evaluation of Medicaid beneficiaries at risk of opioid misuse or overdose,” auditors concluded. “The data we reviewed are critical for nationally quantifying the opioid crisis’s impact on Medicaid and for monitoring the crisis, as well as for conducting general program integrity efforts across states.”

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

Among the challenges cited by OIG is that a Medicaid beneficiary can have multiple IDs within a state. As a result, auditors contend that “it is not possible to identify all at-risk beneficiaries in need of opioid-related treatment and to take appropriate action, or to monitor utilization of services to protect beneficiaries from poorly coordinated care.”

Another problem is the lack of National Provider Identifiers (NPIs) for providers that order and dispense opioids, making it impossible to identify all providers who may be overprescribing opioids and take appropriate action, or to identify providers for investigations of fraud, waste or abuse. According to OIG, 19 states were missing pharmacy or prescriber NPIs.

In addition, 17 states were missing diagnosis codes, without which auditors contend “it is not possible to exclude all patients with cancer diagnoses for whom higher doses of opioids may be appropriate or to identify patients’ medical conditions to determine medical necessity for services.”

To address these issues, OIG recommended that CMS work to ensure that individual beneficiaries can be uniquely identified at a national level using T-MSIS, ensure the correct submission of prescriber NPIs, as well as clarify requirements for diagnosis codes.

The agency concurred with OIG’s three recommendations.

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