WASHINGTON, DC – The Government Accountability Office (GAO) today released a report on actions the Centers for Medicare and Medicaid Services (CMS) should take to ensure proper regulatory compliance by states with regard to encounter data reliability in managed care organizations (MCO). This study was undertaken by GAO in response to questions raised by the Committee on Energy and Commerce regarding the reliability of Medicaid managed care encounter data.
GAO selected a sample of eight states to review MCO encounter data; California, Nebraska, New Hampshire, New York, Ohio, Texas, Utah, and West Virginia. GAO found that all eight states “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.”
States report this encounter data to CMS’s Transformed Medicaid Statistical Information System (T-MSIS). However, GAO found that “CMS has not provided states with information on the circumstances under which the agency will determine whether to defer or disallow federal matching funds in response to T-MSIS data submissions that do not comply with the agency’s standards.”
This encounter data serves as a foundational reporting requirement which each state currently complies with. In addition, states must submit certain other information to CMS, including periodic independent audits of state encounter information and annual assessments of encounter data. However, GAO found that CMS had provided states with limited information on these newer regulatory requirements, and how states should comply.
GAO recommended that CMS provide more information to states on; the “scope and methodology requirements for encounter data audits; required content of the annual assessments; and circumstances for deferring or disallowing matching funds in response to noncompliant T-MSIS data submissions.”
The GAO report highlights some remaining dysfunction within CMS’s accountability and data collection procedures, and reinforces the continued need for congressional oversight of these programs. The committee will continue to work with CMS to improve these procedures, and support CMS in its processes.