Medicaid Encounter Data Problems Continue

Posted by IntegrityM | | Government Evaluation, Medicaid

In May 2009, the U.S. Department of Health and Human Services Office of Inspector General (OIG) released a report regarding Medicaid managed care encounter data.  The OIG found all 40 States with capitated managed care reported collecting encounter data from their managed care plans. However; 15 States did not include encounter data in their Medicaid Statistical Information System (MSIS) data submissions to the Centers for Medicare & Medicaid Services (CMS).  

OIG recommended that CMS:

  1. Clarify existing Federal requirements that States include encounter data in MSIS submissions, (2) enforce existing Federal requirements that States include encounter data in MSIS submissions, and
  2. Seek legislative authority to impose sanctions against States that fail to meet the MSIS reporting requirements for encounter data.  

CMS concurred with the first two recommendations, but not the third at the time of the report’s release, believing it should focus on the first two recommendations before seeking legislative authority to sanction.  

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CMS Encounter Data Reporting Requirements

A little over 6 years later, OIG released another report regarding States’ reporting of Medicaid managed care encounter data.  In this report, OIG found 8 States did not report any encounter data by the required deadline.

CMS accepted MSIS claims files from 6 States knowing that required encounter data were not present, 2 States’ MSIS claims files were nearly 2 years overdue, 11 States did not report encounter data from all managed care entities, and it could not determine whether 7 States reported encounter data for all managed care entities.  

OIG recommended for CMS to:

  1. Use its authority to withhold appropriate Federal funds from States (the Affordable Care Act gave CMS authority to withhold Federal funds from States not complying with requirements to report encounter data) and
  2. Monitor encounter data to ensure States report data for all managed care entities.  

CMS concurred with both recommendations.

Importance of Reporting Managed Care Encounter Data

Why all the concern over encounter data?  Approximately 70 percent of Medicaid recipients nationwide are enrolled in managed care programs. This percentage is expected to increase with Medicaid expansion.  

Encounter data offer information about services provided to enrolled recipients.  Encounter data are to managed care what claims are to fee-for-service programs. Encounter data play an essential role in rate setting, quality assurance, utilization review, and assessing managed care plan performance. “Missing” encounter data prevents these activities from taking place.

Encounter Data & the Medicaid Statistical Information System (MSIS)

Encounter data also play an important role in MSIS.  MSIS is a national database of Medicaid encounter data, fee-for-service claims, and beneficiary eligibility information.  

CMS uses MSIS to produce, manage, and analyze information on Medicaid beneficiaries, services, and payments.  Public and private organizations use MSIS data for research and policy analysis, and law enforcement agencies and others use MSIS to detect fraud, waste, and abuse.

Medicaid Encounter Data Submission and Processing is Important

Bottom line, attempts to get the “full picture” of Medicaid are not possible using available data.  One of the six States CMS accepted MSIS submissions from without encounter data had 100 percent of Medicaid recipients enrolled in managed care plans; all six States had at least 50 percent enrollment in managed care.  


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