8 States Failed to Submit Medicaid Managed Care Encounter Data to CMS

In the past, the HHS Office of the Inspector General (OIG) has raised concerns about the completeness, timeliness, and accuracy of Medicaid managed care encounter data. While a review of Q3 claims files for fiscal year 2011 revealed an improvement over the 2009 report, OIG still determined that 8 of 38 states reviewed did not report data from any managed care entities by the deadline.

Approximately 70% of all Medicaid beneficiaries receive their healthcare services through managed care, and state Medicaid programs are required to report encounter data—ie, information about the services provided—to a national database.

In 2009, OIG found that 15 states had not reported encounter data compared with 8 states in the newest report. In addition, 11 states did not report encounter data for all managed care entities, and for 7 states OIG could not assess the data reported because of issues, such as invalid plan IDs, blank plan IDs, “dummy” plan IDs, and multiple plan IDs.

Of the 8 states that did not submit data, 6 of them submitted files with no encounter data, which CMS knowingly accepted, and 2 submitted their claim files with encounter data for Q3 of fiscal year 2011 nearly 2 years after they were due.

Of the 11 states that did not report data from all entities, 4 didn’t report encounter data because they were unable to collect it from the managed care entities while another 2 were unable to report all required data because of limitations in their data system.

The states that reported only partial data varied widely as to the percentages of managed care entities they had data for. Washington and Texas were only missing a small percentage of managed care entities while Colorado and Illinois were missing a higher percentage.

In the end, the OIG report recommends that CMS ensures states comply with the requirement to report encounter data from managed care entities by withholding federal funds from states that fail to do so and monitor encounter data to ensure it is all reported.