Data on Medicaid Managed Care payments to providers are incomplete and inaccurate
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Data brief (United States. Department of Health and Human Services. Office of Inspector General)
- Contributor(s):
- United States. Department of Health and Human Services. Office of Inspector General. Office of Evaluation and Inspections, issuing body.
- Publication:
- Washington, D.C. : U.S. Department of Health and Human Services, Office of Inspector General, March 2021
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Economics, Medical -- statistics & numerical data Government Regulation Insurance, Health, Reimbursement Managed Care Programs -- economics Medicaid -- economics United States United States. Department of Health and Human Services
- Genre(s):
- Technical Report
- Abstract:
- Why OIG Did This Review. Effective oversight of Medicaid requires a national system with complete and accurate data. The Centers for Medicare & Medicaid (CMS) established the Transformed Medicaid Statistical Information System (T-MSIS) for this purpose. Payment data are a critical component of T-MSIS. These data include the amounts paid, billed, and allowed for every service provided to Medicaid enrollees, including those services provided through managed care. Managed care has become the primary delivery system for Medicaid. Each managed care plan provides the State with data about what the plan paid providers for their encounters with Medicaid enrollees. The State is then required to submit these data to T-MSIS. The Office of Inspector General (OIG) and others have consistently identified deficiencies in the quality of T-MSIS data, including particular concerns with the quality of data for managed care. CMS and others rely on T-MSIS data to provide oversight; to identify trends; and to detect fraud, waste, and abuse. States use payment data to set the capitation rates paid to managed care plans for each enrollee and to monitor the services provided by the plans. How OIG Did This Review. We analyzed the payment data from the encounter claims in T-MSIS for January 2020 for the largest managed care plan in each of the 39 States that provide comprehensive, risk-based managed care.
- Copyright:
- The National Library of Medicine believes this item to be in the public domain. (More information)
- Extent:
- 1 online resource (1 PDF file (29 pages))
- Illustrations:
- Illustrations
- NLM Unique ID:
- 9918383975306676 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/9918383975306676