Medicaid claims lack key data that could help find fraud

CMS also slow to get pertinent claims information to the public, OIG reports.

By Chris Silva — Posted Sept. 17, 2009

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Medicaid claims information submitted by states to the Centers for Medicare & Medicaid Services is slow in being released to the public and often does not contain many data elements that can assist in fraud detection, according to a report by investigators from the Dept. of Health and Human Services Office of Inspector General.

In an Aug. 26 letter to Cindy Mann, the director of the CMS Center for Medicaid and State Operations, OIG states that CMS did not fully disclose or document information about the accuracy of data collected by the Medicaid Statistical Information System. Timely, accurate and comprehensive data can be used to help interagency efforts in combating health care fraud, the report notes.

States must submit claims files to CMS within 45 days after the end of each quarter. The system is designed to serve as an accurate database pertaining to standardized enrollment, eligibility and paid claims of Medicaid beneficiaries.

In a review of MSIS files, OIG determined that data took an average of more than 1½ years after the initial state submission before being relayed by CMS to the public. This time frame included an average of six months that states took to submit MSIS files in a CMS-acceptable format and averages of four months and nine months for CMS to validate the data and release the files.

CMS also could not explain why it approved more than 1,500 exceptions to a process designed to identify claims errors. The MSIS program produces reports that show the numbers and types of errors identified. But CMS periodically adjusted individual state error tolerances to allow particular files or sets of files to pass data validation tests.

"These undocumented error tolerance adjustments allowed the affected state MSIS files to clear quality review with an unknown number of errors," OIG reported.

Also, MSIS does not capture a number of data elements that can assist in fraud, waste and abuse detection, OIG wrote. The system, for example, does not capture the referring physician's identification number. Without it, fraud analysts cannot use MSIS to assess whether a qualified physician submitted the order as required for a beneficiary to receive certain medical benefits.

The report was issued directly to CMS in final form with no specific recommendations. It did not include a CMS response.

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