Last week the Government Accountability Office (GAO), a nonpartisan independent government agency that serves as a “watchdog” for Congress, released a report on the reliability of states’ Medicaid managed care encounter data. GAO was compelled to do this report because questions have been raised about the reliability of states’ Medicaid managed care encounter data, which are often used to set rates paid to MCOs. In this report GAO examined 8 states (California, Nebraska, New Hampshire, New York, Ohio, Texas, Utah, and West Virginia) to assess the reliability of encounter data and oversight practices, as well as CMS’s actions for helping to ensure encounter data reliability. GAO made the following three recommendations to CMS in this report:.
The Administrator of CMS should provide states with more information on how to fulfill the requirement for independent encounter data audits, including information on the required audit scope and methodology, and what should be described in the resulting report.
The Administrator of CMS should provide states information on the required content of the annual assessment of encounter data reporting.
The Administrator of CMS should provide states with information on the circumstances under which CMS would defer or disallow matching funds in response to noncompliant encounter data submissions.
CMS agreed with the first two recommendations and neither agreed nor disagreed with the final recommendation.
The report also provided background on Medicaid managed care encounter data, the role of collecting more accurate Medicaid data and the lack of information that states have to comply with current federal managed care rules (note that these 2016 rules are currently being revisited by the Trump Administration).
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