Report: States Lag in Reporting to Medicaid Managed Care Database

July 8, 2015 in News

Several states are failing to report certain required information about Medicaid managed care beneficiary services to a national database, according to a recent report from the HHS Office of Inspector General, Modern Healthcare reports (Schencker, Modern Healthcare, 7/6).


Report Details


For the report, OIG looked at encounter data reported to the Medicaid Statistical Information System by 38 states in the third quarter of 2011 (OIG report, 7/3). Encounter data explain what services are provided to beneficiaries in managed care plans. Such data are used for:

  • Setting rates;
  • Quality assurance;
  • Reviewing utilization; and
  • Performance evaluation of managed care entities.

Report Findings


OIG found that eight states did not meet the reporting deadline for submitting encounter data on any entity to a national database and 11 states did not report data for all managed care entities.


OIG noted, “The high proportion of beneficiaries enrolled in managed care makes accurate ‘encounter data’ … essential for the oversight of Medicaid as well as prevention of fraud, waste and abuse.”


OIG said that states in the last few years have improved encounter data reporting but noted that work still needs to be done and that CMS should boost efforts to improve reporting.  


OIG issued several recommendations to CMS, including:

  • Using authority granted by the Affordable Care Act to “withhold appropriate federal funds, to an extent commensurate with the State’s level of noncompliance” from states that fail to meet reporting requirements; and
  • Tracking encounter data to make sure states report information for every managed care facility.



CMS said it already has given notice of the creation of a proposed rule that would allow funds to be withheld from states that fail to meet requirements. Under the proposed rule, federal funding would be extended for information systems that help states improve data collection and reporting.


In addition, CMS said it agrees that it should boost encounter data monitoring. The agency said it works with states on data collection and reporting and that it will “continue to work with States to ensure they submit accurate and timely data” (Modern Healthcare, 7/6).

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