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Recent Industry News

Managed Care

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The General Accountability Office (GAO) recently released a report on the Centers for Medicare and Medicaid Services’ (CMS) data deficiencies surrounding personal care services for Medicaid beneficiaries.  The study was initiated due to the rapid growth of long-term care Medicaid spending for in-home and community-based services.  In 2015, $75 billion was spent on Medicaid long-term care and this number is expected to grow to $111 billion by 2026.  Personal care services are a large subset of long-term, in-home care.  These services allow millions of individuals to age in place and maintain their independence by providing assistance with basic life activities.  However, personal care services are at high risk for improper payments, including fraudulent claims, because of missing, siloed and inaccurate federal Medicaid claims data.  For example, the GAO found more than $4.9 billion in claims submitted without a provider identification number for 2012.

The GAO report examines two CMS systems that collect the Medicaid personal care services data and analyzes what the data revealed.  The Medicaid Statistical Information System (MSIS) collects provider claims information on services provided to individual Medicaid beneficiaries and state payments for these services.  The Medicaid Budget and Expenditure System (MBES) compiles total aggregate Medicaid expenditures across 80 broad service categories for each state.  The GAO also reviewed relevant federal guidance and documents, and interviewed CMS officials and researchers to examine how the data could be used for CMS oversight responsibilities.

The GAO reported the following findings:

  • CMS does not collect complete or consistent data from states on Medicaid personal care services. The lack of accurate data impairs CMS’s ability to monitor the provision of and spending on these services;
  • Untimely, incomplete, inaccurate or inconsistent data led to reporting errors and data gaps. For example, 15% of claims lacked provider identification numbers.  Additionally, over 400 different procedure codes were used with widely varying quantity and time periods to identify the services; and
  • States’ failure to separately identify expenditures for personal care services constituted two-thirds of discovered errors.

CMS is developing a new Medicaid claims system to replace MSIS and has established a new office for program management and monitoring.  However, CMS has not issued guidance on personal care services to address gaps, or made plans to use data for effective oversight and monitoring of personal care expenditures.

The GAO recommended that CMS:

  1. Establish standard reporting guidance for key data;
  2. Ensure linkage between data on the provision of services and reported expenditures;
  3. Ensure state compliance with reporting requirements; and
  4. Develop plans to use data for oversight.

The Department of Health and Human Services (HHS) agreed that CMS must improve state compliance with reporting requirements and develop plans for CMS to use the data.

The GAO report is available at:

http://www.gao.gov/assets/690/682046.pdf.

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