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Not All States Reported Medicaid Managed Care Encounter Data as Required


Approximately 70 percent of all Medicaid beneficiaries receive services through managed care. The high proportion of beneficiaries enrolled in managed care makes accurate "encounter data"-i.e., information about the services provided to Medicaid beneficiaries enrolled in managed care-essential for the oversight of Medicaid as well as prevention of fraud, waste, and abuse. State Medicaid programs are required to report encounter data to a national database, the Medicaid Statistical Information System (MSIS). However, previous OIG reviews have raised concerns about the completeness, timeliness, and accuracy of national Medicaid data. For example, in 2009 OIG found that the encounter data reported to MSIS were incomplete, and recommended that CMS enforce Federal requirements for reporting encounter data. Another 2009 OIG report found that over one and a half years elapsed between when States submitted MSIS files and when CMS accepted them.


We examined the third-quarter fiscal year 2011 MSIS claims files for the 38 States that had the types of managed care programs for which encounter data must be reported to MSIS. For each State we reviewed, we determined whether encounter data was present in MSIS for all of the managed care entities with which the State had contracts. For each State with missing encounter data, we contacted State Medicaid officials to determine why these data were missing. Finally, we conducted interviews with CMS and contractor staff regarding oversight of States' reporting to MSIS.


States' reporting of encounter data to MSIS improved since our 2009 report, but some States are still not reporting data for all contracted managed care entities. In the 2009 report, OIG found that 15 States did not report encounter data to MSIS. In the current report, 8 of the 38 States we reviewed did not report encounter data from any managed care entities by the required deadline. An additional 11 States did not report encounter data for all managed care entities. Finally, because of issues with the data that seven States submitted, we could not assess whether those States reported encounter data for all of their managed care entities.


To ensure that all States comply with the requirement to submit encounter data, we recommend that CMS use its authority to withhold appropriate Federal funds from States that fail to submit encounter data to MSIS until those States report encounter data as required. We also recommend that CMS monitor encounter data to ensure they are reported for all managed care entities. CMS concurred with both recommendations.