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Management Issue 6:
Availability and Quality of Data for Effective Program Oversight

Why This Is a Challenge

The Department and OIG rely heavily on the availability and completeness of data to ensure that the over 300 departmental programs are operating as intended and to help identify instances of fraud, waste, and abuse. The Department's programs compile an enormous amount of data on beneficiaries, providers, drugs, equipment and supplies, the delivery of services, and the quality of care. When these data are unavailable, are incomplete, or contain inaccuracies, program oversight and monitoring activities are hindered. OIG work has shown challenges in the following areas:

Medicaid program data are not current, available, complete, and accurate. The Medicaid Statistical Information System (MSIS) is the only national database of Medicaid claims and beneficiary eligibility information. In a 2009 report, OIG found that MSIS data were an average of 1.5 years old when released to users for data analysis. Moreover, CMS does not enforce certain MSIS data requirements, such as the submission of managed care encounter data. To conduct necessary Medicaid oversight, OIG must sometimes request data directly from each State.

Medicare program data are not complete and accurate. CMS compiles voluminous amounts of data on, among other things, provider enrollment and ownership, medical care encounters, prescription drugs, claims and payment, and adverse actions taken against providers. OIG has found that while Medicare data are largely available for analysis and review, databases such as the Provider, Enrollment, Chain and Ownership System (PECOS); the Prescription Drug Event Database; and the Healthcare Integrity and Protection Data Bank are missing data and/or contain inaccurate information, resulting in limited usefulness for oversight purposes.

Public health and human services programs data are not timely, complete, accurate, and available for oversight purposes. The Department is responsible for ensuring that required entities report timely and accurate data on public health and human services programs to ensure that programs operate as intended and use data to help combat acute and chronic diseases and disabilities. However, OIG work has shown that databases such as ACFs Program Information Report, FDA's Food Facility Registry and its National Drug Code Directory, HRSAs 340B covered-entity database, and IHS's Health Service Directory contain incomplete and inaccurate data.

Improved quality of data received through exchanges with other Departments is needed. OIG work has found that external databases have quality issues similar to those found in Department databases. For example, a recent audit report found that the Social Security Administration (SSA) does not always verify the day of death, which impedes the usefulness of data matches between the SSA Master Death File and the Department's National Claims History File. Addressing concerns about the quality of data received from other agencies will be increasingly important as the Department expands CMS's Integrated Data Repository the ACA to include claims and payment data from other agencies, such as SSA, the Department of Veterans Affairs, and the Department of Defense.

Progress in Addressing the Challenge

The Operating Divisions (OPDIVs) have taken or planned some steps to address data-related vulnerabilities identified by OIG. For instance, in response to OIG recommendations regarding FDA's National Drug Code Directory, FDA has implemented an electronic reporting system for drug product information that may encourage manufacturers to update their listings more frequently. In response to ACA requirements, CMS is revalidating all enrollment information for the approximately 1.5 million providers and suppliers currently in PECOS and plans to cross-check enrollment data to other referential sources to better ensure accuracy. CMS also intends to increase efforts to consistently enforce the federal reporting requirements for managed care encounter data and has committed to conducting a review of laws and regulations to identify areas in which it can strengthen reporting. CMS has acknowledged problems related to the availability, completeness, accuracy and timeliness of State Medicaid data and has launched various projects aimed at improvement.

What Needs To Be Done

To formulate a plan and take corrective action, the Department will need to review the vulnerabilities specific to each database. Until the Department makes all necessary data available and corrects specific instances of incomplete or inaccurate data, program oversight will be hindered. As the Department integrates other agencies' data, it will need to examine their validity before relying on them for oversight purposes.

Key OIG Resources

Management Issue 7: Oversight of CMS Program and Benefit Integrity Contractors

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Office of Inspector General, U.S. Department of Health and Human Services | 330 Independence Avenue, SW, Washington, DC 20201