Encounter Data Submitted by Community Care Oklahoma for 2003 Monthly Capitation Payments

The objective of our review was to determine whether the encounter data the Centers for Medicare and Medicaid Services (CMS) used as the basis for the 2003 monthly capitation payments made on behalf of beneficiaries enrolled in CommunityCare's Senior Health Plan were valid and accurate. All of the encounter data supporting inpatient claims for beneficiaries in our sample met our definition of “valid encounter data.” Furthermore, in accordance with chapter 7 of the CMS “Managed Care Manual” and the CMS “Risk Adjustment Training Manual,” CMS appropriately used the diagnoses provided to assign risk factors to beneficiaries in our sample. However, medical records did not always substantiate the encounter data used to determine beneficiaries' risk factors. We recommended that CommunityCare (1) strengthen internal controls to ensure that providers maintain medical records, (2) insert into provider contracts provisions that promote the accurate recording of encounter data, and (3) train providers to code diagnoses accurately. CommunityCare generally agreed with our findings.