NOTE: The abstract below is a shortened version of the RADAR on Medicare Advantage article “OIG: T-MSIS Lacks Full Medicaid Managed Care Payment Data.”

By Lauren Flynn Kelly

A new review of the CMS Transformed Medicaid Statistical Information System (T-MSIS) found that most states did not provide complete or accurate data on managed care payments to providers for January 2020, according to an HHS Office of Inspector General report released March 30.

Managed care organizations, which cover about 70% of the Medicaid population, are required to submit an encounter claim for each enrollee encounter or visit to a provider. States must then validate those claims for accuracy before submitting them to T-MSIS.

Having accurate payment data is essential to monitoring and administering the Medicaid program, OIG explained. For example, states use payment data to set capitation rates for MCOs and to monitor the services they provide. CMS and other stakeholders can use the data to manage and oversee plans, and to examine payments to detect fraud, waste and abuse. And with more individuals enrolling in and using Medicaid over the last year, “[p]rotecting the fiscal integrity of Medicaid during the pandemic has taken on a new urgency,” OIG argued.

Yet 31 out of 39 states with managed care last year did not provide complete or accurate data to T-MSIS on provider payments for January 2020 made by their largest plan. A record was considered incomplete or inaccurate if it had inappropriate zeros, missing data or negative amounts, clarified OIG. Moreover, many states had incomplete or inaccurate information for two or more types of payment data.

Although CMS has identified improving data quality in the system as a priority, OIG maintained that CMS must “strengthen its efforts to improve the accuracy and completeness of managed care payment data in T-MSIS.” Specifically, it recommended that CMS:

✦ Review states’ managed care payment data in T-MSIS and certify that states have corrective action plans to improve data completeness and quality, as appropriate;

✦ Publicize the findings of such reviews, including the extent to which the payment data are complete and accurate for each individual managed care plan; and

✦ Clarify and expand its initiative on payment data.

CMS did not agree with any of the recommendations. In a letter dated Jan. 19, then-CMS Administrator Seema Verma responded that the agency has over the last several years taken steps to improve T-MSIS.