Officials with CMS agreed with some, but not all, of the OIG’s recommendations.
The Health and Human Services Office of Inspector General issued a report on Medicare Advantage this month, suggesting seven changes to the way officials ensure the accuracy and completeness of the program’s encounter data.
The report sampled more than 100 million Medicare Advantage cases from the first quarter of 2014 and found one or more potential errors in 28% of the encounter records. After correcting a problem with the data, however, officials with the Centers for Medicare and Medicaid Services say only 5% of the relevant records have potential errors.
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“Some of these errors may raise concerns about the legitimacy of services documented in the data, such as records that lacked a beneficiary last name or a valid identifier for the billing provider,” the OIG report states.
Although CMS officials seem receptive to most of the OIG’s ideas, they take issue with a few suggestions deemed too burdensome.
“When undertaking a complex data collection effort such as this one, CMS is mindful of balancing immediate needs with long-term goals for use of the data, as well as provider and plan burden,” the CMS response says. “Therefore, while there are additional data fields that may be helpful for study, CMS must focus on development of fields necessary for payment purposes before broadening the scope of collection and validation.”
Officials with CMS say they concur with four of the OIG’s seven recommendations, which are outlined below.
1. Address errors in the encounter data
The OIG report recommends that CMS consider a variety of ways to reduce the number of errors in its Medicare Advantage encounter data, such as introducing more reject edits, pinpointing the reasons why data went missing, restoring data if appropriate, and determining why some code values fail to follow the program’s format specifications.
CMS concurs: The agency says it will continue working to address possible errors by assessing the validity of high-priority data points and by reviewing instructions for consistency.
2. Provide targeted oversight
Officials with CMS should also consider keeping a closer eye on Medicare Advantage Organizations (MAOs) that exhibit high percentages of possible data errors. The OIG provided CMS with a list of those MAOs that could benefit from technical assistance and guidance.
CMS concurs: The agency says it will review the OIG’s list and “consider how to incorporate this information into our already extensive oversight activities.”
3. Verify all billing provider identifiers
Each and every Medicare Advantage billing provider’s identifier should be verified as both valid and active on all records in the data, the OIG report says. While CMS already rejects submissions that are formatted incorrectly or coming from providers under sanction, the OIG recommends extending these efforts with reject edits that ensure the validity and active status of each provider identifier on a record.
CMS concurs: The agency says it will add an edit that checks the validity of a provider’s identifier.
4. Require ordering and referring provider identifiers
Minimum documentation requirements should be amended to clearly require identifiers for ordering and referring providers on certain records, the OIG recommends. Such requirements would be appropriate for home health services, clinical laboratory, imaging, and durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), according to the report.
CMS does not concur: The agency says MAOs often do not collect this information on ordering, operating, or facility provider identifiers, so they cannot report it. That being said, CMS says it will look into the question of whether collecting these identifiers might be needed.
5. Ensure rendering providers are noted
When there’s no rendering provider identifier listed in a Medicare Advantage encounter record, CMS considers the rendering and billing providers to be one in the same. But the OIG’s review found a number of records with only one identifier listed, even though there were likely two different providers handling billing and rendering. So the OIG recommends that CMS clearly communicate which situations require the inclusion of a rendering provider’s information and figure out a way to reject records that lack the required information.
CMS does not concur: The agency again bases its objection on the fact that MAOs often do not collect this information and that CMS has to take into account the administrative burden extensive reporting requirements can place on participants.
6. Track responses to reject edits
The main way CMS can ensure the data it collects are complete and accurate is through its edit process, which results in some data being rejected. So the OIG recommends that CMS keep track of how MAOs respond to these submission rejections. How many do the MAOs correct and resubmit? How many do they void? Tweaks to the submission requirements could be worthwhile to support this objective, the report notes.
CMS does not concur: The agency says this recommendation would require both CMS and MAOs to modify their systems, and that would be “administratively burdensome both to build and maintain,” pulling limited resources away from the work currently being done.
7. Establish and monitor performance thresholds
The OIG recommends that CMS establish performance thresholds and monitor whether MAOs meet them. When a provider falls short, CMS should issue notices of noncompliance, send warning letters, and implement corrective action plans to improve performance, the report states.
CMS concurs: The agency says it has already begun developing its thresholds and compliance plans, the framework for which was already described in the 2018 Call Letter.
Steven Porter is an associate content manager and Strategy editor for HealthLeaders, a Simplify Compliance brand.