Watchdog: Better Data Needed to Fight Medicaid Fraud


The Centers for Medicare and Medicaid Services oversight data needs work, according to the Government Accountability Office.

An audit from the Government Accountability Office states better data should help the Centers for Medicare and Medicaid Services oversee the $80 billion it doles out for personal services provided in homes for long-term care.

These services, which include bathing, dressing and toileting, are among the highest risk for improper payments and fraud in the agency’s nearly $1 trillion portfolio.

In this case, GAO states CMS often fails to collect complete data sets and does not have standardized reporting guidance for the key data it uses for oversight.

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GAO analyzed two systems, the Medicaid Statistical Information System and the Medicaid Budget and Expenditure System, that cross-pollinate to highlight trends such as how fee-for-service spending changes over time.

But the data contained within these systems is often incomplete. GAO found old and inconsistent data in MSIS: The most recent information was from 2012 and pertained to only 35 of the 50 states.

“Further, 15 percent of claims lacked provider identification services, over 400 different procedure codes were used to identify the services and the quantity and time periods varied widely,” the audit states. “Without good data, CMS is unable to effectively monitor who is provided personal care services or the type, amount and dates of services. CMS may also face challenges determining whether beneficiaries were eligible for services and assessing the reasonableness of the services claimed.”

GAO’s examination of MBES found that “17 percent of expenditure lines were not reported correctly,” mostly due to states failing to separately identify personal care services as required by CMS.  

“Inaccurate and incomplete reporting limits CMS’ ability to ensure federal matching funds are provided consistent with states’ approved programs,” the audit states.

CMS plans to replace MSIS with a new system and has established a new data oversight office but GAO contends the agency’s actions aren’t enough.

“CMS has not issued guidance related to reporting of personal care services that addresses the gaps GAO identified or developed plans for how it can be used for oversight purposes,” GAO states. “Without improved data and plans for how it can be used for oversight, CMS could continue to lack critical information on personal care service expenditures.”

CMS’ parent agency, the Department of Health and Human Services, which last June teamed with the Justice Department in the largest fraud takedown in Medicare’s history, agreed with GAO’s recommendations to ensure state compliance with reporting requirements and develop better plans to use its data.