RISE West 2018 featured a presentation by Joanna Bisgaier, Ph.D., deputy regional inspector general at the U.S. Department of Health & Human Services, on MA encounter data. Among the findings of the OIG report: The most common errors involved duplicated services, incorrect original control numbers, inappropriate codes, and missing values from other data.
PALM SPRINGS, Calif— Joanna Bisgaier, Ph.D., deputy regional inspector general at the U.S. Department of Health & Human Services, was one of the featured speakers at RISE West 2018, where she provided an overview of the Office of Inspector General’s recent report on Medicare Advantage (MA) Encounter Data.
Overall, she said, 28% of the 102 million submitted records from January to March 2014 had at least one potential error among the 56 data elements under review.
The biggest error involved missing values in billing provider identifiers, a mistake that the Centers for Medicare & Medicaid Services has since corrected. CMS said that most of the potential errors were created when the agency removed provider identifiers from records in the edit process. Those corrections mean the actual error rate was 5% and involved duplicated services, incorrect original control numbers, inappropriate codes, missing values from other data, inconsistent date values, inactive/invalid billing provider identifiers, and beneficiary data did not match CMS records.
As a result of the findings, the OIG has recommended that CMS:
- Take actions to address potential errors in the MA encounter data, provide targeted oversight of MA organizations that submitted a higher percentage of records with potential errors
- Ensure that billing provider identifiers are active and valid on all records, require MA organizations to submit ordering and referring provider identifiers and ensure they submit provider identifiers for all applicable records
- Track how MA organizations respond to edits that reject data, and establish and monitor performance thresholds related to MA organization’s submissions of records with complete and valid data
Bisgaier said that CMS has already addressed some of these errors by notifying MA organizations of edit results and rejecting some data. The agency has done so by generating automated reports of edit results for each record; conducting group calls, presentations and technical instructions; issuing periodic “report cards”; and making direct contact with specific Medicare Advantage organizations.
As for the future efforts of the OIG to ensure that payments to the MA organizations are accurate and that beneficiaries have access to the appropriate quality of care, Bisgaier said that strengthening and improving the MA program is one of its top management challenges. It will soon undertake a new study that uses the encounter data to determine the financial impact of risk assessments and chart reviews on risk scores in Medicare A. It also wants to look at the diagnosis codes on encounter data and how the codes increase scores and payments. “We feel like we are just getting started," Bisgaier said, noting that the agency learned a lot about data based on the first report, and officials want to determine how to best use the data to protect the program.
For more information about this topic and other CMS policies and regulations, consider attending The 13th Annual RISE Nashville Summit.