GAO: Data challenges impede Medicaid oversight

In 2016, there were $36 billion in Medicaid improper payments, according to a U.S. Government Accountability Office report.

To address growing concerns about the data CMS uses to oversee Medicaid, GAO interviewed CMS officials and reviewed agency guidance, laws and regulations. GAO found that the Medicaid expenditure and utilization data available to CMS is not sufficient to ensure appropriate payments.

Here are three things to know.

  • CMS uses two main data sources to oversee Medicaid. It utilizes the CMS-64 to calculate a state's federal matching funds and the Medicaid Statistical Information System to report individual beneficiary claims data.
  • These two state-level data sources often lack accurate information about how states finance program costs. This data might leave out the amount of local government funding or report finances up to three years late, making it difficult for CMS to identify abnormal billing patterns.
  • CMS has put forth its new Transformed Medicaid Statistical Information System, or T-MSIS, as a method to improve Medicaid data collection, since it has a focus on accuracy and timeliness of state-level data. However, the rollout of this initiative has been delayed for several years; as of October 2016, only 18 states were submitting data to this system.

Moving forward, GAO — with agreement from HHS — recommended that CMS focus on improving Medicaid data, in part by "expediting efforts to assess and ensure the quality of T-MSIS data."

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