The Medicaid Statistical Information System was approved in 1984 for use as an optional state reporting tool for fee-for-service claims data, either on paper or via electronic transmission. State participation in the MSIS was mandated by Congress in 1997 for claims filed after 1999.
As of July 2009, according to Wright's 27-page report, “MSIS data Usefulness for Detecting Fraud, Waste and Abuse,” 34 states were transmitting their MSIS files to the CMS electronically instead of sending them in on data cartridges or tape. The aim of the MSIS reporting program is to use the data to assist in the detection of fraud and abuse in the Medicare and Medicaid programs. Other data uses are to produce statistical reports, support Medicaid-related research, create spending forecasts and works of policy alternatives analysis, respond to inquires by members of Congress and “other health-related data matches,” according to the report.
The Medicaid Integrity Group was launched in 2006 as a fraud-fighting unit within the Center for Medicaid and State Operations at CMS. The group uses a special database and analysis system, commonly known as the MIG Data Engine, that is fed by MSIS data, which makes timely reporting of that data important, according to the inspector general's office. States must submit files quarterly on Medicaid eligibility and on four types of services provided, inpatient services, long term care, prescription drugs and other claims. States are required to submit eligibility data within three and a half months of the end of a quarter, the report said. Service data must be submitted within 45 days, it said.
CMS puts the state data though a quality review process before adding it to the MSIS production database. If the data fails to pass quality review, the files are returned to states for correction and resubmission, but the CMS does not limit the number of times states may resubmit corrected data nor does it set a deadline for re-submission of corrected data. Not until all five types of quarterly files are corrected will files from a state for that quarter be added to the MSIS production database, however, “users do not always need access to all five validated MSIS files to identify potentially fraudulent trends,” the report said. The report notes that the fraud-fighting Medicaid Integrity Group can and does use MSIS data that have not be validated to conduct “preliminary fraud, waste and abuses analysis.”
The inspector general found that on average during the study period, it took the states, the CMS and its data contractors more than 18 months for quarterly data to make its way through the process and reach the MSIS database for use by the public.
On average, states contributed six months to the delay through late submissions of data to the CMS, the report said. Nearly two thirds (63%) of the state files in the study period were initially submitted after CMS due dates, while almost one third (31%) were sent late by six months or more, the report said. In addition, more than a quarter (26%) of state files initially submitted “required correction and resubmission to clear CMS quality review,” it said.
Part of the states' problems in meeting those criteria were inflicted by CMS in that “midyear changes in state eligibility requirements often require states to correct and resubmit the MSIS eligibility files from previous quarters,” the report said. On the other hand, the CMS made more than 1,500 “error tolerance adjustments” at the state level “based on special state circumstances” that were not fully disclosed to data users and allowed “the affected state MSIS files to clear quality review with an unknown number of errors.”
The CMS and its contractor, Mathmatica Policy Research, used up another four months on average to validate the state data and an additional nine months to release the data to the public via the MSIS database, the report said. In the end, however, “as of June 2009, the MSIS had not captured many data elements that can assist in fraud, waste and abuse detection,” the inspector general's report concluded. The “many” was later defined in the report as 46 of 100 data elements that the Medicaid Integrity Group “identified as useful for fraud, waste and abuse detection,” were not captured, including service provider identifiers, procedure, product and service descriptions, billing information and beneficiary and eligibility information. For example, MSIS did not capture over half (55%) of the consolidated Medicaid Service Provider Identifier data elements that the Medicaid Integrity Group finds useful in “assisting in fraud, waste and abuse detection,” the report said.
The report contained no recommendations, only noting that study found opportunities for states and the CMS to reduce time delays in gathering and reporting Medicaid data.
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