Use of Claims Data for Analysis of Provider Payment Rates

GAO-14-56R: Published: Jan 6, 2014. Publicly Released: Jan 6, 2014.

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Carolyn L. Yocom
(202) 512-7114


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What GAO Found

Among the 9 states and 35 services examined, GAO found that all states varied Medicaid payments for at least some services. However, the states differed in the number of services for which they varied payments, in the factors that accounted for variation, and in the magnitude of the variation. Many of the states varied payment rates by at least one of the factors GAO was able to explore in detail: provider type, service setting, and/or patient age. Some states also varied their payment rates for other reasons, such as by geographic region or by physician specialty. GAO also found that most of the median Medicaid payment rates calculated from claims data generally confirmed payment rates published in studies of fee schedules conducted by the American Academy of Pediatrics and the Urban Institute; however, some of the published fee schedule rates were rarely used in practice. Collectively, GAO's findings demonstrate that Medicaid fee-for-service claims data can be a useful source of information for analyzing provider payments. These data have the potential to provide a more complete representation of provider payment than do fee schedules, as claims data can capture both the distribution and frequency of actual payments to providers.

Why GAO This Study

GAO prepared this report under the authority of the Comptroller General to conduct work on GAO's initiative to assist Congress with its oversight responsibilities for the Medicaid program. In this report, GAO provides information on: (1) the extent to which state Medicaid programs vary the rates paid to providers for a given service and the basis for the variation; and (2) the extent to which Medicaid provider payment rates calculated from claims data confirm rates reported in studies of states' fee schedules.

What GAO Recommends

GAO makes no recommendations in this report. The Department of Health and Human Services reviewed a draft of this report and provided technical comments, which GAO incorporated as appropriate.

For more information, contact Carolyn L. Yocum at (202) 512-7114 or

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