Recommendation: To ensure that MA encounter data are of sufficient quality for their intended purposes, the Administrator of CMS should establish specific plans and time frames for using the data for all intended purposes in addition to risk adjusting payments to MAOs.
Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
Status: Open
Priority recommendation
Comments: HHS generally agreed with this recommendation. Although CMS reports using MA encounter data for purposes other than risk adjustment, as of February 2020, it has not fully developed specific plans and time frames with dates for all uses. CMS reports that it has begun testing the use of MA encounter data for public health purposes, such as identifying beneficiaries with a history of opioid-related overdose and with other conditions, such as cancer and sickle cell. Further, CMS uses MA encounter data to help identify beneficiaries at risk in areas affected by public health emergencies. CMS reports that its Office of the Actuary (OACT) has used MA encounter data to analyze MA beneficiary utilization of certain Part B drugs. Further, OACT reports that it intends to assess other areas where it could use MA encounter data, such as analyses comparing Medicare fee-for-service and MA. As of February 2020, the agency has not developed specific plans and time frames for this and other intended purposes. For example, although CMS intends to use MA encounter data for program integrity purposes, it has not yet developed specific plans and time frames to do so. We will continue to monitor CMS's progress in developing specific plans and time frames with dates for all intended purposes of MA encounter data.
Recommendation: To ensure that MA encounter data are of sufficient quality for their intended purposes, the Administrator of CMS should complete all the steps necessary to validate the data, including performing statistical analyses, reviewing medical records, and providing MAOs with summary reports on CMS's findings, before using the data to risk adjust payments or for other intended purposes.
Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
Status: Open
Priority recommendation
Comments: HHS generally agreed with this recommendation, however, HHS did not commit to completing data validation before using MA encounter data for risk adjustment. As of February 2020, CMS has continued to make progress in examining the completeness and accuracy of MA encounter data, but more work remains to fully validate these data. CMS has developed and is implementing an MA Encounter Data Integrity and Monitoring plan, which includes data analysis, guidance, and monitoring. As part of this plan, CMS has established preliminary performance metrics for MA encounter data completeness and accuracy. CMS is also conducting analyses related to accuracy and completeness, but has not established performance benchmarks for these analyses. While the agency plans to communicate findings from the analyses to Medicare Advantage organizations, it has not yet done so. Finally, CMS has not verified MA Encounter data by reviewing medical records. While these steps are encouraging, without fully validating the completeness and accuracy of MA encounter data, CMS would be unable to confidently use these data for risk adjustment or other program management or policy purposes.
