Kusserow on Compliance: OIG reports the new Medicaid data system inadequate

The OIG reported that historical inadequacies in Medicaid data have hindered program integrity, research, budgeting, and policy. As a result the OIG has designated the improvement of Medicaid data as a top management HHS challenge. In 2016, the federal Government and states spent $574 billion on Medicaid, serving more than 74 million enrolled individuals. Complete, accurate, and timely Medicaid data are vital for the effective administration and oversight of the Medicaid program by states and the federal Government. The Transformed Medicaid Statistical Information System (T-MSIS) is a new data system that was developed to improve the completeness, accuracy, and timeliness of Medicaid data. The OIG provided a status update on the implementation of T-MSIS, building on its previous review of the 2013 T-MSIS pilot.

In conducting its review, the OIG analyzed the implementation status of T-MSIS using 40 states’ approved plans for data submission; and interviewed staff from CMS and 16 states about their experiences implementing T-MSIS. The OIG reported the following:

  1. States and CMS reported early implementation challenges resulted in delays with T-MSIS
  2. Technological problems and competing priorities for states’ resources caused delays
  3. The goal date for when T-MSIS will contain data from all states has been repeatedly postponed
  4. CMS expects that all states will be reporting to T-MSIS by the end of 2017
  5. 21 of 53 state programs were submitting data to T-MSIS
  6. States and CMS continue to raise concerns about completeness and reliability of the data
  7. States indicate that they are unable to report data for all the T-MSIS data elements
  8. Even with a revised data dictionary for each data element, states and CMS report concerns about states’ varying interpretations of data elements
  9. Without uniform interpretations of data elements, the data submitted will not be consistent across states, making any analysis of national trends or patterns inherently unreliable.

The OIG concluded that successfully getting all states’ data into T-MSIS requires states and CMS to prioritize T-MSIS implementation. However because of CMS’s history of delaying target dates for implementation, the OIG expressed concerned that CMS and states will delay further rather than assign the resources needed to address the outstanding challenges. The OIG further noted that without a fixed deadline, some states and CMS may not make the full implementation of T-MSIS a management priority.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2017 Strategic Management Services, LLC. Published with permission.

Examining the role of data and analytics in fighting fraud, waste, and abuse

On June 7, 2016, a podcast interview of Dr. Caryl Brzymialkiewicz, Chief Data Officer for the HHS Office of Inspector General (OIG) was made available by the OIG. In the podcast, Brzymialkiewicz provided insight into how the OIG uses data and analytics to reduce healthcare fraud, waste and abuse.

The Chief Data Office officially came into existence last year, but the OIG’s advanced analytic team has been around for several years. Brzymialkiewicz indicated that her office is currently focusing on: (1) how to accelerate the work of the advanced analytic team; (2) how to help the OIG to become even more effective and efficient; (3)  improving access to data; (4) supporting OIG investigators in their cases, with audits and evaluations, and in determining what other datasets they need; and (5) making sure the data the OIG has is high quality data. One current example of the office’s focus is its work with CMS as it creates a new nationwide Medicaid data set. According to Brzymialkiewicz, “we’re working closely with [CMS] to understand, as they’re implementing their new system, what does [it] mean, [and] how can we potentially tap into that environment.”

Brzymialkiewicz defined advanced analytics as “having high quality lead-generation for either our investigators, our auditors, our evaluators or for compliance oversight.” According to Brzymialkiewicz, advanced analytics data can either lead to someone that is potentially committing fraudulent activity or OIG investigators can bounce information from a hotline call or from a whistleblower  against the data to help make a case of fraud.

Brzymialkiewicz described her office’s predictive analytics space, where they use statistical models to generate risk scores. These scores can result in a pharmacy or provider being designated low, medium, or high risk. She opined that for high risk entities the OIG might want to apply a little more scrutiny. She indicated that her office plans to accelerate their predictive analytic work.

With regard to internal support at OIG, Brzymialkiewicz stated that her office is working to support senior leadership, to help inform their decisions, to facilitate the right conversations about where to allocate resources, and to help position the OIG to compete for increasingly scarce resources across the entire government.

Her office is heavily invested in developing additional tools to fight fraud, waste and abuse. She described the development process as one of trying to democratize data, so that rather than requiring the whole organization to understand programing language, investigators will instead have easy-to-use tools in their hands to accomplish their goals.

Finally, she described the need for link analysis to determine the possible connectedness between providers. According to Brzymialkiewicz, this would allow the OIG to look at providers that have high risk scores to see how they are connected to other entities that may also be committing fraud.