Washington Medicaid claims information submitted by states to the Centers for Medicare & Medicaid Services is slow in being released to the public and often does not contain many data elements that can assist in fraud detection, according to a report by investigators from the Dept. of Health and Human Services Office of Inspector General.
In an Aug. 26 letter to Cindy Mann, the director of the CMS Center for Medicaid and State Operations, OIG states that CMS did not fully disclose or document information about the accuracy of data collected by the Medicaid Statistical Information System. Timely, accurate and comprehensive data can be used to help interagency efforts in combating health care fraud, the report notes.
States must submit claims files to CMS within 45 days after the end of each quarter. The system is designed to serve as an accurate database pertaining to standardized enrollment, eligibility and paid claims of Medicaid beneficiaries.
In a review of MSIS files, OIG determined that data took an average of more than 1½ years after the initial state submission before being relayed by CMS to the public. This time frame included an average of six months that states took to submit MSIS files in a CMS-acceptable format and averages of four months and nine months for CMS to validate the data and release the files.
CMS also could not explain why it approved more than 1,500 exceptions to a process designed to identify claims errors. The MSIS program produces reports that show the numbers and types of errors identified. But CMS periodically adjusted individual state error tolerances to allow particular files or sets of files to pass data validation tests.
"These undocumented error tolerance adjustments allowed the affected state MSIS files to clear quality review with an unknown number of errors," OIG reported.
Also, MSIS does not capture a number of data elements that can assist in fraud, waste and abuse detection, OIG wrote. The system, for example, does not capture the referring physician's identification number. Without it, fraud analysts cannot use MSIS to assess whether a qualified physician submitted the order as required for a beneficiary to receive certain medical benefits.
The report was issued directly to CMS in final form with no specific recommendations. It did not include a CMS response.
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An anti-abortion group is asking the Illinois Supreme Court to order immediate enforcement of a state law requiring physicians to notify a minor's parent or legal guardian at least 48 hours before performing an abortion.
The Parental Notice of Abortion Act of 1995 was blocked from taking effect for more than a decade until the high court in 2006 finally issued mandated rules allowing young women to ask a court to bypass the notice requirement. It would be up to the court to decide if a waiver is in the minor's best interest. After additional litigation, the 7th U.S. Circuit Court of Appeals in July upheld the law's constitutionality in Zbaraz v. Madigan and dissolved a long-standing injunction preventing its implementation. The statute took effect Aug. 4.
But concerns from the medical community about compliance prompted the state medical board to delay enforcement of the law by three months. Under the act, any doctor who does not act in good faith to obey the law would face a misdemeanor charge as well as disciplinary action by the medical board.
In an Aug. 5 announcement, the agency said it wanted to give physicians more time to institute new protocols "to ensure both compliance with the act and protection of patients' medical care" and "to effectively counsel their minor patients about all of their options."
But Chicago's Thomas More Society, a faith-based law firm, and a group of parents that oppose abortion say doctors have had plenty of time to get up to speed. They allege that the medical board lacked the legal authority to change the rules, according to a petition filed Aug. 31 with the Illinois Supreme Court.
The Dept. of Financial and Professional Regulation, Illinois' medical board, is reviewing the case, said spokeswoman Susan Hofer. She declined to comment further. The Illinois State Medical Society has not taken a position on the matter.
Illinois is among 35 states that have abortion parental consent or notice laws, according to the Guttmacher Institute, a nonprofit organization that supports worldwide advances in reproductive health and tracks related policy.
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