Posted on September 16, 2010 14:55
Categories: Medicaid | State and Local
Topics: Managed Care | Medicaid | Rates/Reimbursement | State Data
This report by the U.S. Government Accountability Office (GAO), released on August 4, 2010, finds regional gaps in the oversight and data collection tools used to ensure the actuarial soundness of Medicaid managed care organizations’ rates. The report found that current CMS regulations lack standards governing the data used to set those rates and do not require states to report on the quality of the data they provide to CMS. In particular, the GAO found that Tennessee received $5 billion in annual federal funds for rates that were not certified by an actuary. In addition, the GAO found that Nebraska’s Medicaid program has not reviewed its managed care rates since the implementation of new regulations for actuarial rate review. The report notes that CMS has already taken steps to address these issues but suggests that further reforms are needed. The GAO recommends that CMS track states’ compliance with requirements for actuarial rate review and implement regulations to verify the quality of state data used to determine Medicaid managed care rates.
From the report:
To assess CMS’s efforts to ensure the quality of data used to set rates, we reviewed CMS policies and guidance related to rate setting. In addition, in interviews with officials from CMS’s central office and the selected regional offices, we asked about steps CMS takes to ensure data quality, including what information CMS requires states to include in their rate-setting submissions to demonstrate the appropriateness and reliability of the data used to set rates and whether any audits or studies of rate setting had been performed. We also assessed, as part of our review of CMS files, the information provided in states’ rate-setting submissions about steps taken to ensure data quality, including statements made by states’ actuaries. In interviews with state Medicaid officials, we asked about their processes to ensure data quality and their experiences with CMS oversight of data quality. We also reviewed relevant audit findings from the Washington State Auditor’s Office. Finally, we contacted officials from five health plans to discuss their efforts to ensure the quality of the data submitted to states for rate setting.
Full report: CMS’s Oversight of States’ Rate Setting Needs Improvement (PDF | 1.5MB)
United States Government Accountability Office. (2010). Medicaid managed care - CMS’s oversight of states’ rate setting needs improvement.
E-mail to Friend |
Print |
Permalink |
Post RSS
