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Report File
Date Issued
Submitting OIG
Department of Health & Human Services OIG
Other Participating OIGs
Department of Health & Human Services OIG
Agencies Reviewed/Investigated
Department of Health & Human Services
Report Number
OEI-03-15-00060
Report Description

For the Medicare Advantage (MA) program, CMS contracts with private insurance companies, known as MA organizations (MAOs), to provide Medicare coverage for 18.6 million beneficiaries. In fiscal year 2016, MA expenses reached $200 billion. In 2012, CMS began collecting detailed information from MAOs regarding each service provided to MA beneficiaries. This information is known as MA encounter data. These data must be accurate for CMS to review the medical care that beneficiaries are receiving and use the data to increase payments to MAOs for beneficiaries in poorer health. Ensuring the completeness, validity, and timeliness of the MA encounter data is also critical to safeguard program integrity and to ensure that MA beneficiaries receive needed medical care.

Report Type
Inspection / Evaluation
Agency Wide
Yes
Questioned Costs
$0
Funds for Better Use
$0

Open Recommendations

This report has 2 open recommendations.
Recommendation Number Significant Recommendation Recommended Questioned Costs Recommended Funds for Better Use Additional Details
5479 Yes $0 $0

CMS should ensure that MAOs submit rendering provider identifiers for applicable records.

5480 No $0 $0

CMS should track MAOs' response to reject edits

Department of Health & Human Services OIG

United States