U S Government Accountability Office

Medicare Advantage, Limited Progress Made to Validate Encounter Data Used to Ensure Proper Payments U S Government Accountability Office

" CMS collects MA encounter data to help ensure the proper use of federal funds by improving risk adjustment in the MA program-the private health plan alternative to traditional Medicare-and for other potential purposes. CMS's ability to make proper payments depends on the completeness and accuracy of MA encounter data. In July 2014, GAO reported that CMS had taken some, but not all, appropriate actions to validate the completeness and accuracy of encounter data and had not fully developed plans for using them. GAO was asked to provide an update on its July 2014 findings. In this report, GAO identifies (1) steps CMS has taken to validate MA encounter data, and (2) CMS's plans and time frames for using MA encounter data-as well as stakeholder perspectives on these steps and plans. To do this work, GAO compared CMS activities with the agency's protocol for validating Medicaid encounter data-comparable data collected and submitted by entities similar to MAOs-and federal internal control standards. In addition, GAO reviewed relevant agency documents and interviewed CMS officials on MA encounter data collection and reporting. GAO also reviewed comments in response to CMS's 2014 proposed rule and reports from stakeholder organizations.