OIG: T-MSIS Lacks Full Medicaid Managed Care Payment Data

A new review of the CMS Transformed Medicaid Statistical Information System (T-MSIS) found that most states did not provide complete or accurate data on managed care payments to providers for January 2020, according to an HHS Office of Inspector General report released March 30. Moreover, two states failed to provide any T-MSIS data for that month. The national data system is critical to ensuring proper oversight of Medicaid, and maintaining accurate Medicaid data is more important than ever as the COVID-19 pandemic continues to drive enrollment and changes in utilization, observed OIG.

Managed care organizations, which cover about 70% of the Medicaid population, are required to submit an encounter claim for each enrollee encounter or visit to a provider. States must then validate those claims for accuracy before submitting them to T-MSIS. The claims include information such as the total amounts billed, allowed and paid for the encounter or visit, but they do not include the capitated payments that the state pays to the managed care organization, according to the report.

© 2021 MMIT

Lauren Flynn Kelly Managing Editor, Radar on Medicare Advantage

Lauren has been covering health business issues, including drug benefits and specialty pharmacy, for more than a decade. She served as editor of Drug Benefit News (the predecessor to Radar on Drug Benefits) from 2004 to 2005 and again from 2011 to 2016, and now manages Radar on Medicare Advantage. Lauren graduated from Vassar College with a B.A. in English.

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