CMS Regularly Reviews Part C Reporting Requirements Data, But Its Followup and Use of the Data Are Limited

WHY WE DID THIS STUDY

In 2012, 27 percent of Medicare beneficiaries were enrolled in Medicare Advantage (MA) plans. CMS has collected data from MA organizations under the Part C Reporting Requirements since 2009. These data are intended to serve as a resource for CMS to conduct the oversight, monitoring, compliance, and auditing activities that are necessary to ensure the quality of benefits that MA plans provide to enrollees. CMS contracted with Acumen to review and analyze all Part C Reporting Requirements data submitted by MA organizations, identify data issues, and notify affected MA organizations. The Part C Reporting Requirements data are a significant resource for oversight and improvement of the MA program because they pertain to the performance of MA organizations and often are not available to CMS from other sources.

HOW WE DID THIS STUDY

We reviewed the extent and types of data issues that Acumen identified for Part C Reporting Requirements measures that were active in 2010 and 2011. We determined the steps that Acumen took to identify these data issues and the steps CMS took to address them. We reviewed the extent to which CMS used the Part C Reporting Requirements data to monitor and assess MA organizations' performance.

WHAT WE FOUND

CMS implemented regular and extensive reviews of the Part C Reporting Requirements data, but it conducted minimal followup on data issues identified for 2010 and 2011. MA organizations that submitted outlier data values accounted for most of the data issues that Acumen identified. Other issues included inconsistent and overdue data. CMS did not contact any MA organizations to determine whether outliers reflected inaccurate reporting or atypical performance, or to ensure that inconsistent data were corrected. Despite its investments in contractor reviews of the data, CMS has made limited use of the Part C Reporting Requirements data.

WHAT WE RECOMMEND

Our findings indicate that additional effort is needed to ensure appropriate oversight and use of these data. We recommend that CMS (1) determine whether outlier data values submitted by MA organizations reflect inaccurate reporting or atypical performance, (2) use appropriate Part C Reporting Requirements data as part of its reviews of MA organizations' performance, and (3) establish a timeline for releasing Public Use Files for the Part C Reporting Requirements data. CMS concurred with our recommendations.