Medicaid Data Can Be Used To Identify Instances of Potential Child Abuse or Neglect

Why OIG Did This Audit

This audit report is one of a series of OIG reports that addresses the identification, reporting, and investigation of incidents of potential abuse and neglect of our Nation's most vulnerable populations, including children, the elderly, and individuals with developmental disabilities. OIG is committed to detecting and combating such abuse and neglect.

Our objectives were to determine: (1) whether Medicaid claims data can be used to identify incidents of potential child abuse or neglect and, if they can, the number of incidents of potential abuse or neglect of children receiving Medicaid benefits that we identified using hospital emergency rooms (ERs) claims data; (2) whether the incidents were reported to child protective services (CPS) agencies and other appropriate agencies; and (3) who may have committed those incidents and where they occurred.

How OIG Did This Audit

Our audit covered 31,780 Medicaid claims that contained diagnosis codes specifically indicating the treatment of injuries potentially caused by abuse or neglect of Medicaid beneficiaries younger than age 18. These claims related to 29,534 children receiving Medicaid benefits who received ER services from January 1, 2017, through December 31, 2017. For a stratified random sample of 100 Medicaid beneficiaries, we reviewed the medical records and other documentation to determine whether they contained evidence of potential child abuse or neglect. We then determined whether the incidents of potential child abuse or neglect were reported to CPS and other appropriate agencies.

What OIG Found

We determined that Medicaid claims data can be used to identify incidents of potential child abuse or neglect and, using that data, estimated that 29,260 of the 29,534 Medicaid beneficiaries in our sampling frame were involved with incidents of potential child abuse or neglect that were supported by Medicaid claims data and evidence contained in the medical records. We further estimated that, of the beneficiaries in our population associated with incidents of potential child abuse or neglect, 3,928 were involved with incidents that were not reported to CPS. We also determined that most incidents of potential child abuse or neglect identified in our sample occurred in familiar settings by perpetrators known to the victims. Centers for Medicare & Medicaid Services (CMS) did not identify similar incidents of potential child abuse or neglect during our audit period or encourage the States to identify the incidents.

What OIG Recommends and CMS Comments

We recommend that CMS: (1) issue guidance, such as an Informational Bulletin, to inform States that performing a data analysis to identify Medicaid claims containing one or more diagnosis codes indicating potential child abuse or neglect could help identify incidents of potential child abuse or neglect and help ensure compliance with their mandatory reporting laws and (2) assess the sufficiency of existing Federal requirements to report suspected child abuse and neglect of Medicaid beneficiaries to determine whether CMS should strengthen those requirements or seek additional authorities to provide oversight over the reporting of suspected child abuse and neglect of Medicaid beneficiaries.

In written comments on our draft report, CMS concurred with our second recommendation but did not concur with our first recommendation. Specifically, CMS said that the majority of the sample cases identified in our audit occurred in a home or public place, which does not fall under CMS's jurisdiction for Federal oversight. CMS also stated that claims review may not be timely enough to address acute problems because claims and encounter data can be lagged and transformed as they move through the submission process. CMS added that its regulations require all facilities and their practitioners to comply with the mandatory reporting laws for abuse and neglect applicable to their State. We respectfully disagree with CMS and continue to recommend that CMS inform States that the use of the Medicaid claims data can help identify incidents of potential child abuse or neglect and ensure compliance with their mandatory reporting laws.