Department of Health
Medicaid Managed Care Encounter Data Many of New York’s Medicaid recipients are enrolled in managed care programs. Each month, the managed care providers are required to submit to the Department of Health information describing the medical services provided to Medicaid recipients. We examined the practices used by the Department to ensure that the information submitted by managed care providers (called encounter data) is complete, accurate and timely. We found that improvements are needed in the completeness, accuracy and timeliness of the data. For example, when we examined the medical records maintained by selected managed care providers for a sample of 200 Medicaid recipients, we found that many of the medical services provided to these recipients had not been reported to the Department. We further found that, even when services were reported to the Department, the reported information was not always complete or reliable. For example, some of the reported data for the recipients in our sample did not contain essential required information, such as the type of service provided. In addition, some of the data contained inconsistencies that undermined its reliability, and some of the reported services were not supported by medical records.
We also found that encounter data could be used more effectively by the Department in its efforts to monitor the services provided to Medicaid recipients in managed care programs. For example, when we compared reported encounter data to other Medicaid data maintained by the Department, we identified as much as $3.8 million in duplicate payments as well as other potential problems. We made a number of recommendations aimed at improving the reliability and usefulness of the encounter data reported to the Department.
For a complete copy of Report 2000-S-54 click here.
For a copy of the 90-day response click here.
For a copy of the associated follow-up report click here.