MCO Claims Data Critical to CMS and State Oversight of Medicaid Programs

How can states and CMS guarantee Medicaid managed care organization spending is justified? Without complete claims data, they simply can’t.

Authors: Jason Duhon, Betsy Walton 

The use of managed care plans to provide services to Medicaid beneficiaries will only continue to increase as states expand Medicaid coverage. As such, it’s essential for states operating managed care programs to concentrate efforts and investments on providing accurate, timely, and reliable MCO encounter data to:

  • Justify capitation rate payment levels to MCOs; 
  • Assure access and quality standards are met; and 
  • Oversee the appropriateness of Medicaid expenditures borne by states and the federal government.

Failure to do so can result in significant CMS penalties, and there’s a high likelihood states will pass those penalties on to MCOs. But it’s not just MCOs that are responsible for encounter reporting issues – State Medicaid agencies are also compounding the situation, as some may not have the system design in place to accept MCO encounter claims reporting.


Methods for Monitoring and Enforcing Encounter Quality 


Read more about the managed care requirements for encounter reporting
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