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DEPARTMENT OF HEALTH & HUMAN SERVICES
Office of Inspector General
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Washington, D.C. 20201
AUG 2 6 2009
TO: Cindy Mann
Director of the Center for Medicaid and
State Operations
FROM: StUa wright
Deputy Inspector General
for Evaluation and Inspections
.
SUBJECT: Memorandum Report: "MSIS Data Usefulness for Detecting Fraud, Waste, and
Abuse," OEI-04-07-00240
This report provides information about the Medicaid Statistical Information System (MSIS) data
from fiscal years (FY) 2004 to 2006. Specifically, it provides information on: (1) the length of
time that the States and the Centers for Medicare & Medicaid Services (CMS) took to submit and
the accuracy ofMSIS data; and
release the MSIS data; (2) CMS disclosure and documentation of 
(3) the extent to which the MSIS captued information for detecting fraud, waste, and abuse.
We found that, on average, FYs 2004-2006 MSIS data took an average of over 1 Y2 years after
the initial State data submission before CMS released them to the public. This timeframe
included an average of 6 months that States took to submit the MSIS fies in a CMS-acceptable
format and averages of 4 and 9 months for CMS to validate and release the files to the public,
respectively. In addition, CMS did not fully disclose or document information about the
the MSIS data. Finally, as of June 2009, the MSIS had not captured many data
accuracy of 
elements that can assist in fraud, waste, and abuse detection.l
Timely, accurate, and comprehensive MSIS data can be used to meet the Health Care Fraud
Prevention and Enforcement Action Team (HEAT) objectives.2 In May 2009, HHS and the
3
Department of Justice established HEAT as an interagency effort to combat health care fraud. 
1 The Offce ofInspector General (OIG) conference call with CMS, June 2009.
2 Departent of  Health and Human Services (HHS). "Breaking News: Medicare Fraud Strike Force Operations
Lead to Charges Against 32 Doctors and Health Care Executives for More Than $16 Milion in Alleged False
Biling in Houston." Available online at h ://www.hhs. 'ov/sto medicarefraud/. Accessed on June 19,2009.
3 HHS. "Attorney General Holder and HHS Secretary Sebelius Announce New Interagency Health Care Fraud
Prevention and Enforcement Action Team." Available online at
htt ://www.hhs. ov/news/ ress/2009 res/05/20090520a.htinI. Accessed on June 19,2009.
o EI -04-07 -00240 MSIS Data Usefulness for Detecting Fraud, Waste, and Abuse Page 2  Cindy Mann 
 
 
HEAT includes a focus on expanding data usage to more effectively identify and prevent 
Medicaid fraud. 
 
BACKGROUND 
 
In 1965, Title XIX of the Social Security Act established Medicaid to provide certain basic 
services to categorically and medically needy populations.4  Medicaid programs are jointly 
funded by Federal and State governments but solely administered by States pursuant to Federal 
statutes, regulations, and policies.  CMS oversees State Medicaid programs and ensures that 
State-submitted expenditures for Federal reimbursement are appropriate.  In FY 2006, Medicaid 
covered over 57 million beneficiaries at a cost of over $308 billion.5 6  The Federal share of this 
cost was approximately $174 billion.7 
 
Medicaid Statistical Information System 
CMS maintains the MSIS database, the only nationwide Medicaid eligibility and claims 
information source.  In FY 1984, MSIS was approved as a voluntary State reporting option of  
beneficiary-level Medicaid fee-for-service claims data in an electronic format.8  This option 
permitted States to forego data submission via a paper (i.e., hardcopy) format.   The Balanced 
Budget Act of 1997 mandated MSIS-program participation from the 50 States and the District of 
Columbia (hereinafter referred to as States) for Medicaid claims filed on or after January 1, 
1999.9  To improve the timeliness of the MSIS files release, CMS encourages States to submit 
their files electronically.10  As of July 2009, 34 States were sending their MSIS files 
electronically.11   
 
 
4 42 U.S.C.  1396-1396v, Social Security Act,  1901-1936. 
5 MSIS State Summary Data Mart, 2006 Unique Eligibilities Count.  Available online at http://msis.cms.hhs.gov/.  
Accessed on December 1, 2008. 
6 CMS, Office of the Actuary, National Health Statistics Group, Health Expenditure Data, Table 11:  Expenditures 
for Health Services and Supplies Under Public Programs, by Type of Expenditure and Program:  Calendar Year 
2006.  Available online at http://www.cms.hhs.gov/NationalHealthExpendData/downloads/tables.pdf.  Accessed on 
December 1, 2008.  
7 Ibid. 
8 The MSIS reporting option was part of the annual State submission of the Statistical Report on Medical Care: 
Eligibles, Recipients, Payments and Services (HCFA-2082), started in FY 1972.  As of FY 1997, the MSIS data can 
be provided in one of two ways: (1) the annual submission of the hardcopy 1984 version, or (2) quarterly fixed 
electronic format of Medicaid eligibility and claims.  States that successfully comply with all MSIS requirements 
and submit data for a full fiscal year can receive a waiver from submitting the hardcopy HCFA-2082.  CMS 
technical comments on OIGs draft memorandum report, August 2009. 
9  42 U.S.C.  1396b(r).  In addition to requiring fee-for-service data, the Balanced Budget Act of 1997 mandated 
the electronic transmission of individual enrollee encounter data.  Encounter data provide details about services 
provided to Medicaid beneficiaries enrolled in managed care. 
10 States are encouraged to submit their files via Electronic File Transmission (EFT) instead of cartridges or tape.  
This results in faster transmission and retransmission of the MSIS data.  The EFT is identified in the MSIS Tape 
Specification and Data Dictionary, Release 3.  Available online at http://www.cms.hhs.gov/MSIS.  Accessed on 
August 11, 2009.   
11 CMS technical comments on OIGs draft memorandum report, August 2009. 
   
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The MSIS system of records notice indicates that CMS collects MSIS data from States to 
establish an accurate, current, and comprehensive database containing standardized enrollment, 
eligibility, and paid claims of Medicaid beneficiaries to be used for the administration of 
Medicaid at the Federal level.12  The system of records also notes that CMS collects MSIS data 
to produce statistical reports, support Medicaid-related research, and assist in the detection of 
fraud and abuse in the Medicare and Medicaid programs.13  According to CMS, the MSIS is 
also used for health care research and evaluation activities, program utilization and expenditure 
forecasts, policy alternatives analysis, congressional inquiry responses, and other health-related 
database matches.14 
 
The MSIS timeliness, reliability, and comprehensiveness are further important because the data 
is also used as an information source for other CMS databases, such as the MSIS State Summary 
Data Mart, the MSIS Drug Utilization Data Mart, the Medicaid Analytical Extract, the Enterprise 
Cross-Reference Database, and the Medicaid Integrity Group (MIG) Data Engine.  See  
Appendix A for descriptions of these databases 
 
CMS Efforts To Use MSIS Data for Detecting Medicaid Fraud, Waste, and Abuse 
The Deficit Reduction Act of 2005 (DRA) included several provisions to reduce Medicaid fraud, 
waste, and abuse.  For example, it created a new Medicaid Integrity Program and appropriated 
$100 million over 2 years for CMS to implement the program.  The DRA appropriated an annual 
budget of $75 million for the programs continued operations postimplementation.15   
 
To oversee the Medicaid Integrity Program planning and implementation, CMS created the 
Medicaid Integrity Program Advisory Committee.16  The committee identified Medicaid data 
collection, including MSIS data, as key to the Medicaid Integrity Programs success.17   
 
The Medicaid Integrity Group.  In 2006, CMS established MIG, as part of the Center for 
Medicaid and State Operations (CMSO), to implement DRAs Medicaid Integrity Program and 
 
12 71 Fed. Reg. 65527 (Nov. 8, 2006).  The Privacy Act of 1974 (Privacy Act); (5 U.S.C.  552a) required agencies 
to publish in the Federal Register a notice of the existence and character of a system of records, such as MSIS.  
The Privacy Act defines a system of records as a group of any records under the control of any agency from 
which information is retrieved by the name of the individual or by some identifying number, symbol, or other 
identifying particular assigned to the individual. 
13 System of Records No. 09-70-0541.  71 Fed. Reg. 65527 (Nov. 8, 2006).  This system of records states that MSIS 
will also be used to combat waste.  Available online at 
http://www.cms.hhs.gov/PrivacyActSystemofRecords/downloads/0541.pdf.  Accessed on December 1, 2008. 
14 CMS, MSIS Overview.  Available online at http://www.cms.hhs.gov/MSIS/.  Accessed on December 1, 2008. 
15 DRA, section 6034(a) (codified at 42 U.S.C.  1396u-6). 
16 The Medicaid Integrity Program Advisory Committee is made up of State Medicaid Directors; State Program 
Integrity Directors; Medicaid Fraud Control Unit Directors representing 16 States; as well as representatives of the 
Federal Bureau of Investigation, HHS OIG, and CMS regional offices.  Source:  CMS, Comprehensive Medicaid 
Integrity Plan, June 2008.  Available online at 
http://www.cms.hhs.gov/DeficitReductionAct/Downloads/FY08CMIP.pdf.  Accessed on December 1, 2008.   
17 CMS, Comprehensive Medicaid Integrity Plan (CMIP), August 2007.  Available online at 
http://www.cms.hhs.gov/DeficitReductionAct/Downloads/CMIP2007.pdf.  Accessed on December 1, 2008.   
   
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carry out CMSs national strategy to combat Medicaid fraud, waste, and abuse.18  CMSO and its 
contractors seek to identify improper payments and coordinate integrity efforts with various State 
and local entities.19   
 
In 2007, MIG began soliciting input from other CMS components, Department of Justice, and 
OIG officials involved in Medicaid fraud detection to identify useful data elements for Medicaid 
fraud, waste, and abuse detection (hereinafter referred to as MIG-identified data elements) and 
identified 182 such data elements.  Not all of these data elements are currently captured in the 
MSIS database. 
 
Additionally, a Medicaid Data Integration Workgroup has also been established.  This 
workgroup consists of consultants from a number of entities including:  CMSO, the CMS Office 
of Financial Management, the CMS Office of Information Services (OIS), OIG, and several 
States.  To address multiple business functions across CMS, the workgroup recently 
recommended adding approximately 96 more variables to the 182 MIG-identified data elements 
(bringing the total to 278).   
 
In 2008, CMS established a new system of records titled, Medicaid Integrity Program 
System.20  The primary purpose of this system is to establish an accurate, current, and 
comprehensive database containing standardized enrollment, eligibility, and paid claims of 
Medicaid beneficiaries to assist in the detection of fraud, waste, and abuse.21  This system, 
commonly referred to as the MIG Data Engine, became operational in November 2008 and is 
using MSIS data to support MIGs activities.22  According to CMS officials, this system has 
resulted in the identification, or probable identification, of substantial overpayments.23   
 
MSIS File Submission and Data Validation Processes 
CMS requires States to submit one Medicaid-eligibility and four claims data files to CMS 
quarterly.24 25  CMS then tests the files to ensure that the data pass quality review.  The MSIS 
files that pass quality review are posted to the production database on CMSs mainframe 
computer and are considered validated MSIS data.   
 
 
18  CMS, CMIP, July 2006.  Available online at http://www.cms.hhs.gov/DeficitReductionAct/Downloads/CMIP 
Initial July 2006.pdf.  Accessed on December 1, 2008. 
19 Ibid. 
20 System of Records No. 09-70-0599.  73 Fed. Reg. 11638 (Mar. 4, 2008).  CMSs Medicaid Integrity Program 
established the new system of records. 
21 Ibid.   
22 CMS technical comments on OIGs draft memorandum report, August 2009. 
23 Ibid. 
24 The State Participation Procedures Manual.  Available online at http://www.cms.hhs.gov/MSIS.  Accessed on 
December 1, 2008. 
25 The four types of MSIS claims files are inpatient services, long term care, prescription drug, and other claims. 
   
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The MSIS files that do not pass quality review are returned to States for correction and 
resubmission.  CMS does not limit the number of times States may resubmit corrected MSIS data 
or specify the amount of time States have to make corrections and resubmit the revised data.  
After all five files successfully pass quality reviews, CMS releases the data to most public 
users.26  The processes of MSIS file submission and data validation occur in three phases:  initial 
submission, quality review, and final release. 
 
Initial submission.  The initial submission phase starts at the end of each quarter and ends when 
CMS receives and successfully copies a properly formatted MSIS file to its mainframe computer 
for quality review.   
 
File submission schedules and formatting requirements are defined in the MSIS Tape 
Specification and Data Dictionary (MSIS Data Dictionary).27  States must submit their four 
Medicaid claims files to CMS within 45 days after the end of each quarter.28  However, CMS 
allows States to submit their Medicaid eligibility file up to 312 months after the end of each 
quarter.29  If the files are formatted improperly, CMS rejects the submission.  States must then 
resubmit properly formatted files before the next phase may begin.   
 
Quality review.  The quality review phase starts when CMS copies a properly formatted State file 
to its mainframe computer.  This phase ends when the file passes data validation edits and 
distributional checks defined in the MSIS Data Dictionary maintained on CMSs public Web 
site.     
 
Data validation edits occur when the MSIS Data Validation computer program compares the 
Medicaid data within each file to formatting rules and permitted error rates (i.e., error tolerances) 
established in the MSIS Data Dictionary.30  If a files errors exceed the established error 
tolerances, CMS rejects the file and returns it to the State for correction and resubmission.   
 
CMSs MSIS Data Validation program produces error reports that show the number and types of 
errors identified.  CMS shares the error reports with States to facilitate underlying data-problem 
identification and correction. 
 
 
26 According to CMS officials, MIG receives and uses MSIS data prior to the quality review.  CMS technical 
comments on OIGs draft memorandum report, August 2009. 
27 CMS.  The MSIS Tape Specification and Data Dictionary, Release 2, version 5.  Available online at 
http://www.cms.hhs.gov/MSIS.  Accessed on February 6, 2009.   
28 The State Participation Procedures Manual.  Available online at http://www.cms.hhs.gov/MSIS.  Accessed on 
December 1, 2008. 
29 Ibid.  
30 The MSIS Data Validation program is a system of mainframe computer applications that copy, edit, and track 
files throughout the MSIS file submission and data validation process.  These applications include the initial 
submission formatting checks, quality review data validation edits, as well as the final release data-posting routines.  
The MSIS Data Validation program does not control or track distributional checks performed by CMSs data quality 
contractor, Mathematica Policy Research, Inc. (Mathematica). 
   
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Default error tolerances are defined in the MSIS Data Dictionary.  However, not all State MSIS 
files are subject to the default error tolerances.  CMS periodically adjusts individual State error 
tolerances to allow particular files or sets of files to pass data validation tests.  For example, 
CMS may adjust MSIS error tolerances when a States data systems are unable to accommodate 
MSIS file formats or when unique State coding issues trigger false errors. 
 
When the data files pass data validation edits, CMS forwards the data to its data quality 
contractor, Mathematica, to conduct distributional checks.31  These checks reveal data 
irregularities by comparing mathematical averages, ranges, frequency distributions, and payment 
totals to expected outcomes.  For example, Mathematicas distributional checks may analyze 
MSIS claims files to calculate a States average Medicaid payment for a specific item or service 
and compare it to the average payment from a previous quarter to identify significant or 
unexpected changes.  Mathematica also compares the MSIS data to other CMS sources such as 
State waiver programs.32 
 
CMS allows Mathematica to work directly with States to research and correct data irregularities 
(i.e., anomalies).  For example, Mathematica found that a State submitted an MSIS eligibility file 
with all records marked as dual-eligible (i.e., Medicaid beneficiaries who are also eligible for 
Medicare benefits).  Mathematica worked with the State and determined that this was a 
programming error that required State correction and file resubmission. 
 
Anomalies that are not caused by errors in the underlying data are documented and disclosed to 
MSIS data users in the MSIS State Anomalies/Issues Report maintained on CMSs public Web 
site.33  For example, Mathematica identified a dramatic increase in the total number of  
Medicaid-eligible beneficiaries reported in a States quarterly eligibility file.  However, changes 
in the States eligibility rules justified the increase, which was then documented in the MSIS 
State Anomalies/Issues Report.  
 
Final release.  The final release phase starts when Mathematica notifies CMS that a file has 
passed quality review and ends when CMS posts the validated MSIS data in the file to a 
production database on its mainframe computer.  In general, most public MSIS data users do not 
have access to MSIS data until CMS posts the validated data to its production database.34   
 
 
31 CMS.  Active Projects Report 2008 Edition, Project Number 500-00-0047/04, MSIS Expansion and Data Quality 
Support.  Available online at http://www.cms.hhs.gov/ActiveProjectReports/05_APR_2008_Edition.asp.  Accessed 
on December 1, 2008. 
32 CMS technical comments on OIGs draft memorandum report, August 2009. 
33 CMS.  MSIS State Anomalies/Issues Report.  Available online at 
http://www.cms.hhs.gov/MedicaidDataSourcesGenInfo/Downloads/anomalies.pdf.   
Accessed on December 1, 2008. 
34 According to CMS officials, MIG uses these files for preliminary analysis before they are validated.  Some 
internal users, e.g., OIG, have direct mainframe access to validated MSIS files.  Some external users, e.g., the 
Congressional Budget Office, have established data use agreements with CMS in which they receive predefined 
extracts of validated MSIS files.   
   
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CMS officials stated that most MSIS data users require complete sets (i.e., one Medicaid eligible 
file and four Medicaid claims files) of quarterly MSIS data for analysis.  Therefore, CMS does 
not typically post MSIS files to its production database until all five files have cleared quality 
review.   
 
Related Work  
In May 2009, OIG released a report that assessed the extent to which CMS accepts MSIS 
submissions without encounter data.35  Encounter data are the primary record of Medicaid 
services provided to beneficiaries enrolled in capitated Medicaid managed care.  In a February 
2002 report, the Government Accountability Office (GAO) recommended that CMS analyze 
MSIS data to detect potentially improper Medicaid payments.36  GAOs June 2006 follow-up 
report reiterated this recommendation because it found that CMS had not included MSIS data in 
its Medicaid oversight activities.37 
 
METHODOLOGY 
 
Scope 
To assess the usefulness of MSIS data for detecting fraud, waste, and abuse, we determined: 
 
  the average length of time MSIS FYs 20042006 files were in each phase of file submission 
and data validation processes, as of June 2007, before release to the public; 
  the extent to which CMS disclosed and documented information about the accuracy of MSIS 
data as of June 2007;38 and 
  the extent to which, as of September 2008, MSIS contained data elements useful for fraud, 
waste, and abuse detection. 
 
Data Sources 
We reviewed the following documents to understand the MSIS programs Federal and State 
requirements: 
 
  DRA 
  State Participation Procedures Manual 
  MSIS Data Dictionary 
  MSIS Data Anomalies/Issues Report 
 
 
35 Medicaid Managed Care Encounter Data:  Collection and Use, OEI-07-06-00540. 
36 Medicaid Financial Management:  Better Oversight of State Claims for Federal Reimbursement Needed,   
GAO-02-300, February 2002.  Available online at http://www.gao.gov/new.items/d02300.pdf.  Accessed on 
December 1, 2008. 
37 Medicaid Financial Management:  Steps Taken to Improve Federal Oversight But Other Actions Needed to 
Sustain Efforts, GAO-06-705, June 2006.  Available online at http://www.gao.gov/new.items/d06705.pdf.  
Accessed on December 1, 2008. 
38 CMS extracted processing data from the MSIS Data Validation program for our review in June 2007. 
   
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We used data from the following sources to assess MSIS data usefulness for fraud, waste, and 
abuse detection: 
 
  CMSs MSIS Data Validation program; 
  Mathematicas MSIS Data Quality Review Status Reporting Database; and 
  MIGs compilation of data elements that can assist in Medicaid fraud, waste, and abuse 
detection. 
 
Data Collection and Analysis 
We interviewed officials from CMSO, OIS, and Mathematica to gather information about the 
MSIS file submission and data validation processes.  We also interviewed MIG officials to 
gather information about the extent to which they compiled data elements that can be useful for 
Medicaid fraud, waste, and abuse detection. 
 
Determining MSIS file processing times.  To determine the number of days during which MSIS 
files spent in each phase of the file submission and data validation processes (initial submission, 
quality review, and final release), we analyzed the processing dates of 3,060 State FYs        
20042006 quarterly MSIS files as of June 2007.39  As of that date, CMS had validated and 
released 54 percent (1,655 of 3,060) of the files.  We obtained processing dates from CMSs 
MSIS Data Validation program and Mathematicas Data Quality Review Status Reporting 
Database.   
 
  For the initial submission phase, we counted the number of days from the end of the quarter 
to the first time CMS successfully copied a States MSIS file submission to its mainframe 
computer.  
 
  For the quality review phase, we counted the number of days from the end of the initial 
submission phase to the date when Mathematica reported that the MSIS data completed 
distributional checks.  
 
  For the final release phase, we counted the number of days from the end of the quality review 
phase to the date when CMS posted validated MSIS data to the production database on its 
mainframe computer.  
 
For the 1,655 MSIS files that completed all phases of the MSIS file submission and data 
validation processes as of June 2007, we calculated, by file type, the average, median, minimum, 
and maximum days during which they were in each phase. 
 
 
39 Each quarter, CMS requires States to submit one eligibility file and four claims files of MSIS data.  For           
FYs 20042006, CMS required the 51 States to submit a total of 3,060 quarterly MSIS files (3 years x 51 States x            
4 quarters x 5 files = 3,060 required MSIS files). 
   
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We also counted, by file type, the number of initial submission files that States did not submit by 
the established due dates and 6 months (180 days) after CMSs due dates.  We then counted, by 
file type, the number of States that submitted at least one file after CMSs due dates and              
6 months after CMSs due dates.   
 
For claims files, we calculated CMSs due date as 45 days from the end of the quarter and the    
6-month-late date as 225 (45 + 180) days from the end of the quarter.  For eligibility files, we 
based our analysis on the more conservative delayed MSIS eligibility file submission 
requirement (up to 105 days).40  We calculated CMSs eligibility file due dates as 105 days from 
the end of the quarter and the 6-month-late mark as 285 (105 + 180) days from the end of the 
quarter. 
 
We also determined the number of State file submissions, including the initial submission, 
required for MSIS data to clear the data validation process quality review phase.  We counted the 
number of times that States resubmitted MSIS files before Mathematica reported to CMS that the 
data completed distributional checks and then added one for the initial submission.  For example, 
MSIS files that completed the quality review phase without correction required one State file 
submission (zero resubmission plus one initial file submission). 
 
Assessing CMSs disclosure and documentation of MSIS data accuracy.  To assess the extent to 
which CMS disclosed and documented the accuracy of MSIS error tolerance adjustments, we 
determined the number of CMS data validation adjustments that increased error tolerances above 
default levels documented in the MSIS Data Dictionary.  To do so, we reviewed 9,639 error 
tolerance adjustment records that CMS programmers extracted from the MSIS Data Validation 
program as of June 2007.  We first eliminated 7,197 adjustments (75 percent) that had no effect 
on the MSIS Data Validation programs error tolerance levels (inactive adjustments).41  The 
remaining 2,442 adjustments (25 percent) increased error tolerances to levels above or equal to 
those programmed into MSIS Data Validation software (active adjustments).  Of the 2,442 active 
adjustments, we reviewed 1,528 adjustments (63 percent) that increased the error tolerance levels 
above defaults documented in the MSIS Data Dictionary.  We did not review 914 active 
adjustments that set the error tolerances at levels equal to the defaults documented in the MSIS 
Data Dictionary.  See Appendix B for a breakdown of inactive and active error tolerance 
adjustments as of June 22, 2007. 
 
To assess the extent of the 1,528 error tolerance adjustments that we reviewed, we determined 
the earliest and latest adjustment dates, counted the number of adjustments, and calculated the 
percentage of total adjustments per year.  We also counted the number of States and MSIS data 
 
40 According to the MSIS State Participation Procedures Manual, States may submit MSIS quarterly eligibility 
files on a regular or delayed submission schedule 45 days or 312 months from the end of the quarter, respectively.  
For our review, we define 312 months as 105 days.  Available online at http://www.cms.hhs.gov/MSIS/.  Accessed 
on August 7, 2009.  
41 These inactive adjustments included adjustments to MSIS files of U.S. territories, data elements not subjected to 
data validation tests, unused MSIS data elements, and invalid MSIS file type/data element combinations. 
   
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elements affected by the 1,528 active error tolerance adjustments.  Finally, we counted the 
number of States and MSIS data elements for which CMS increased the data validation error 
tolerance levels to 100 percent.  Error tolerance levels set to 100 percent allow an unknown 
number of errors to be present in the data when it passes quality review.   
 
To assess controls over error tolerance adjustments, we asked CMS for justification and approval 
documentation related to the 1,528 error tolerance adjustments reviewed.  To determine whether 
MSIS data users had access to information about error tolerance adjustments, we searched the 
MSIS Data Dictionary and the MSIS State Anomalies/Issues Report for references of these 
1,528 error tolerance adjustments.   
 
Assessing data elements contained in MSIS.  To determine the extent to which MSIS data 
contained information that can assist in Medicaid fraud, waste, and abuse detection, we 
compared existing MSIS data elements, as of September 2008, to those that MIG identified as 
assisting in fraud, waste, and abuse detection.  
 
First, we consolidated similar data elements from the 182 individual data elements that MIG 
identified into 100 data elements.42  Second, we sorted the 100 consolidated data elements into 
four categories:  (1) Service Provider Identifiers; (2) Procedure, Product, and Service 
Descriptions; (3) Billing Information; and (4) Beneficiary and Eligibility Information.  Third, we 
consolidated similar data elements from MSISs 255 individual data elements into 85 data 
elements.43 44  Finally, to identify equivalent data elements, we compared the 100 consolidated 
data elements that MIG identified, to the 85 consolidated MSIS data elements.45  MIG officials 
reviewed and concurred with our data consolidation and comparison approaches.  See   
Appendix C for comparisons of data elements consolidated from their listing and the MSIS Data 
Dictionary. 
 
Limitations  
We did not verify the accuracy of the MSIS data files or evaluate controls over Mathematicas 
distributional checks.   
 
We did not review the accuracy of existing differences in the actual and reported MSIS file error 
tolerances because CMS periodically adjusts individual State error tolerances to allow particular 
files or sets of files to pass data validation tests.  For example, CMS may adjust MSIS error 
 
42 For example, MIG collects the amount billedper item and total billed or charged amounttotal claim for 
both institutional and medical Medicaid claims.  We consolidated these four data elements into a single amount 
billed data element. 
43 For example, each of the four MSIS claim files (i.e., inpatient, long term care, prescription drug, and other) 
include an amount charged data element.  We consolidated these four data elements into a single amount 
charged data element. 
44 For this analysis we used the MSIS File Specification and Data Dictionary, Release 3 effective February 15, 2009, 
because it provided the most current listing of MSIS data elements. 
45 For example, we considered the amount billed MIG data element to be equivalent to the amount charged 
MSIS data element.  
   
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tolerances when a States data systems are unable to accommodate MSIS file formats or when 
unique State coding issues trigger false errors.  We report only on the extent to which CMS was 
able to provide documentation to support the rationale for making changes to the error 
tolerances.   
 
We based our analysis on the extent to which, as of September 2008, MSIS captured  
data elements that MIG identified as those that can assist in Medicaid fraud, waste, and abuse 
detection.  Although not comprehensive or specifically required by statute, MIG, other CMS 
components, Department of Justice, and OIG identified these data elements as useful to detect 
fraud, waste, and abuse.   
 
Standards 
We conducted this study in accordance with the Quality Standards for Inspections approved by 
the Council of the Inspectors General on Integrity and Efficiency. 
 
RESULTS 
 
MSIS Data From FYs 20042006 Took an Average of 112 Years After the Initial State Data 
Submission Before CMS Released Them to the Public  
As of June 22, 2007, 54 percent (1,655 of 3,060) of the FYs 20042006 MSIS files that we 
reviewed had completed all phases of CMSs file submission and data validation processes.  
These files took on average over 112 years (595 days) to complete all phases of the processes and 
before their release to the public.  On average, States took over 6 months (187 days) to submit 
files in a CMS-acceptable format.  Once States submitted files in acceptable formats, CMS took 
over 4 months (127 days) to validate and an additional 9 months (281 days) to release the files to 
the public.46  
 
The remaining 46 percent (1,405 of 3,060) of MSIS files that had not completed file submission 
and data validation at the time of our review were in various phases of the processes.  States had 
not submitted 10 percent of these MSIS files.  See Appendix D for the file submission and data 
validation status of all 3,060 MSIS files that we reviewed by year. 
 
Table 1 provides, by file type, the average number of days spent in each phase for the  
1,655 MSIS files that completed the file submission and data validation processes.  See 
Appendix E for the average, median, minimum, and maximum days during which MSIS files 
spent in each of these phases. 
 
 
 
 
 
 
46 According to CMS officials, MIG utilizes MSIS data that have not been validated to conduct preliminary fraud, 
waste, and abuse analysis.  CMS technical comments on OIGs draft memorandum report, August 2009. 
   
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Table 1:  Average Days That MSIS Files Spent in Each Phase of the 
MSIS File Submission and Data Validation Processes 
    Number of Days 
MSIS   Number  Initial Quality Final  Overall  
File Type  of Files  Submission  Review Release Processing 
Eligibility  331  195  287  113  595 
Claims  1,324  185  87  323  595 
All Files  1,655  187  127  281  595 
Averages equal the mean processing days of the 1,655 FYs 20042006 MSIS files reviewed.   
Source:  OIG analysis of the file submission and data validation status of FYs 20042006 MSIS 
files as of June 2007. 
 
States submitted nearly two-thirds of the initial MSIS file submissions after the CMS due dates.  
Of the files that had completed initial file submission and data validation, States submitted  
63 percent (1,041 of 1,655) after the CMS due dates.  All but two States submitted at least one 
initial MSIS file submission after the due dates.  Of those, 32 States submitted 31 percent  
(513 of 1,655) of the initial MSIS file submissions over 6 months after the due dates. 
 
Table 2 provides the number of initial MSIS State file submissions reviewed that occurred after 
the due dates and the number of States submitting those files.   
 
 
Table 2:  Initial File Submissions That Occurred After the CMS Due Dates 
 
Submissions Received  Submissions Received Over  
 
MSIS   Files   After the CMS Due Dates  6 Months After the CMS Due Dates * 
File Type  R eviewed  Files  Percentage  **  States  Files  Percentage **  States 
Eligibility      331  192  58%  44  95  29%  27 
Claims  1,324  849  64%  48  418  32%  31 
 
All  1,655  1,041  63%  49  513  31%  32 
 
* This group is a subset of all submissions received after the due dates.   
** Percentages p ertain to aggregate characteristics of MSIS file types and will not sum to 100 percent.   
  Source:  OIG analysis of the file submission and data validation status of FYs 20042006 MSIS files as of  
June 2007. 
 
 
MSIS files requiring State correction and resubmission took more than five times longer to clear 
quality review than those that did not require correction and resubmission.  Twenty-six percent 
(431 of 1,655) of the State MSIS file submissions required correction and resubmission to clear 
CMS quality review.  Each State had at least one file that required correction and resubmission.   
 
When MSIS files did not require correction and resubmission, quality review took on average     
2 months (63 days).  When MSIS files required State correction and resubmission, the quality 
review took on average 10 months (310 days), more than five times longer.   
 
A greater percentage of eligibility files than claims files required correction and resubmission to 
complete quality review.  Over 50 percent (176 of 331) of eligibility files from 48 States required 
   
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correction and resubmission to complete quality review.  In contrast, less than  
20 percent of claims files (255 of 1,324) from 46 States required correction and resubmission to 
complete quality review.   
 
CMS officials reported that midyear changes in State eligibility requirements often require States 
to correct and resubmit the MSIS eligibility files from previous quarters.  As a result, MSIS 
eligibility files generally took longer to complete quality review than the claims files.  On 
average, the 176 eligibility files requiring correction and resubmission took over a year (400 
days) to complete quality review.  The 255 claims files requiring correction and resubmission 
completed quality review, on average, in just over 8 months (247 days).  In contrast, on average, 
eligibility files not requiring correction and resubmission completed quality review in just over   
5 months (160 days), and claims files not requiring State correction and resubmission completed 
quality review in just over 112 months (49 days). 
 
Table 3 provides the number of days that the MSIS files we reviewed spent in quality review.  
This table compares files that required correction and resubmission to those that did not. 
 
Table 3:  Number of Days That State MSIS File Submissions Spent in Quality Review 
State MSIS Files Requiring Correction and  State MSIS Files Not Requiring Correction 
    Resubmission  and Resubmission 
MSIS   Files   Average  Average 
File Type  Reviewed  Files  Percentage *  States  Days **  Files  Percentage *  States  Days ** 
Eligibility    331  176  53%  48  400  155  47%  38  160 
Claims  1,324  255  19%  46  247  1,069  81%  49  49 
All  1,655  431  26%  51  310  1,224  74%  51  63 
* Percentages pertain to aggregate characteristics of MSIS file types and will not sum to 100 percent.   
** Average days required to clear the quality review phase of the MSIS file submission and data validation process.   
Source:  OIG analysis of the file submission and data validation status of FYs 20042006 MSIS files as of June 2007. 
 
CMS held validated claims files nearly three times longer than validated eligibility files, before 
releasing them to the public.  Although MSIS claims files often completed quality review before 
eligibility files, CMS did not release the validated MSIS files until all five of the States 
quarterly file submissions (four claims files and one eligibility file) completed quality review.  
CMS held validated MSIS files for over 9 months (281 days), on average, before releasing the 
data to the public.  These delays occurred because CMS was waiting for the companion files to 
complete quality review before releasing all five related claims and eligibility files 
simultaneously to the public.  The final release phase accounted for nearly half (47 percent) of 
the average time MSIS files spent in all phases of file submission and data validation 
   
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processes.47  However, users do not always need access to all five validated MSIS files to 
identify potentially fraudulent trends.48   
 
CMS held validated MSIS eligibility files for nearly 4 months (113 days) on average before 
releasing the data to the public while waiting for companion files to complete quality review.    
In contrast, CMS held validated MSIS claims files for nearly 11 months (323 days) on average, 
nearly three times longer, for the same reason.   
 
CMS Did Not Fully Disclose or Document Information About the Accuracy of MSIS Data  
CMS released MSIS data to the public without disclosing or documenting individual State 
adjustments to the error tolerances in either the MSIS Data Dictionary or MSIS Data 
Anomalies/Issues Report.  The MSIS Data Dictionary reflects only the established national 
error tolerance levels, and the Data Anomalies/Issues Report reflects only quality review 
results, not State-level error tolerance level changes from the National level. 
 
As of June 2007, 63 percent (1,528 of 2,442) of CMSs active data validation error tolerance 
adjustments increased the error tolerances to values greater than published defaults.  The 1,528 
adjustments involved 75 percent (191 of 255) of all MSIS data elements and affected at least one 
MSIS file submission from each State.  CMS periodically adjusts individual State error 
tolerances to allow particular files or sets of files to pass data validation tests (e.g., when States 
data systems are unable to accommodate MSIS file formats, or unique State coding issues trigger 
false errors).  However, it did not document and/or disclose information about the accuracy of 
adjusting these error tolerances to a value greater than published defaults.   
 
CMS did not fully or accurately disclose error tolerance adjustments and resulting error rates to 
MSIS data users.  Neither the MSIS Data Dictionary nor the MSIS Data Anomalies/Issues 
Report fully discloses changes made to individual State MSIS error tolerance levels.  The MSIS 
Data Dictionary describes error tolerances as defaults and indicates that adjustments are based 
on special State circumstances.  However, CMS did not identify any of the State-specific error 
tolerance adjustments in the MSIS Data Dictionary. 
 
The MSIS Data Anomalies/Issues Report referenced 4 of the 1,528 active error tolerance 
adjustments that increased the error tolerances to values greater than published defaults.  
However, one of the four references did not disclose the adjusted error tolerance level and two of 
the four references disclosed incorrect adjusted error tolerance levels.  In addition, the MSIS 
Data Anomalies/Issues Report posted to CMSs Web site was over 3 years old at the time of 
 
47 The 281 days during which CMS held validated MSIS files is nearly half (47 percent) of the 595 days it took 
CMS on average to validate and release for public use the 1,655 FYs 20042006 MSIS files reviewed.   
48 Users can utilize the unique MSIS beneficiary identification numbers contained in the MSIS claims files to 
identify potentially fraudulent Medicaid billing patterns.  If necessary, users can also utilize prior quarters validated 
MSIS eligibility file for the preliminary identification of these beneficiaries. 
   
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our review.49  Furthermore, CMS did not publicize error rates resulting from undisclosed error 
tolerance adjustments.  For example, CMS did not post error reports to its public Web site. 
 
CMS did not document the justification and approval of error tolerance adjustments.  CMS 
could not provide documentation for the justification and approval of the 1,528 active error 
tolerance adjustments that increased the error tolerances to values greater than published 
defaults.  Just over half of these error tolerance increases (765 of 1,528) had been in place for 
over 7 years.  According to CMS officials, States are notified of error tolerance adjustments, but 
the justification and approval of individual adjustments are not logged or documented.  See 
Appendix F for the number of undocumented error tolerance adjustments CMS made per year.   
 
Twenty-nine percent of CMSs undocumented error tolerance adjustments increased MSIS data 
validation error tolerances to 100 percent.  Twenty-nine percent (446 of 1,528) of CMSs 
undocumented error tolerance adjustments we reviewed increased the default error tolerance 
from 5 percent or less to 100 percent.  These undocumented error tolerance adjustments allowed 
the affected State MSIS files to clear quality review with an unknown number of errors.  The  
446 adjustments occurred between April 1999 and May 2007, involved 72 MSIS data elements, 
and affected at least one MSIS file submission from all States.   
 
For example, between August 1999 and December 2003, CMS made 17 adjustments affecting  
13 States to increase the MSIS Diagnosis-Code-Principal data element error tolerance level 
from 5 percent to 100 percent.50  See Appendix G for the date CMS adjusted the MSIS 
Diagnosis-Code-Principal data element error tolerance in each of the 13 States.  
 
MSIS Did Not Capture Many of the Data Elements That Can Assist in Fraud, Waste, and 
Abuse Detection  
There are no requirements for MSIS to contain specific data elements.  However, MSIS does not 
currently capture a number of data elements that can assist in fraud, waste, and abuse detection.  
For example, MSIS does not include all data elements that MIG has identified as assisting in 
fraud, waste, and abuse detection.     
 
MSIS did not capture almost half of the consolidated data elements we reviewed that MIG 
identified as useful for fraud, waste, and abuse detection.  The consolidated MSIS data elements 
did not capture 46 percent (46 of 100) of the consolidated data elements reviewed that MIG 
identified as useful for fraud, waste, and abuse detection.51  Data elements were missing in all 
four categories that we developed for our review: 
 
49 As of October 1, 2008, the MSIS Data Anomalies/Issues Report linked to CMSs MSIS Data public Web site 
was dated September 5, 2005.  Available online at 
http://www.cms.hhs.gov/MedicaidDataSourcesGenInfo/02_MSISData.asp.  Accessed on December 1, 2008. 
50 The MSIS Diagnosis-Code-Principal data element contains the code for the principal diagnosis on the claim.  
Principal diagnosis is the condition chiefly responsible for a patients admission. 
51 We compared 85 MSIS data elements consolidated from the MSIS Data Dictionary to 100 data elements 
consolidated from MIGs list of 182 data elements.  MIG identified these data elements in collaboration with other 
CMS components.  
   
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  Service Provider Identifiers 
  Procedure, Product, and Service Descriptions 
  Billing Information 
  Beneficiary and Eligibility Information  
 
See Appendix C for comparisons of the consolidated data elements MIG identified as assisting in 
fraud, waste, and abuse detection to the consolidated MSIS data elements in each of these four 
categories. 
 
MSIS did not capture over half of the consolidated Medicaid Service Provider Identifier data 
elements reviewed.  MSIS did not capture 55 percent (11 of 20) of the Medicaid Service Provider 
Identifier data elements we consolidated from the list of data elements that MIG identified as 
assisting in fraud, waste, and abuse detection.  For example, MSIS did not capture the referring 
providers identification number.  The referring provider is the physician who ordered the 
medical procedure, product, or service.  Without the referring provider identification number, 
fraud analysts cannot use MSIS data to assess whether a qualified physician submitted the order 
as required to receive certain medical benefits.  In a 2002 report, OIG used referring provider 
identification numbers to estimate that Medicare paid $61 million for improperly documented 
services in 1999.52   
 
MSIS did not capture almost half of the consolidated Medicaid Procedure, Product, and Service 
Description data elements reviewed.  MSIS did not capture 48 percent (16 of 33) of the Medicaid 
Procedure, Product, and Service Description data elements we consolidated from the list of data 
elements that MIG identified as assisting in fraud, waste, and abuse detection.  For example, 
MSIS did not capture data elements that specify the tooth number, quadrant, or surface subject 
for dental procedures.  Without these details, fraud analysts would have difficulty using MSIS 
data to detect fraudulent Medicaid claims for duplicate or medically unnecessary dental 
procedures.  Because MSIS did not include the necessary data elements, OIG obtained Medicaid 
data from individual States for its 2007 report that incorrect information about the tooth surface 
subject to dental procedures contributed to an estimated $12 million in improper Medicaid 
payments in 2003.53  
 
MSIS did not capture over one-third of the consolidated Medicaid Billing Information data 
elements reviewed.  MSIS did not capture 42 percent (15 of 36) of the Medicaid Billing 
Information data elements we consolidated from the list of data elements that MIG identified as 
assisting in fraud, waste, and abuse detection.  For example, MSIS did not capture dispensing fee 
payment information.  Without details regarding fees paid, fraud analysts cannot use MSIS data 
to assess whether the total amounts claimed and reimbursed contain inappropriate fees.  For 
example, in a 2008 report, OIG analyzed data obtained directly from States to determine that 
 
52 Durable Medical Equipment Ordered With Surrogate Physician Identification Numbers, OEI-03-01-00270. 
53 Improper Payments for Dental Services, OEI-04-04-00210. 
   
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Medicaid dispensing fee reimbursement rates were about $2 higher than the average Medicare 
Part D dispensing fee.54  
 
MSIS did not capture over one-third of the consolidated Medicaid Beneficiary and Eligibility 
Information data elements reviewed.  MSIS does not capture 36 percent (4 of 11) of the 
Medicaid Beneficiary and Eligibility Information data elements we consolidated from the list of 
data elements that MIG identified as useful for fraud, waste, and abuse detection.  Three of the 
four missing data elements were for the beneficiarys name (i.e., first, middle, and last name).  
Absence of beneficiary names may hinder analysts ability to reliably match Medicaid claims 
data to other data sources for fraud, waste, and abuse data analysis and detection.  Specifically, 
according to CMS, the link between data sources would be more reliable if MSIS captured the 
beneficiarys name.55    
 
CONCLUSION 
 
MSIS is the only source of nationwide Medicaid claims and beneficiary eligibility information.  
CMS collects MSIS data directly from States to, among other things, assist in detecting fraud, 
waste, and abuse in the Medicaid program.  Timely, accurate, and comprehensive MSIS data can 
contribute to more effective health care fraud, waste, and abuse identification and prevention. 
 
We determined that during FYs 20042006, MSIS data were an average of 112 years old when it 
was released to all users.  In addition, CMS did not fully disclose or document information about 
the accuracy of MSIS data.  Furthermore, MSIS did not capture many of the data elements that 
can assist in fraud, waste, and abuse detection.  
 
Our results indicate opportunities for States and CMS to reduce the timeframes for file 
submission and validation, respectively.  Furthermore, there are opportunities for CMS to 
improve the documentation and disclosure of error tolerance adjustments; and expand current 
State Medicaid data collection and reporting to further assist in fraud, waste, and abuse detection.   
 
This report is being issued directly in final form because it contains no recommendations.  If you 
have comments or questions about this report, please provide them within 60 days.  Please refer 
to report number OEI-04-07-00240 in all correspondence. 
 
 
54 Review of the Relationship Between Medicare Part D Payments to Local, Community Pharmacies and the 
Pharmacies Drug Acquisition Costs, A-06-07-00107. 
55 For example, CMSs Enterprise Cross-Reference Database matches identification information from three 
independent data sources:  (1) Medicares Enrollment Database, (2) the Outcome and Assessment Information Set, 
and (3) MSIS to identify Medicaid beneficiaries who are also eligible for Medicare benefits.  The Medicare 
Enrollment Database and the Outcome and Assessment Information Set include the beneficiarys name; MSIS does 
not.    
   
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APPENDIX A 
 
Databases Dependent on Medicaid Statistical Information System Data 
 
Medicaid Statistical Information System (MSIS) data are used as a source of information for the 
following Centers for Medicare & Medicaid Services (CMS) databases: 
 
The MSIS State Summary Data Mart:  The MSIS State Summary Data Mart generates Medicaid 
eligibility and overall program utilization statistics.  The MSIS State Summary Data Mart extracts 
data from both validated MSIS eligibility and claims files posted to the production database.56  
This data mart is accessible to the public via the Internet. 
The MSIS Drug Utilization Data Mart:  The MSIS Drug Utilization Data Mart generates Medicaid 
drug utilization statistics for groups of drugs.  The MSIS Drug Utilization Data Mart extracts MSIS 
prescription drug information only from validated MSIS claims files posted to the production 
database.  This system is not dependent upon Medicaid beneficiary information from validated 
MSIS eligibility files.57  This data mart is accessible to the public via the Internet. 
The Medicaid Analytical Extract:  The Medicaid Analytical Extract is a set of person-level data 
files of Medicaid eligibility, service utilization, and payments.  The database extracts data from 
both validated MSIS eligibility and claims files posted to the production database to convert the 
fiscal year-based MSIS quarterly files into calendar year files.  These data are only accessible to 
users who enter into a data use agreement with CMS.58 
The Enterprise Cross-Reference Database:  The Enterprise Cross-Reference (ECR) Database 
matches identification information from three independent data sources:  (1) the Medicare 
Enrollment Database, (2) the Outcome and Assessment Information Set, and (3) MSIS.  The 
ECR Database identifies name, Social Security number, and gender from each system to 
establish linkages and identify Medicare beneficiaries who are also eligible for Medicaid benefits 
(dual-eligible beneficiaries).  The ECR Database extracts this information from validated MSIS 
claims files posted to the production database.  These data are not accessible to the public.59 
 
The Medicaid Integrity Group Data Engine:  CMS stores the MSIS data on this system to support 
CMS fraud, waste, and abuse analysis efforts and assist Medicaid Integrity Group contractors 
perform postpayment provider audits.  These data are not accessible to the public.60 
 
56 CMS, MSIS State Summary Data Mart.  Available online at http://msis.cms.hhs.gov/.  Accessed on December 1, 
2008. 
57 CMS, MSIS Drug Utilization Data Mart.  Available online at http://msis.cms.hhs.gov/drugmart.htm.  Accessed on 
December 1, 2008. 
58 CMS, Medicaid Analytical Extract Web site.  Available online at 
http://www.cms.hhs.gov/MedicaidDataSourcesGenInfo.  Accessed on December 1, 2008. 
59 CMS, Enterprise Cross-Reference User Guide, January 2007. 
60 CMS technical comments on OIGs draft memorandum report, August 2009. 
   
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APPENDIX B   
 
Characteristics of Medicaid Statistical Information System Error Tolerance Adjustments  
 
Medicaid Statistical Information System Data Validation Error  Number of 
Tolerance Adjustments as of June 2007  Adjustments 
Inactive Error Tolerance Adjustments   
Adjustments to invalid Medicaid Statistical Information System (MSIS) file 
type/data element combinations (e.g., adjustments to Age data elements that do 
not exist in MSIS claims files)  3,470 
Adjustments to data elements not subjected to data validation tests  
(e.g., systemically generated and header data elements)  1,759 
Adjustments that change error tolerances to levels already established by 
programmed defaults  1,204 
Adjustments to unused data elements  693 
Adjustments to U.S. Territory MSIS files not currently collected by the  
Centers for Medicare & Medicaid Services  71 
                                                                   Inactive Error Tolerance Adjustments  7,197 
                                                                                                     Percentage of Total 75% 
Active Error Tolerance Adjustments   
Adjustments that change programmed defaults to error tolerance levels 
documented in the MSIS Data Dictionary  914 
Adjustments that increase programmed defaults above error tolerance levels 
documented in the MSIS Data Dictionary (1,528 of 2,442 = 63% of Total Active 
Adjustments)  1,528 
                                                                       Active Error Tolerance Adjustments 2,442 
                                                                                                       Percentage of Total 25% 
                       Total Inactive and Active Error Tolerance Adjustments  9,639 
   
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APPENDIX C 
 
Comparison of Medicaid Data Elements   
The following tables compare 100 data elements we consolidated from a list of 182 data 
elements the Medicaid Integrity Group (MIG) identified, in collaboration with other components 
in the Centers for Medicare & Medicaid Services (CMS), Department of Justice, and Office of 
Inspector General (OIG) officials, as useful for Medicaid fraud, waste, and abuse analysis 
(hereinafter referred to as MIG-identified data elements) to 85 similar data elements we 
consolidated from 255 Medicaid Statistical Information System (MSIS) data elements.  Blank 
MSIS data element fields indicate that MSIS does not contain similar data elements.  We 
grouped the consolidated data elements into four categories that we developed for our review:   
 
  Service Provider Identifiers  
 
  Procedure, Product, and Service Descriptions  
 
  Billing Information 
 
  Beneficiary and Eligibility Information   
 
Table C-1:  Comparison of MIG and MSIS Medicaid Service Provider Identifier Data Elements 
MIG Data Elements  MSIS Data Elements 
01  Provider Billing Name      
02  Provider Business Employer Identification (ID) Number       
03  Provider Business Entity      
04  Provider Business Owner Name       
05  Provider Business State      
06  Provider Business Street Address      
07  Provider Business Town/City      
08  Provider Business/Practice Name       
09  Provider Category  01  Provider-Taxonomy 
10  Provider ID  Admitting  02  Provider-ID-Number-Servicing 
11  Provider ID  Billing  03  Provider-ID-Number-Billing 
12  Provider ID  Prescriber  04  Provider-ID-Number-Servicing 
13  Provider ID - Prescriber Drug Enforcement Agency ID   05  Provider-ID-Number-Servicing 
14  Provider ID  Referring      
15  Provider ID  Servicing  06  Provider-ID-Number-Servicing 
16  Provider ID  07  National-Provider-ID 
17  Provider License/Certification Number      
18  Provider Servicing Flag      
19  Provider Specialty  08  Specialty-Code 
20  Provider Type  09  Provider-Taxonomy 
Source:  OIG comparison of data elements described in the CMS MSIS Data Dictionary, Release 3, effective February 15, 2009, to data elements 
MIG identified as useful for Medicaid fraud, waste, and abuse data analysis and detection as of September 2008. 
   
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Table C-2:  Comparison of MIG and MSIS Medicaid Procedure, Product, and Service Description Data 
Elements 
MIG Data Elements  MSIS Data Elements 
01  Admission Date  01  Admission-Date 
02  Admission Diagnosis Code  02  Diagnosis-Code 
03  Brand Necessary Drug Indicator      
04  Diagnosis Code  03  Diagnosis-Code 
05  Diagnostic Related Group (DRG) Code  04  DRG 
06  Discharge Hour      
07  DRG Allowed Charge/DRG Rate      
08  DRG Allowed Charge Source  05  DRG Indicator 
09  DRG Code Description      
10  Drug Name      
11  Drug Type (Brand/Generic)      
12  Explanation of Benefit Code      
13  National Drug Code   06  National-Drug-Code 
14  Nursing Facility Indicator  07  Nursing-Facility-Days 
15  Package Size of Drug Dispensed       
16  Patient Discharge Code   08  Patient-Status 
17  Per Diem Rate       
18  Place of Service   09  Place-of-Service 
19  Prescription Dispensed Date       
20  Prescription Written Date   10  Date-Prescribed 
21  Procedure (Proc) Code   11  Proc-Code 
22  Procedure Code Description       
23  Procedure Code Modifier   12  Proc-Code-Mod 
24  Service End Date   13  Ending-Date-of-Service 
25  Service Start Date   14  Beginning-Date-of-Service 
26  Surgery Date  15  Proc-Date-Principal 
27  Therapeutic Class of Drug       
28  Tooth Number       
29  Tooth Quadrant       
30  Tooth Surface       
31  Type of Admission       
32  Type of Bill   16  Type-of-Claim 
33  Type of Facility   17  Place-of-Service 
Source:  OIG comparison of data elements described in CMSs MSIS Data Dictionary, Release 3, effective February 15, 2009, to data elements 
MIG identified as useful for Medicaid fraud, waste, and abuse data analysis and detection as of September 2008. 
 
   
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Table C-3:  Comparison of MIG and MSIS Medicaid Billing Information Data Elements 
MIG Data Elements  MSIS Data Elements 
01  Amount Billed   01  Amount-Charged 
02  Amount of Timed Anesthesia Units Billed   02  Service-Code-Mod 
03  Amount Paid  03  Medicaid-Paid-Amount 
04  Amount Paid by Other Insurance   04  Other-Third-Party-Payment 
05  Amount Paid for DRG Outlier Payments       
06  Average Wholesale Price of Prescription      
07  Control Number of Claim  05  Internal-Control-Number-Original 
08  Control Number Per Item  06  Line-Number-Original 
09  Date Paid  07  Date-of-Payment-Adjudication 
10  Dispense Fee Paid      
11  Drug Price Paid by System      
12  Drug Strength      
13  Final Paid Claim Indicator      
14  Manual Override/Forced Claim Indicator      
15  Medicare Allowed Amount  08  Medicare-Coinsurance-Payment 
16  Medicare Coinsurance Computed  09  Medicare-Coinsurance-Payment 
17  Medicare Coinsurance Reported  10  Medicare-Coinsurance-Payment 
18  Medicare Covered Drug Indicator      
19  Medicare Crossover Amount Paid  11  Medicare-Coinsurance-Payment 
20  Medicare Crossover Date Paid       
21  Medicare Deductible Computed   12  Medicare-Coinsurance-Payment 
22  Medicare Deductible Reported   13  Medicare-Coinsurance-Payment 
23  Net Claim Charge   14  Amount-Charged 
24  Number of Days Not Reimbursable       
25  Number of Days Reimbursed   15  Medicaid-Covered-Inpatient-Days 
26  Number of Days Supplied   16  Days-Supply 
27  Number of Refills   17  New-Refill-Indicator 
28  Number of Units Billed   18  Quantity-of-Service 
29  Number of Units Paid   19  UB-Rev-Units 
30  Prior Authorization Number       
31  Quantity Billed   20  Quantity-of-Service 
32  Remittance Advice Number       
33  Revenue Code   21  UB-Revenue-Code 
34  Split Claim Indicator       
35  Suspended Claim Date       
36  Total Charges Not Covered       
Source:  OIG comparison of data elements described in CMSs MSIS Data Dictionary, Release 3, effective February 15, 2009, to data elements MIG 
identified as useful for Medicaid fraud, waste, and abuse data analysis and detection as of September 2008. 
   
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Table C-4:  Comparison of MIG and MSIS Medicaid Beneficiary and Eligibility Data Elements 
MIG Data Elements  MSIS Data Elements 
01  Recipient County Code  01  County-Code 
02  Recipient Date of Birth  02  Date-Of-Birth 
03  Recipient Eligibility Code   03  Eligibility-Group 
04  Recipient Eligibility Reason Code  04  Basis-of-Eligibility 
05  Recipient Family/Client ID      
06  Recipient First Name      
07  Recipient ID Number  05  MSIS-ID-Number 
08  Recipient Last Name      
09  Recipient Middle Name      
10  Recipient State Code  06  State-Abbreviation 
11  Recipient ZIP Code  07  ZIP-Code 
Source:  OIG comparison of data elements described in CMSs MSIS Data Dictionary, Release 3, effective February 15, 2009, to data elements MIG 
identified as useful for Medicaid fraud, waste, and abuse data analysis and detection as of September 2008. 
 
   
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APPENDIX D   
 
Status of Medicaid Statistical Information System Files Reviewed by Year 
 
The table below shows the number of Medicaid Statistical Information System (MSIS) files that 
we reviewed (1) that had not yet been submitted by States to the Centers for Medicare & 
Medicaid Services (CMS), (2) that were in the CMS data validation process, and (3) that had 
been released by CMS as valid data. 
 
Number of MSIS Files Reviewed in Each CMS Processing Phase by Year 
Not  In  Released as 
Fiscal Year    Submitted  Processing  Valid Total 
2004  0     0     1,020   100%  1,020  100% 
2005  40  4%  440  43%  540  53%  1,020  100% 
2006*  258  25%  667  65%  95  9%  1,020  100% 
20042006  298  10%  1,107  36%  1,655  54%  3,060  100% 
* Because of rounding, the fiscal year (FY) 2006 percentages do not total 100 percent.   
Source:  Office of Inspector General analysis of 3,060 FYs 20042006 State MSIS eligibility and claims 
file submissions. 
 
   
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APPENDIX E  
 
Days That Medicaid Statistical Information System Files Spent in Processing 
 
Average, Median, Minimum, and Maximum Days That Validated Medicaid 
Statistical Information System Files Spent in All Phases of the File 
Submission and Data Validation Process 
Average  Median  Minimum  Maximum 
File Type  Files 
Days  Days  Days  Days 
Eligibility   331  595  572  70  1,057 
Claims  1,324  595  567  70  1,095 
All Files  1,655  595  567  70  1,095 
N=1,655 fiscal years (FY) 2004-2006 State Medicaid Statistical Information System (MSIS) file 
submissions that had cleared all three phases of the file submission and data validation process as of 
June 2007.   
Source:  Office of Inspector General analysis of 3,060 FYs 20042006 State MSIS eligibility and claims 
 
file submissions.
 
 
 
 
 
   
OEI-04-07-00240                                            MSIS Data Usefulness for Detecting Fraud, Waste, and Abuse   Page 26  Cindy Mann 
 
 
APPENDIX F  
 
Number of Undocumented Medicaid Statistical Information System Error Tolerance 
Adjustments by Year 
 
Undocumented Active Medicaid Statistical Information System Data 
Validation Error Tolerance Adjustments From 1999 to 2007 
Year of  Number of  Percentage  
Undocumented  Undocumented  of Total Undocumented 
Adjustment  Adjustments  Adjustments 
1999  249  16% 
2000    516    34% 
2001  116  8% 
2002  103  7% 
2003  57  4% 
2004  239  16% 
2005  92  6% 
2006  89  6% 
2007  67  4% 
   Overall  1,528  100% 
N=1,528 active adjustments that increased Medicaid Statistical Information System (MSIS) data 
validation error tolerances over the default levels documented in the MSIS Data Dictionary.  
Because of rounding, the percentages do not total 100 percent.   
Source:  Office of Inspector General analysis of 9,639 error tolerance adjustments programmed 
into the MSIS Data Validation program in June 2007. 
 
   
OEI-04-07-00240                                            MSIS Data Usefulness for Detecting Fraud, Waste, and Abuse   Page 27  Cindy Mann 
 
 
APPENDIX G   
 
Dates of Medicaid Statistical Information System Error Tolerance Adjustments 
 
The table below shows the dates when the Centers for Medicare & Medicaid Services adjusted 
the error tolerances of the Medicaid Statistical Information System (MSIS) Diagnosis-Code-
Principal data element from 5 percent to 100 percent for 13 States.  These adjustments allowed 
the affected MSIS files to clear quality review with an unknown number of errors. 
 
MSIS Diagnosis-Code-Principal Error Tolerances Adjusted 
From 5 Percent to 100 Percent 
MSIS File Type  State  Adjustment Date 
Inpatient Claims  DC  December 15, 2003 
  GA  July 19, 2000 
  LA  January 05, 2000 
  NV  March 13, 2000 
  ND  November 17, 1999 
  OH  August 18, 1999 
  SC  October 12, 1999 
  SD  March 16, 2000 
  TX  December 21, 2000 
  WA  July 18, 2000 
  WV  September 21, 1999 
  WY  May 26, 2000 
Other Claims  LA  January 5, 2000 
  NV  March 9, 2000 
  TN  February 1, 2001 
  TX  December 26, 2000 
Source:  Office of Inspector General analysis of 9,639 error tolerance adjustments 
programmed into the MSIS Data Validation program in June 2007. 
 
 
 
OEI-04-07-00240                                            MSIS Data Usefulness For Detecting Fraud, Waste, and Abuse