U.S. Department of Health and Human Services 
 Office of Inspector General 
 
Data Brief 
 
 March 2021, OEI-02-19-00180 
Data on Medicaid Managed Care Payments to Providers Are 
Incomplete and Inaccurate 
Why OIG Did This Review 
Key Takeaways 
Effective oversight of Medicaid requires a national system with complete and 
o Most States did not provide
accurate data.  The Centers for Medicare & Medicaid (CMS) established the 
complete or accurate data in the 
Transformed Medicaid Statistical Information System (T-MSIS) for this purpose. 
national data systemT-MSIS 
Payment data are a critical component of T-MSIS.  These data include the 
on Medicaid managed care 
amounts paid, billed, and allowed for every service provided to Medicaid 
payments to providers, and two 
enrollees, including those services provided through managed care. 
States failed to provide any data 
for January 2020.    Managed care has become the primary delivery system for Medicaid.  Each 
managed care plan provides the State with data about what the plan paid 
o CMS and States need complete
providers for their encounters with Medicaid enrollees.  The State is then 
and accurate payment data to
required to submit these data to T-MSIS.  The Office of Inspector General (OIG) 
effectively monitor and
and others have consistently identified deficiencies in the quality of T-MSIS 
administer Medicaid managed
data, including particular concerns with the quality of data for managed care.  
care, the primary delivery system
of the Medicaid program.
CMS and others rely on T-MSIS data to provide oversight; to identify trends; 
o The need for complete and and to detect fraud, waste, and abuse.  States use payment data to set the 
accurate payment data is more capitation rates paid to managed care plans for each enrollee and to monitor 
important than ever, given the the services provided by the plans.  
unprecedented stress the
COVID-19 pandemic has placed How OIG Did This Review 
on the Medicaid program. We analyzed the payment data from the encounter claims in T-MSIS for January 
2020 for the largest managed care plan in each of the 39 States that provide 
comprehensive, risk-based managed care.   
What OIG Found  
Most States did not provide complete or accurate 
payment data in T-MSIS on managed care payments to 
providers; two States failed to provide any data for 
January 2020.  Notably, about half of States did not 
provide complete or accurate information about the 
amounts that managed care plans pay to providers for 
servicesthe amount paid.  Almost three-quarters of the 
States provided incomplete or inaccurate information 
about the maximum amounts that managed care plans 
allow for servicesthe amount allowed.  Over a quarter 
of the States provided incomplete or inaccurate 
information about the amounts that providers bill 
managed care plans for servicesthe amount billed.  
With the rise in Medicaid enrollment and changes in utilization, the COVID-19 pandemic has demonstrated how 
essential it is to have complete and accurate national Medicaid data.  T-MSIS data are more important than ever to  ensure proper oversight and that Medicaid funds are spent appropriately.  These data can be used to identify emerging 
trends as well as to inform public health efforts.   
What OIG Recommends 
We recommend that CMS review States managed care payment data in T-MSIS and ensure that States have corrective 
action plans to improve data completeness and quality, as appropriate.  Further, CMS should make public its reviews of 
States managed care data.  Finally, CMS should clarify and expand its initiative on payment data.  CMS did not concur 
with any of our three recommendations.  CMS noted that it has already set priority areas for improving the reporting of 
T-MSIS data and it will continue to assess how to further expand data quality improvement efforts.  We continue to
press CMS to take the recommended actions to improve the managed care payment data in T-MSIS so that these data
can be used to effectively monitor and oversee the Medicaid program.      
Primer: T-MSIS and Medicaid Managed Care 
   
Provider Payment Data  
T-MSIS  
  T-MSIS is a national data system that contains data from Medicaid managed care and Medicaid 
fee-for-service for all 50 States and the District of Columbia. 
  Managed care data in T-MSIS can be used to provide oversight of services and payments in 
Medicaid managed care.  Medicaid managed care is the primary delivery system for Medicaid 
services, covering 70 percent of the Medicaid population.  In total, 39 States provide 
comprehensive, risk-based managed care.  
  Managed care plans submit an encounter claim (claim) for each enrollee encounter or visit to a 
provider.  Each claim includes information about the individual services provided during a visit.  
States are required to validate encounter claims for accuracy before submitting the claims to T-
MSIS.   
 
      Provider Payment Data  
  Each encounter claim includes the total amounts billed, allowed, and paid for the encounter or 
visit.  Some claims also include the amounts billed, allowed, and paid for each individual service.  
These data do not include the capitated payments that the State pays to the managed care plan.  
The amount the  The maximum  The amount the 
provider billed the  payment amount  managed care plan
managed care plan  the managed care  paid the provider 
for the service planallowed for the  for the service
service
Billed  Allowed  Paid 
Amount Amount Amount
   
  Encounter claims are organized into four files by type of service: 
es Hospital inpatient   es Nursing facilities es Prescription and  es Physician services
c c c c
ervi facility ervi Mental health  ervi dorvuegr-sthe-counter  ervi Outpatient hospital 
s s facilities s s services
ent  are  Intermediate care  acy  Dequuraipbmlee mntedical  her  Dental services
pati m c facilities arm Other services  d ot Clinic services
In ter Ph provided by a  an Laboratory services
g- pharmacy t 
Lon atien Hseorvmicee hsealth 
p
ut Other professional 
O services
 
     
RESULTS 
 
 
Most States did not provide complete or accurate data in  
T-MSIS on Medicaid managed care payments to providers; two 
States failed to provide any data 
 
For 31 of the 39 States with managed care, the State did not provide complete or 
accurate data in T-MSIS on payments to providers for the States largest plan.1  These 
data come from encounter claims for January 2020 and include the amounts paid, 
allowed, or billed for each encounter or visit with a provider.2  We considered a State 
to have incomplete or inaccurate data if it had inappropriate zeros, missing data, or 
negative amounts. 
Accurate payment data are critical for monitoring and administering the Medicaid 
program.  States use payment data to set the capitation rates that they pay to 
managed care plans for each enrollee and to monitor the services provided by the 
plans.3  CMS and other stakeholders rely on the payment data in T-MSIS to manage 
and oversee managed care plans, as well as to monitor plan payments to providers to 
detect fraud, waste, and abuse.  This information is also essential to CMS and others 
to compare costs for certain services and populations and to compare costs across 
States.   
A national system with complete and accurate payment data is particularly important 
given the rise in Medicaid enrollment and changes in utilization during the COVID-19 
pandemic.  Protecting the fiscal integrity of Medicaid during the pandemic has taken 
on a new urgency.  CMS and others can use these data to administer the program 
and conduct oversight, including to identify emerging fraud schemes nationwide and 
to monitor payments to providers.   
Many States had incomplete or 
17 States had incomplete or 
inaccurate information for two or 
inaccurate information for 
more of the following types of 
multiple types of payment data. 
payment data: amounts paid, amounts 
allowed, and amounts billed.  See text 
9 States had incomplete or inaccurate 
box.  
information for all three types of 
Even more concerning, 2 of the 31  payment data   
States failed to submit any claims
8 States had incomplete or inaccurate 
meaning any payment data or record 
information for two types of payment 
of services providedfrom their 
data   
largest plans.  One of these States, 
 
Colorado, submitted no claims for its 
Data Brief: Data on Medicaid Managed Care Payments to Providers Are Incomplete and Inaccurate,  
OEI-02-19-00180        Results | 4  largest plan for January 2020.  The other State, North Dakota, submitted no claims in 
T-MSIS for its only comprehensive, risk-based managed care plan for January 2020 
and all of 2019.  The lack of claims in T-MSIS makes it impossible for CMS and others 
to effectively evaluate the Medicaid managed care program in these two States. 
About half of States did not provide complete or accurate 
information about the amounts paid for services 
Of the 39 States with managed care, 19 States had incomplete or inaccurate 
information for the total amounts paid for services for their largest plan.4  This 
includes the total amount that managed care plans pay for Medicaid services for an 
enrollee for an encounter such as a hospital stay, or for all services provided during an 
office visit.   
Having complete and accurate data about the amounts that Medicaid managed care 
plans pay for services for enrollees is critical.  Such data permit CMS and others to 
detect irregular billing practices and overpayments to providers that could indicate 
fraud or abuse of the program.  For example, the amount paid can be used to identify 
providers who receive unusually high or low payments.   
In total, the 19 States had incomplete or inaccurate data for the amount paid, for a 
median of 40 percent of their claims.5  Four StatesMissouri, Nevada, Utah, and 
Wisconsinhad incomplete or inaccurate data for over half of their claims.  Two 
States did not submit any claims, including any data on paid amounts.  See Exhibit 1 
and Appendix B. 
Most commonly, States had inappropriate zeros for the amount paid, which may 
inaccurately indicate that plans did not pay anything for the service.  In other cases, 
States did not have any information for the amounts paid (i.e., the data were missing).  
CMS states that an unreasonable percentage of zeros or missing amounts paid may 
indicate a data quality issue.6  In some circumstances, States may have submitted 
zeros or did not provide any data for the amount paid when a plan pays its providers 
through an arrangement other than on a fee-for-service basis, such as sub-capitated 
or value-based arrangements.7  CMS currently does not have specific guidance about 
how States should submit payment data in T-MSIS for these arrangements.  
 
 
 
Data Brief: Data on Medicaid Managed Care Payments to Providers Are Incomplete and Inaccurate,  
OEI-02-19-00180        Results | 5  Exhibit 1: States With Incomplete or Inaccurate Data for Amounts Paid 
AK  ME 
VT  NH 
WA  MT  ND  MN  WI  MI  NY  MA  RI 
No comprehensive, risk-based 
ID  WY  SD  IA  IL  IN  OH  PA  NJ  CT  managed care plans 
Less than 10% of claims were 
incomplete or inaccurate 
OR  NV  CO  NE  MO  KY  WV  VA  MD  DE 
Between 10% and 24% of the 
claims were incomplete or 
CA  UT  NM  KS  AR  TN  NC  SC  DC  inaccurate 
Between 25% and 50% of the 
claims were incomplete or 
AZ  OK  LA  MS  AL  GA  inaccurate 
Over 50% of the claims were 
incomplete or inaccurate 
HI  TX  FL 
No managed care data 
submitted  
 
Source: OIG analysis of T-MSIS data, 2020. 
Note:  This analysis is based on the largest managed care plan in each State and includes claims processed in 
January 2020.  
 
States were more likely to have 
incomplete or inaccurate data for 
Sta t es were more likely to have  
certain types of services than for 
others.  Notably, 23 States had  inco  mplete or inaccurate information 
incomplete or inaccurate data for  for the amounts paid for certain 
the amounts paid for the  types of services.  
category of outpatient and other 
services, which includes visits  23 States had incomplete or inaccurate 
with primary care providers and  data for outpatient and other services 
specialists.  Many States also had 
21 States had incomplete or inaccurate 
incomplete or inaccurate data for 
data for hospital inpatient services 
the amounts paid for hospital 
inpatient services.  See text box.   13 States had incomplete or inaccurate 
data for long-term care services  
In total, 25 percent of claims for 
outpatient and other services  10 States had incomplete or inaccurate 
were incomplete or inaccurate,  data for pharmacy services 
compared to 13 percent of claims 
for hospital inpatient services, 
Data Brief: Data on Medicaid Managed Care Payments to Providers Are Incomplete and Inaccurate,  
OEI-02-19-00180        Results | 6  10 percent of claims for long-term care services, and 6 percent of claims for pharmacy 
services.  
In addition, many States had incomplete or inaccurate data for the amounts paid for 
individual services provided during an encounter.8  In addition to providing the total 
amounts paid for each encounter or visit, States commonly provide the amount paid 
for each individual service provided during an encounter or visit.  Twenty-eight States 
had incomplete or inaccurate data for the amounts paid for these individual services.  
Many of these States had incomplete or inaccurate data for physician, outpatient, and 
laboratory services.  See Appendix A.    
Further, a number of States provided inconsistent data for the individual services and 
the total encounter.  For nine States, 10 percent or more of their claims had amounts 
paid for individual services that did not sum to the total amount paid for that 
encounter.  When these amounts do not match, it indicates that there are inaccuracies 
or missing information in the amounts paid for at least one of the individual services 
or for the total amount paid for that encounter.  
 
Information about the date of payment was also often incomplete 
Seven States had incomplete information about the date when the managed 
 
care plan paid the provider, presenting additional challenges for oversight.  
The paid date is important because it may be used to categorize claim 
payments into the appropriate fiscal quarter or year.   
 
Almost three-quarters of the States provided incomplete or 
inaccurate information about the amounts allowed for services 
Of the 39 States with managed care, 28 States had incomplete or inaccurate 
information for the amounts allowed for their largest plan.  The amount allowed is the 
maximum payment amount that a managed care plan allows for a service.   
Having complete and accurate data about the amounts allowed is critical for effective 
oversight of the Medicaid program.  Such data permit CMS and others to determine 
whether the Medicaid managed care plan paid more than the amount allowed for a 
service, which could indicate potential overpayments.  Overpayments can increase the 
cost of the Medicaid program and can also affect enrollees who may be responsible 
for certain out-of-pocket costs, which are a portion of the cost of each service.  In 
addition, CMS and others are able to use the amounts allowed to compare negotiated 
rates for services across different plans and different States and to analyze whether 
certain rates affect access to care. 
Many States had incomplete or inaccurate data for the allowed amount for almost all 
their claims.  See Exhibit 3 and Appendix B.  Notably, 17 States had incomplete or 
inaccurate data for over 90 percent of their claims.  CMS staff note that when States 
use a certain standardized form adopted by CMS to submit claims to T-MSIS, they are  
Data Brief: Data on Medicaid Managed Care Payments to Providers Are Incomplete and Inaccurate,  
OEI-02-19-00180        Results | 7  unable to include the allowed amount because there is no field for it in the 
standardized form.  This may explain why the allowed amount is often missing on the 
claims that States submit to T-MSIS.  In addition, CMS has not yet provided guidance 
to States on how to submit this amount to T-MSIS.   
Most commonly, States had inappropriate zeros for the amount allowed; in other 
cases, they did not have any information for the amounts allowed (i.e., the data were 
missing).   
Exhibit 3: States With Incomplete or Inaccurate Data for Amounts Allowed  
AK  ME 
VT  NH 
WA  MT  ND  MN  WI  MI  NY  MA  RI 
No comprehensive, risk-based 
ID  WY  SD  IA  IL  IN  OH  PA  NJ  CT  managed care plans 
 
Less than 10% of claims were 
incomplete or inaccurate 
OR  NV  CO  NE  MO  KY  WV  VA  MD  DE 
Between 10% and 24% of the 
claims were incomplete or 
CA  UT  NM  KS  AR  TN  NC  SC  DC  inaccurate 
Between 25% and 50% of the 
claims were incomplete or 
AZ  OK  LA  MS  AL  GA  inaccurate 
Over 50% of the claims were 
HI  TX  FL  incomplete or inaccurate 
No managed care data 
submitted 
 
Source: OIG analysis of T-MSIS data, 2020. 
Note:  This analysis is based on the largest managed care plan in each State and includes claims processed in 
January 2020.  
Data Brief: Data on Medicaid Managed Care Payments to Providers Are Incomplete and Inaccurate,  
OEI-02-19-00180        Results | 8   
  
States commonly had incomplete 
or inaccurate data for the amount  States commonly had incomplete or 
allowed for multiple types of  inaccurate information for the 
services, including outpatient and 
amounts allowed for multiple types 
other services and inpatient and 
of services. 
long-term care services.  See text 
box.  
28 States had incomplete or inaccurate 
data for outpatient and other services 
In total, 72 percent of claims for 
long-term care services had  28 States had incomplete or inaccurate 
incomplete or inaccurate  data for hospital inpatient services 
amounts allowed, compared to 
24 States had incomplete or inaccurate 
64 percent of claims for 
data for long-term care services  
outpatient and other services and 
60 percent of claims for hospital 
 
inpatient services.  
In addition, many States had incomplete or inaccurate data for the amounts allowed 
for individual services provided during an encounter.9  Twenty-nine States had 
incomplete or inaccurate data for the amount allowed for these individual services.   
Further, 10 States had an amount paid for an individual service that was greater than 
the amount the managed care plan allowed for that service.  This was true for at least 
10 percent of those States claims.  An amount paid to a provider that exceeds the 
amount allowed could indicate the managed care plan made an overpayment to the 
provider.   
Over a quarter of the States provided incomplete or inaccurate 
information about the amounts billed for services 
Of the 39 States with managed care, 10 States had incomplete or inaccurate 
information for the total amounts billed for services for their largest plan.  Having 
complete and accurate data about the amounts billed is important because these 
amounts can be used by CMS and others to analyze providers billing practices.  They 
can use these amounts to identify how much providers are billing Medicaid managed 
care plans for services and track providers that are outliers. 
The 10 States had incomplete or inaccurate data for the amounts billed, for a median 
of 33 percent of their claims.  Three States had incomplete or inaccurate data for over 
half of their claims.  See Exhibit 5 and Appendix B.  
Most commonly, States had inappropriate zeros for the amount billed; in other cases, 
they did not have any information for the amounts billed (i.e., the data were 
missing).10   
Data Brief: Data on Medicaid Managed Care Payments to Providers Are Incomplete and Inaccurate,  
OEI-02-19-00180        Results | 9  Exhibit 5: States With Incomplete or Inaccurate Data for Amounts Billed   
AK  ME 
VT  NH 
WA  MT  ND  MN  WI  MI  NY  MA  RI 
No comprehensive, risk-based 
managed care plans 
ID  WY  SD  IA  IL  IN  OH  PA  NJ  CT 
 
Less than 10% of claims were 
incomplete or inaccurate 
OR  NV  CO  NE  MO  KY  WV  VA  MD  DE 
Between 10% and 24% of the 
claims were incomplete or 
CA  UT  NM  KS  AR  TN  NC  SC  DC  inaccurate 
Between 25% and 50% of the 
claims were incomplete or 
AZ  OK  LA  MS  AL  GA  inaccurate 
Over 50% of the claims were 
HI  TX  FL  incomplete or inaccurate 
No managed care data 
submitted 
 
Source: OIG analysis of T-MSIS data, 2020. 
Note:  This analysis is based on the largest managed care plan in each State and includes claims processed in 
January 2020.    
Fewer than one-third of States 
had incomplete or inaccurate data 
Fewer than one-third of States had 
for the amounts billed for each 
incomplete or inaccurate information 
type of service.  Ten States had 
for the amounts billed for each type 
incomplete or inaccurate data for 
outpatient and other services.   of service. 
See text box.   
10 States had incomplete or inaccurate 
In total, 7 percent of claims for  data for outpatient and other services 
outpatient and other services 
7 States had incomplete or inaccurate 
were incomplete or inaccurate, 
data for hospital inpatient services 
compared to 6 percent of claims 
for pharmacy services, 3 percent  7 States had incomplete or inaccurate 
of claims for long-term care  data for long-term care services  
services, and 2 percent of claims 
6 States had incomplete or inaccurate 
for hospital inpatient services. 
data for pharmacy services 
In addition, eight States had 
incomplete or inaccurate data for 
the amount billed by providers for 
individual services provided during an encounter.11   
 
Data Brief: Data on Medicaid Managed Care Payments to Providers Are Incomplete and Inaccurate,  
OEI-02-19-00180        Results | 10   
RECOMMENDATIONS 
 
 
Effective oversight requires a national system with complete and accurate payment 
data, including data from plans that provide managed care.  CMS and others use the 
national systemT-MSISto oversee and administer the Medicaid program, which 
covers 70.6 million enrollees and has $613.5 billion in expenditures.12  In addition, 
States use payment data to set the capitation rates that they pay to managed care 
plans for each enrollee and to monitor the services provided by the plans.       
CMS has made improving data quality in T-MSIS a priority.  It is currently focused on 
improving a number of data elements, including the Medicaid managed care payment 
data for amount paid and amount billed in T-MSIS.13  Notably, CMS conducts periodic 
checks of T-MSIS data for quality issues, provides guidance on the submission of the 
data in various documents, and works with the States one-on-one to address 
concerns related to the priority areas, which include payment data.  In addition, it 
provides certain T-MSIS data to the public for research purposes and plans to release 
more recent data as the data become more complete.   
Despite these actions, CMS needs to strengthen its efforts to improve the accuracy 
and completeness of managed care payment data in T-MSIS.  Our findings show that 
some States are not submitting data to T-MSIS for their largest managed care plans, 
and when States are submitting data, the payment data are often incomplete or 
inaccurate.  These deficiencies limit the usability of Medicaid T-MSIS data and hinder 
oversight and accountability of Medicaid managed care.   
These findings echo longstanding issues highlighted in other studies that have 
consistently identified deficiencies in the quality of T-MSIS data.14  Most recently, OIG 
found that States did not always submit complete Medicaid data needed for 
oversight, such as provider identifiers and diagnosis codes for opioid 
prescriptions.15  In addition, the Government Accountability Office (GAO) reviewed 
CMSs assessment of its progress on the top priority areas and found that while some 
data has improved, not all data met the standards set in the priority areas, including 
the data for managed care.16    
Having complete and accurate Medicaid data are especially important given the 
COVID-19 pandemic.  As Medicaid enrollment has increased and utilization has 
changed, it is more important than ever that we are able to track Medicaid managed 
care payments for services and that we monitor utilization to ensure that enrollees are 
receiving necessary care.  Also, these data can be used to detect potential fraud 
schemes that may have arisen during the pandemic and to inform public health 
efforts. 
 
 
Data Brief: Data on Medicaid Managed Care Payments to Providers Are Incomplete and Inaccurate,  
OEI-02-19-00180    Recommendations | 11   
We recommend that CMS:  
Review States managed care payment data in T-MSIS and 
ensure that States have corrective action plans to improve data 
completeness and quality, as appropriate 
CMS should accelerate and strengthen its efforts to improve the completeness and 
accuracy of the managed care payment data in T-MSIS.  In addition to accelerating its 
current efforts to improve T-MSIS data, CMS should also expand its efforts by 
conducting reviews of T-MSIS payment data by each States managed care plans.   
Analyses at the plan level could reveal underlying issues in the data and can provide 
valuable information to CMS and others to help resolve issues and provide better 
oversight.17  CMS should share its results with the States and provide samples of 
potentially problematic claims related to payment data so that States can better 
identify and address underlying issues in a timely manner.   
CMS should also use its authority, as appropriate, to develop corrective action plans 
or to defer or disallow certain Federal funding if States are not submitting complete 
and accurate managed care data.18  These actions would prompt States and plans to 
improve the quality of their data in T-MSIS.  In particular, CMS should work with the 
two States that failed to submit any claims datanot just payment datafor their 
largest plans.   
Make public its reviews of States managed care payment data  
CMS should publicly report the results of its reviews of the managed care data in  
T-MSIS.  These public reports should include results summarizing the extent to which 
the payment data are complete and accurate for each individual managed care plan.  
CMS should build off its T-MSIS Analytic Files Data Quality State snapshots to create a 
version that is specific to managed care and provides findings on data quality at the 
plan level.19  Making these reviews public would hold States and managed care plans 
more accountable for submitting complete and accurate payment data at the plan 
level.  It would also make researchers and other stakeholders aware of problems with 
incomplete or inaccurate data in T-MSIS for certain managed care plans. 
Clarify and expand its initiative on payment data 
CMS should clarify and emphasize the importance of reporting complete and 
accurate payment data for all managed care plans.  As part of its efforts, CMS should 
clarify its expectations for submitting the amount paid for sub-capitated or value-
based arrangements.  Plans that have these arrangements with their providers may be 
submitting an unreasonable percentage of zeros or missing amounts paid.  Not 
Data Brief: Data on Medicaid Managed Care Payments to Providers Are Incomplete and Inaccurate,  
OEI-02-19-00180    Recommendations | 12  having information about payments made to providers under these arrangements 
impedes the oversight efforts of CMS and others.   
CMSs current initiative on improving the quality of payment data includes measures 
on the completeness and accuracy of the amount paid and the amount billed. 20  CMS 
should expand its current initiative on payment data by measuring the completeness 
and accuracy of the amount allowed and holding States accountable for providing 
this information.  The amount allowed is a required data field for T-MSIS, but some 
standardized claim submission forms do not have a field for that amount.  Almost 
three-quarters of the States have incomplete or inaccurate data on the amount 
allowed.  Incorporating the amount allowed would prompt States to improve the 
quality of these data.  CMS should also provide a solution or alternative option for 
States that are having difficulty submitting the allowed amount.   
CMS should also further emphasize to States the importance of having complete and 
accurate payment data in T-MSIS.  CMS should use the results of this report and its 
own analysis from its data quality initiative to further communicate to States about 
how to improve their payment data and to hold States accountable for the quality of 
the data they submit to T-MSIS. 
Data Brief: Data on Medicaid Managed Care Payments to Providers Are Incomplete and Inaccurate,  
OEI-02-19-00180    Recommendations | 13  AGENCY COMMENTS AND OIG RESPONSE 
 
 
CMS did not concur with any of our three recommendations.  CMS stated that having 
access to robust data strengthens program monitoring.  It noted that it has already 
set priority areas for improving the reporting of T-MSIS data and it will continue to 
assess how to further expand data quality improvement efforts.   
Our findings demonstrate that further action focused on the quality of managed care 
payment data is needed.  Managed care is now the primary delivery system for 
Medicaid.  With over two-thirds of beneficiaries receiving managed care, CMS must 
hold States accountable for the quality of their managed care payment data and raise 
the bar, where needed.  In addition, with the onset of the pandemic, T-MSIS data are 
more important than ever to ensure proper oversight and to ensure we can track 
Medicaid managed care payments for services. 
We continue to press CMS to take the recommended actions to improve the 
managed care payment data in T-MSIS so that these data can be used to effectively 
monitor and oversee the Medicaid program.  We acknowledge that these 
improvements may take some time to address, given the increased demands that 
States face due to the pandemic.  We will follow up with CMS, as appropriate, to 
implement any outstanding recommendations. 
CMS did not concur with our first recommendation that it review States managed 
care payment data in T-MSIS and ensure that States have corrective action plans to 
improve data completeness and quality.   
CMS stated that it identifies Top Priority Items (TPI) to help States focus on improving 
the accuracy and completeness of T-MSIS data and has recently expanded them to 
32.  It also noted that it has already streamlined State Plans of Actionwhich serve as 
corrective action plansto address data quality issues.  CMS also reported that 
States were made aware of enforcement actions and that CMS may reduce enhanced 
Federal Financial Participation for operational costs of systems unable to produce 
timely, accurate, and complete T-MSIS data and that all States had met the reporting 
threshold as of March 2020.  In addition, CMS noted that the two States that were not 
submitting managed care data are now able to do so.  Finally, while CMS commented 
that OIG did not determine whether missing data originated from the managed care 
plans or from the States, it noted that States bear the responsibility for ensuring the 
quality of data submitted to T-MSIS and that it has provided States with tools and 
resources for identifying and resolving data quality issues.  
While we appreciate CMSs efforts, we maintain that CMS should strengthen its efforts 
and conduct reviews of T-MSIS payment data by each States managed care plans.  
We maintain that evaluating payment data for each managed care plan will allow 
CMS to pinpoint data quality issues and solutions that may not be apparent when 
analyzing data at the State level.  We further note that reviewing the payment data at 
Data Brief: Data on Medicaid Managed Care Payments to Providers Are Incomplete and Inaccurate,  
OEI-02-19-00180    Agency Comments and OIG Response | 14  the plan level is critical to improving these data, regardless of where the quality issues 
may have originated.  This type of analysis can help CMS and States sort out and 
better understand why the data may be inaccurate or incomplete in T-MSIS.  This 
approach also complements CMSs current efforts in that it can uncover underlying 
problems that go beyond the particular data fields that are the focus of the TPIs.  
Further, the findings of this reportthat 31 States did not provide complete or 
accurate payment data in T-MSISdemonstrate that CMS needs to do more, 
including ensuring that States have corrective action plans to improve these data.  
CMS did not concur with our second recommendation to make public its reviews of 
States managed care payment data.   
CMS stated that it already publicly reports the results of its reviews through its T-MSIS 
Analytic Files (TAF), which are publicly available data files, and the Data Quality (DQ) 
Atlas, which is a web-based tool that helps users explore the quality and usability of 
the TAFs.  While we appreciate CMSs efforts to provide these data to the public, we 
note that neither the TAFs nor the DQ Atlas include results on managed care payment 
data.  We agree with CMS that publishing information on Medicaid data quality can 
incentivize improvements.  We reiterate that making public its reviews of the extent to 
which the payment data are complete and accurate for each managed care plan is 
important; it will similarly provide a strong incentive for plans to improve their data 
submissions.   
CMS did not concur with our third recommendation to clarify and expand its initiative 
on payment data.   
CMS stated that while it appreciates OIGs recommendation about expanding the 
focus of its initiative to include the amount allowed and holding States accountable 
for providing this information, it is important to note that data quality efforts must be 
balanced with States increasing workloads, which has been made more difficult due 
to the pandemic.  CMS further noted that although the allowed amount for managed 
care payment data is required, there are barriers to obtaining these data because 
plans may be reluctant to submit the data and may experience technical difficulties 
when submitting.  In addition, CMS stated that it recognizes that guidance is needed 
to clarify how States should submit payment data for managed care plans that pay 
providers through payment arrangements other than on a fee-for-service basis and 
will continue existing plans to provide States with the necessary guidance.  
Based on our findings, we maintain that CMS can help States improve their 
submissions of managed care payment data by expanding its initiative to include the 
allowed amount.  We appreciate CMSs willingness to consider these changes in 
future updates to its TPIs and provide additional support to States to meet this new 
requirement.  CMS should provide a solution or alternative option for States that are 
having difficulties submitting the allowed amount.  We also note that providing 
guidance for submitting payment data for payment arrangements that are not on a 
fee-for-service basis would help improve the managed care data. 
For the full text of CMSs comments, see Appendix C.
Data Brief: Data on Medicaid Managed Care Payments to Providers Are Incomplete and Inaccurate,  
OEI-02-19-00180    Agency Comments and OIG Response | 15   
METHODOLOGY 
 
 
This study was based on an analysis of managed care payment data in T-MSIS.  We 
reviewed the claims for the largest comprehensive, risk-based managed care plan in 
each of 39 States.  We analyzed claims processed in January 2020.  We conducted our 
review in August 2020 to allow time for those claims to be submitted to T-MSIS.  
Identification of the managed care plans 
We determined that 39 States had at least one comprehensive, risk-based managed 
care plan.21  Comprehensive managed care plans provide a comprehensive range of 
services that include acute care, primary care, specialty care, and other services.  To 
identify the largest such plan in each of these States, we reviewed Medicaid 
enrollment data published on each States website.22    
We identified each of these plans in T-MSIS.  Using the enrollment data for each plan 
from CMSs Integrated Data Repository, we determined the plan identification 
numbers associated with each plan.23  A plan may have multiple plan identifiers that 
represent, for example, regional locations or specific enrollee populations.  We 
confirmed both the plan names and their plan identifiers with each State. 
Analysis of T-MSIS payment data 
We analyzed the T-MSIS data from CMSs Integrated Data Repository to determine 
the extent to which each State provided complete or accurate payment data for its 
largest plan for claims processed in January 2020.24     
We focused our analysis on key payment data.25  For each States largest plan, we 
determined the completeness and accuracy of the following payment fields: paid 
amount, allowed amount, and billed amount.      
For each type of payment data, we determined the number of States that had 
incomplete or inaccurate data.26  We considered a State to have incomplete or 
inaccurate data if at least 10 percent of the States claims had inappropriate zeros, no 
information, or negative amounts in the payment field.27    
Next, for each type of payment data, we determined the number of States that had 
incomplete or inaccurate data by type of service (i.e., inpatient, long-term care, 
pharmacy, and outpatient and other services).  We then determined the percentage 
of claims with incomplete or inaccurate data in each of the service files for all the 
States.   
In addition to the two analyses described above that we conducted for each 
encounter, we analyzed the individual services provided during each encounter or 
Data Brief: Data on Medicaid Managed Care Payments to Providers Are Incomplete and Inaccurate,  
OEI-02-19-00180    Methodology | 16  visit.  For each type of payment data, we determined the number of States that had 
incomplete or inaccurate data.     
We conducted additional analyses for the paid amount.  We determined the number 
of States and the percentage of claims across all States that had incomplete or 
inaccurate data for physician, outpatient, and laboratory services.  We also 
determined the number of States with claims in which the sum of the amounts paid 
for individual services during an encounter did not equal the total amount paid for 
that encounterwe considered this to be an issue if it occurred in at least 10 percent 
of a States claims. 
Further, we determined the number of States that had incomplete information about 
the date when the managed care plan paid the provider.  We considered a State to 
have such incomplete information if at least 10 percent of the States claims had no 
information in the date field.   
We conducted an additional analysis for the amount allowed.  We determined the 
number of States with claims in which the amount paid for an individual service was 
greater than the amount the managed care plan allowed for that service.  We 
considered a State to have such claims if at least 10 percent of the States claims had 
a paid amount greater than the allowed amount.     
Limitations 
We based our analysis on the data in T-MSIS.  We did not determine whether there 
were additional claims held at the plan or State level that were never submitted to  
T-MSIS.  Additionally, we did not determine whether the claims paid for were 
appropriate or medically necessary.  Lastly, where data were incomplete or inaccurate, 
we did not determine whether the error originated from the managed care plans or 
from the States. 
Standards 
We conducted this study in accordance with the Quality Standards for Inspection and 
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. 
Data Brief: Data on Medicaid Managed Care Payments to Providers Are Incomplete and Inaccurate,  
OEI-02-19-00180    Methodology | 17   
APPENDIX A 
 
Number of States with incomplete or inaccurate data for the 
amounts paid for physician, outpatient, and laboratory services 
Type of service  Number of States  Percentage of claims with 
with incomplete or  incomplete or inaccurate data 
inaccurate data 
Physician services  23  27% 
Outpatient services  17  47% 
Laboratory services  13  34% 
Source: OIG analysis of T-MSIS data, 2020. 
Note:  This analysis is based on the 31 States that indicated that claims are paid at the individual service level, as 
opposed to the encounter level.  It is based on the largest managed care plan in each State and includes claims 
processed in January 2020.
Data Brief: Data on Medicaid Managed Care Payments to Providers Are Incomplete and Inaccurate, 
OEI-02-19-00180  Appendix A | 18   
APPENDIX B 
 
Exhibit B-1.  Percentage of incomplete or inaccurate data for 
amounts paid  
KY
GA
FL
VA
NM
WV
MS
SC
DC
DE
MA
IA
NE
TX
PA
HI
MI
OH
WA
IN
OR
T N 
LA
RI
IL
MD
Median of 
NJ
NY States with 
NH incomplete or 
CA inaccurate 
MN
data = 40% 
KS
AZ
UT
MO
WI
NV
ND
CO
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Missing amounts Inappropriate zeros
Negative amounts No managed care data submitted
Source: OIG analysis of T-MSIS data, 2020. 
Note:  This analysis is based on the largest managed care plan in each State and includes claims 
processed in January 2020.  Highlighted States had incomplete or inaccurate data for the amounts paid 
for 10 percent or more of their claims. 
Data Brief: Data on Medicaid Managed Care Payments to Providers Are Incomplete and Inaccurate, 
OEI-02-19-00180  Appendix B | 19   
Exhibit B-2.  Percentage of incomplete or inaccurate data for 
amounts allowed  
 
AZ
WI
MO
FL
NM
IN
DC
MI
IA
WV
PA
DE
T N 
LA
HI
IL
OR
RI
NH
KS
MN
MS Median of 
NE
States with 
MD
UT incomplete or 
NJ inaccurate 
OH
WA data = 99% 
VA
TX
SC
NY
NV
MA
KY
GA
CA
ND
CO
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Missing amounts Inappropriate zeros
Negative amounts No managed care data submitted
   
Source: OIG analysis of T-MSIS data, 2020. 
Note:  This analysis is based on the largest managed care plan in each State and includes claims 
processed in January 2020.  Highlighted States had incomplete or inaccurate data for the amounts paid 
for 10 percent or more of their claims.
Data Brief: Data on Medicaid Managed Care Payments to Providers Are Incomplete and Inaccurate,  
OEI-02-19-00180    Appendix B | 20   
Exhibit B-3.  Percentage of incomplete or inaccurate data for 
amounts billed  
 
WI
NV
NM
KY
WV
DE
PA
MI
OR
OH
TN
GA
SC
AZ
VA
MO
TX
HI
IA
DC
FL
NJ
MA
MS
MN
WA
LA
IN
CA Median of 
NY
States with 
 R I
NE incomplete or 
IL inaccurate 
NH
data = 33% 
MD
KS
UT
ND
CO
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Missing amounts Inappropriate zeros
Negative amounts No managed care data submitted
   
Source: OIG analysis of T-MSIS data, 2020. 
Note:  This analysis is based on the largest managed care plan in each State and includes claims 
processed in January 2020.  Highlighted States had incomplete or inaccurate data for the amounts paid 
for 10 percent or more of their claims. 
   
Data Brief: Data on Medicaid Managed Care Payments to Providers Are Incomplete and Inaccurate,  
OEI-02-19-00180    Appendix B | 21  APPENDIX C: Agency Comments
DATE:           January 19, 2021 
TO:  Suzanne Murrin 
Deputy Inspector General for Evaluation and Inspections 
FROM:  Seema Verma 
Administrator 
SUBJECT:  Office of Inspector General (OIG) Draft Data Brief: Data on Medicaid Managed 
Care Payments to Providers Are Incomplete and Inaccurate (OEI-02-19-00180) 
The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and 
comment on the Office of Inspector Generals (OIG) draft data brief. CMS recognizes that 
access to high-quality, timely data is essential for ensuring robust monitoring and oversight of 
the Medicaid and Childrens Health Insurance Programs (CHIP), and CMS has made improving 
Medicaid data a top priority.  
Over the past several years, CMS has worked with states to implement changes to the way in 
which Medicaid administrative data, including managed care payment data, is collected from 
states by moving from the Medicaid Statistical Information System (MSIS) to the 
Transformed-MSIS (T-MSIS). As part of the transition to T-MSIS, CMS has strengthened its 
reporting requirements by standardizing definitions, expanding the data being collected, 
adding data quality enhancements through an expansive data quality assessment and 
compliance process, and improving the timeliness of data submission by moving from 
quarterly to monthly state data submissions. Having access to more robust, timely, and 
accurate data via T-MSIS strengthens program monitoring, policy implementation, and 
oversight of Medicaid and CHIP. It also enhances CMS and states ability to identify potential 
fraud, waste, and abuse and improve program efficiency.   
In May of 2017, based on feedback from users of the T-MSIS data and continuous evaluation of 
patterns in the data submitted to T-MSIS, CMS embarked on an initiative to help states focus on 
improving the accuracy and completeness of certain data elements and as such, identified 12 T-
MSIS Priority Items (TPIs) necessary to support business and program oversight needs. States 
have made significant progress in addressing the initial TPIs, and based on additional user 
feedback and analytics reporting goals, CMS continued to expand the number of TPIs in 2019 
and again in 2020 to include additional focus areas in support of the T-MSIS data quality 
continuous improvement effort. As of August 2020, CMS has identified 32 TPIs to help states 
improve Medicaid and CHIP data reporting accuracy and completeness, including two TPIs  
related to the consistency of managed care plan reporting and the completeness and consistency 
of payment data elements for both Fee-for-Service claims and managed care encounter data. As 
states make progress on current TPIs, CMS will continue to engage with stakeholders, including 
states, oversight entities, Congress, policy researchers, and entrepreneurs, in order to determine 
how to further enhance data quality improvement efforts to support business and program 
oversight needs. 
Data Brief: Data on Medicaid Managed Care Payments to Providers Are Incomplete and Inaccurate, 
OEI-02-19-00180                     Appendix C | 22 In order to increase transparency and incentivize states to improve data submitted, CMS has made 
T-MSIS data, as well as state-level data quality assessments, publicly available. For example, each
states data quality status related to 23 TPIs is published monthly on the T-MSIS page on
Medicaid.gov, and CMS plans to publish state-level data quality assessments against the 2021 TPIs
(24-32) on Medicaid.gov early this year. In addition, CMS created the T-MSIS Analytic Files
(TAFs), which are publicly available files that include data on enrollment, demographics, service
utilization, and payments in Medicaid and CHIP at the state level. CMS also published the Data
Quality (DQ) Atlas, an interactive, web-based tool that helps users explore the quality and usability
of the TAFs. DQ Atlas supports insightful, methodologically sound analyses of TAFs by providing
data quality information on a range of key Medicaid and CHIP topics such as enrollment, claims,
expenditures, and service use. The charts, maps, and tables in the DQ Atlas show state-level data
quality assessments and associated measure values for topics that are pertinent to Medicaid and
CHIP, including several related to managed care data.
CMS has been, and will continue to be, a committed partner with all states in support of their good-
faith efforts to meet and maintain compliance with T-MSIS reporting requirements. Although CMS 
has partnered with states to improve data reporting, states are potentially facing limited resources to 
address data quality issues. Now more than ever, in light of the COVID-19 Public Health 
Emergency, states are facing increasing demands in implementing and operating their Medicaid and 
CHIP programs. 
In support of state data quality efforts, CMS has provided states with tools and resources, including 
the T-MSIS operational dashboard and a data quality tool for identifying and resolving data quality 
issues. On a monthly basis, states must submit to CMS over 1,400 data elements in eight different 
files that make up T-MSIS. Once submitted, T-MSIS data are reviewed through two data quality 
methods including edits that identify basic business rule errors, and validation methods that look at 
patterns in each states data in order to identify warnings where data elements fall outside of a 
normal range. These two methods are run even before a second tier of data quality review is applied 
to TAF files. CMS shares data quality results with states as part of its ongoing data quality 
monitoring efforts, and works with states to determine the priority and the timeline for resolution of 
any identified data quality issues. For example, in the cases of Colorado and North Dakota, which 
OIG noted as submitting no encounter data for their largest managed care plan in January 2020, 
CMS has continued to work closely with these states to address root causes of their data submission 
issues. In these instances, Colorado experienced a temporary two month span in which encounter 
data were not reported due to a system issue, which has been subsequently resolved, and North 
Dakota required an enhancement to their eligibility systems to be able to report any information 
related to the states largest plan, which covers their Medicaid Adult Expansion population. 
Funding was appropriated in the June 2019 state budget for this enhancement, and after 
implementing their system, North Dakota began reporting encounters for the plan in the OIGs 
review in May 2020.1 
CMS appreciates the OIGs efforts in assessing the completeness of managed care payment data in 
T-MSIS from January 2020 for the largest managed care plan in 39 states, and will consider how to
use this information to help further improve T-MSIS data reporting. However, since OIG only
looked at one plan per state for one month and did not determine whether missing data originated
from the managed care plans or from the states, it is unclear whether the root cause of the issues
identified is with the quality of the data submitted by specific plans to the states or with the data
states submit overall to T-MSIS. As discussed above, CMS has already set priority areas for states
to improve when reporting T-MSIS data, which include areas for managed care data, and will
1 North Dakota 66th Legislative Assembly State Budget Actions for the 2019-21 Biennium. 
Data Brief: Data on Medicaid Managed Care Payments to Providers Are Incomplete and Inaccurate, 
OEI-02-19-00180                     Appendix C | 23 continue to assess how to further expand data quality improvement efforts based on feedback from 
users of the T-MSIS data, including the OIG and other oversight agencies, to improve monitoring 
and oversight of Medicaid and CHIP. 
OIGs recommendations and CMS' responses are below. 
OIG Recommendation 
CMS should review States managed care payment data in T-MSIS and ensure that States have 
corrective action plans to improve data completeness and quality, as appropriate. 
CMS Response 
CMS does not concur with this recommendation. As previously mentioned, in 2017 CMS began 
identifying TPIs to help states focus on improving the accuracy and completeness of data elements 
necessary to support business and program oversight needs, and has recently expanded the number 
of TPIs to 32. In their recommendation, the OIG notes that CMS should accelerate and strengthen 
its efforts to improve the completeness and accuracy of the managed care payment data in T-MSIS, 
but CMS does not agree that this is an actionable or measurable recommendation, especially during 
a public health emergency. CMS continues to work collaboratively with states to improve the 
timeliness, completeness, and accuracy of T-MSIS data, while balancing these efforts with states 
increasing workloads in implementing and operating their Medicaid and CHIP programs. 
The OIG also notes that CMS should use its authority, as appropriate, to develop corrective action 
plans or to take enforcement action if states are not submitting complete and accurate managed care 
data. However, as part of ongoing data quality improvement, CMS has already streamlined data 
quality compliance and State Plans of Action (SPOAs), which currently serve as corrective action 
plans for states with identified data quality issues, including for managed care data. Each states 
data quality status for the most recent month is published monthly on the T-MSIS page on 
Medicaid.gov, and CMS has found that the public reporting of each states data quality status has 
also provided a strong incentive for compliance. In addition, in a March 2019 Informational 
Bulletin2 states were made aware of enforcement actions stating that CMS may reduce enhanced 
Federal Financial Participation (FFP) for operational costs of systems unable to produce timely, 
accurate, and complete T-MSIS data. As outlined in 42 C.F.R.  433.120, CMS may reduce FFP for 
expenditures for systems with non-compliant functionality, and as of March 2020, all states had met 
the T-MSIS reporting threshold CMS had identified in the Information Bulletin in order to maintain 
full federal funding. As such, CMS believes it has already fulfilled this aspect of the 
recommendation. CMS also ensures continuity in compliance evaluations and related enforcement, 
beyond reporting requirements specified in the Information Bulletin, so that states demonstrate 
continued commitment to improving data quality. 
Finally, the OIG stated that CMS should expand its efforts by conducting reviews of T-MSIS 
payment data by each states managed care plans. However, since OIG did not determine 
whether missing data originated from the managed care plans or from the states, it is unclear 
whether the root cause of the issue is with the quality of the data submitted by specific plans to 
the states or with the data states submit to T-MSIS. Pursuant to CMS regulatory requirements, 
states bear the responsibility for ensuring the quality of data submitted to T-MSIS. CMS is 
committed to working collaboratively with state Medicaid agencies on improving T-MSIS 
data quality focusing on the priority items identified. In support of state data quality efforts, 
CMS has provided states with tools and resources for identifying and resolving data quality 
issues. CMS conducts data quality reviews and shares the results with states as part of its 
2 https://www.medicaid.gov/sites/default/files/Federal-Policy-Guidance/Downloads/cib031819.pdf 
Data Brief: Data on Medicaid Managed Care Payments to Providers Are Incomplete and Inaccurate, 
OEI-02-19-00180                     Appendix C | 24 ongoing data quality monitoring efforts. CMS works with states to determine root causes of 
their data submission issues and the priority and the timeline for resolution of identified data 
quality issues.  
OIG Recommendation 
CMS should make public its reviews of States managed care payment data. 
CMS Response 
CMS does not concur with this recommendation. OIG notes that CMS should publicly report the 
results of its reviews of the managed care data in T-MSIS, which CMS has already done through 
the creation of the TAFs, which are publicly available files that include data on enrollment, 
demographics, service utilization, and payments, including managed care payments, in Medicaid 
and CHIP at the state level. Further, in order to help key stakeholders determine if the available data 
can meet their analytic needs, CMS created the DQ Atlas, an interactive, web-based tool that helps 
users explore the quality and usability of the TAFs. DQ Atlas supports insightful, methodologically 
sound analyses of TAFs by providing data quality information on a range of key Medicaid and 
CHIP topics such as enrollment, claims, expenditures, and service use. The charts, maps, and tables 
in DQ Atlas show state-level data quality assessments and associated measure values for topics that 
are pertinent to Medicaid and CHIP, including several related to managed care data. 
As part of this recommendation, OIG notes that CMS should report publicly on data of individual 
managed care plans to improve accountability for submitting complete and accurate payment data. 
However, since OIG did not determine whether missing data originated from the managed care 
plans or from the states, it is unclear whether the root cause of the issue is with the quality of the 
data submitted by specific plans to the states or with the data states submit to T-MSIS. Pursuant to 
CMS regulatory requirements, states bear the responsibility for ensuring the quality of data 
submitted to T-MSIS. CMS is committed to working collaboratively with state Medicaid agencies 
on improving T-MSIS data quality focusing on the priority items identified. In support of state data 
quality efforts, CMS has provided states with numerous tools and resources for identifying and 
resolving data quality issues. CMS conducts data quality reviews and shares the results with states 
as part of its ongoing data quality monitoring efforts. CMS works with states to determine root 
causes of their data submission issues and the priority and the timeline for resolution of identified 
data quality issues.  
OIG Recommendation 
CMS should clarify and expand its initiative on payment data. 
CMS Response 
CMS does not concur with this recommendation. As noted in the OIGs report, CMS has already 
identified the completeness and consistency of payment data elements as a priority area, and has 
been assessing and documenting state compliance with this TPI since February of 2019. While 
CMS appreciates OIGs recommendation that CMS should expand its current initiative on payment 
data by measuring the completeness and accuracy of the amount allowed and holding states 
accountable for providing this information, it is important to note that data quality efforts must be 
balanced with states increasing workloads in implementing and operating their Medicaid and CHIP 
programs. On a monthly basis, states must submit to CMS over 1,400 data elements, and CMS has 
already identified 32 TPIs to help states improve Medicaid and CHIP data reporting accuracy and 
completeness, including two TPIs related to the consistency of managed care plan reporting and the 
completeness and consistency of payment data elements for both Fee-for-Service claims and 
managed care encounter data. Despite the lack of a standard field for reporting the allowed amount 
Data Brief: Data on Medicaid Managed Care Payments to Providers Are Incomplete and Inaccurate, 
OEI-02-19-00180                     Appendix C | 25 on managed care encounters in the files managed care plans use for the submission of data, CMS 
has specified at 42 C.F.R.  438.242(c)(3) that paid and allowed amounts for managed care 
encounter payment data are included in the requirement for submission of all enrollee encounter 
data. A barrier to obtaining allowed amounts on encounter records is found in the role this data 
plays in provider contracting, as allowed amount values may impact a managed care organizations 
negotiating position. There are also challenges associated with sub-capitated payment 
arrangements; since payment per-service is not exchanged in sub-capitation arrangements, the 
allowed amount detail cannot be obtained. As states make progress on current TPIs, CMS will 
continue to engage with stakeholders to add additional focus areas based on feedback from users of 
the T-MSIS data, including the OIG and other oversight agencies.  
Further, CMS recognizes that additional guidance is needed to clarify how states should submit 
payment data to T-MSIS for managed care plans that pay providers through payment arrangements 
other than a per-service basis, and will continue existing plans to provide states with the necessary 
guidance. CMS agrees that having complete and accurate payment data in T-MSIS is essential for 
ensuring robust monitoring and oversight of the Medicaid and CHIP programs, and will continue to 
be a committed partner with all states in support of their good-faith efforts to meet and maintain 
compliance with the T-MSIS requirements.  
Data Brief: Data on Medicaid Managed Care Payments to Providers Are Incomplete and Inaccurate, 
OEI-02-19-00180    Appendix C | 26  
ACKNOWLEDGMENTS AND CONTACT 
 
Acknowledgments 
Judy Kellis served as the team leader for this study.  Others in the Office of Evaluation 
and Inspections who conducted the study include Alexis Mills.  Office of Evaluation 
and Inspections staff who provided support include Kevin Farber, Kevin Manley, and 
Christine Moritz.  
We would also like to acknowledge the contributions of other Office of Inspector 
General staff, including Devin Sprong.   
This report was prepared under the direction of Jodi Nudelman, Regional Inspector 
General for Evaluation and Inspections in the New York regional office, and  
Nancy Harrison and Meridith Seife, Deputy Regional Inspectors General. 
Contact 
To obtain additional information concerning this report, contact the Office of Public 
Affairs at Public.Affairs@oig.hhs.gov.  OIG reports and other information can be found 
on the OIG website at oig.hhs.gov. 
Office of Inspector General 
U.S. Department of Health and Human Services 
330 Independence Avenue, SW 
Washington, DC 20201 
Data Brief: Data on Medicaid Managed Care Payments to Providers Are Incomplete and Inaccurate, 
OEI-02-19-00180  Acknowledgments and Contact | 27   
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1 We based this analysis on managed care claims for the 38 States and the District of Columbia (hereinafter referred to as 
States) with comprehensive, risk-based managed care.  For the purposes of this report, we considered a State to have 
incomplete or inaccurate data if at least 10 percent of claims for its largest managed care plan were incomplete or inaccurate. 
2 These data do not include the capitated payment amounts that the State pays to the managed care plans.  
3 Jennifer L. Gerstorff and Sabrina Gibson, Medicaid Encounter Data:  The Next National Data Set, In the Public Interest, 
September 2016, pp. 614.  Accessed at https://milliman-cdn.azureedge.net/-
/media/milliman/importedfiles/uploadedfiles/insight/2017/medicaid-encounter-data.ashx on July 7, 2020. 
4 The paid amount is the amount that the managed care plan paid the provider and does not include any copayments made by 
the beneficiary or any payments made by a third party. 
5 Note that for each of the States that did not submit any data for its largest plan, we considered 100 percent of the States 
claims to be incomplete. 
6 See CMS, Top Priority Item 16:  Completeness and Consistency of Claim Payment Data Elements, CMS Guidance: Overview 
of Data Quality Top Priority Items.  Accessed at https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-
blog/entry/54044 on November 9, 2020. 
 
7 In sub-capitated or similar value-based arrangements, plans pay their providers in a manner other than per service: e.g., a 
fixed monthly amount for each enrollee.  Currently, there is no method in T-MSIS for identifying instances where plans have 
sub-capitated or value-based payment arrangements with providers.  To account for these arrangements in our analysis, we set 
a generous threshold and considered a State to have incomplete or inaccurate data if at least 10 percent of claims had 
inappropriate zeros, missing data, or negative amounts for the amount paid. 
8 This analysis is based on the amount paid for individual services for outpatient and other services only.  We determined the 
extent to which the 31 States that indicated that their plans pay claims at the individual service levelas opposed to the 
encounter levelhad incomplete or inaccurate data. 
9 This analysis is based on the amount allowed for individual services for outpatient and other services only.  It is based on the 
31 States that indicated that their plans pay claims at the individual service level, as opposed to the encounter level. 
10 For sub-capitated or similar value-based arrangements, the amount billed may include zeros or missing data.  To account for 
these instances in our analysis, we set a generous threshold and considered a State to have incomplete or inaccurate data if at 
least 10 percent of claims had inappropriate zeros, missing data, or negative amounts for the amount billed. 
11 This analysis is based on the amount billed for individual services for outpatient and other services only.  It is based on the 
31 States that indicated that their plans pay claims at the individual service level, as opposed to the encounter level. 
12 CMS, NHE Fact Sheet.  Medicaid spending data current as of 2019.  Accessed at https://www.cms.gov/Research-Statistics-
Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet on March 9, 2021.  See also 
CMS, September 2020 Medicaid & CHIP Enrollment Data Highlights.  Accessed at 
https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html 
on March 9, 2021.   
13 CMS, CMS Guidance: Overview of Data Quality Top Priority Items.  Accessed at https://www.medicaid.gov/medicaid/data-
and-systems/macbis/tmsis/tmsis-blog/entry/54044 on November 9, 2020. 
14 See OIG, National Review of Opioid Prescribing in Medicaid Is Not Yet Possible (OEI-05-18-00480), August 2019.  See also 
OIG, T-MSIS Data Not Yet Available for Overseeing Medicaid (OEI-05-15-00050), June 2017; OIG, Not All States Reported 
 
Data Brief: Data on Medicaid Managed Care Payments to Providers Are Incomplete and Inaccurate,  
OEI-02-19-00180    Endnotes | 28   
Medicaid Managed Care Encounter Data as Required (OEI-07-13-00120), July 2015; GAO, Data Completeness and Accuracy Have 
Improved, Though Not All Standards Have Been Met, GAO-21-196, January 2021. 
 
15 OIG, National Review of Opioid Prescribing in Medicaid Is Not Yet Possible (OEI-05-18-00480), August 2019. 
16 GAO, Data Completeness and Accuracy Have Improved, Though Not All Standards Have Been Met, GAO-21-196, January 2021. 
17 CMS currently does not have a method to identify all the data submitted by a plan if that plan has multiple plan identifiers. 
To do that, CMS needs to be able to link all plan identifiers to each managed care plan.  This would allow CMS and others to 
easily identify data quality issues and program integrity vulnerabilities for individual plans. 
 
18 CMS has the authority to defer or disallow a portion of a States Medicaid funding if the State does not meet all submission 
requirements for managed care data.  See 42 CFR  438.818(c). 
19 The T-MSIS Analytic Files Data Quality State snapshots are available at https://www.medicaid.gov/dq-atlas/welcome. 
20 See CMS, Top Priority Item 16:  Completeness and Consistency of Claim Payment Data Elements, CMS Guidance: Overview 
of Data Quality Top Priority Items.  Accessed at https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-
blog/entry/54044 on November 9, 2020.   
21 Kaiser Family Foundation, Medicaid MCO Enrollment by Plan and Parent Firm, March 2019.  Accessed at 
https://www.kff.org/medicaid/state-indicator/medicaid-mco-enrollment-by-plan-and-parent-firm-march-
2019/?currentTimeframe=0&sortModel=%7B%22colId%22:%22State%22,%22sort%22:%22asc%22%7D on  
September 26, 2019.  We did not include prepaid ambulatory health plans, prepaid inpatient health plans, and Programs of All-
Inclusive Care for the Elderly because these plans either provide a limited range of services or they provide services to a limited 
population. 
22 We identified the largest plan in each State as of October 2019. 
23 For six States, we were unable to identify each States largest managed care plan because these States did not post 
enrollment data on their respective State websites.  We surveyed each of these States to determine their largest plans. 
24 We used the adjudication date to determine when claims were processed for payment.   
25 For our analysis of the payment data, we excluded denied claims and financial transactions (i.e., capitation payments, 
supplemental payments, and service tracking claims).   
26 For the allowed amount, we excluded pharmacy claims because CMS does not expect States to submit allowed amounts for 
these types of claims.   
27 For the analysis on the amount paid, we eliminated the claims that would appropriately have $0 in the amount paid, 
including claims that were denied and claims that may have been paid for by Medicare because the beneficiary had both 
Medicare and Medicaid coverage.  We considered any zeros in the amount paid in the remaining claims over the 10 percent 
threshold to be inappropriate.  In addition, negative paid amounts may occur in rare instances; these payments may indicate 
money owed to the plan by the provider typically as a result of an overpayment on a prior claim.  We considered any negative 
payments over the 10 percent threshold to be inappropriate.  We applied the same 10 percent threshold to the amounts 
allowed and billed.   
Data Brief: Data on Medicaid Managed Care Payments to Providers Are Incomplete and Inaccurate,  
OEI-02-19-00180    Endnotes | 29