HHS-OIG Data Snapshot 
National Review of Opioid Prescribing in  
 
Medicaid Is Not Yet Possible
 
OEI-05-18-00480 
August 2019 
What OIG Did 
Historically, national Medicaid dataa collection of data submitted by all Stateshave 
Key Takeaway 
not been complete, accurate, and timely.  These data have not yet been adequate for 
A national review of 
national analysis and oversight, even though some States data have been sufficient for 
opioid prescribing 
individual State analysis.1  Because of concerns with the quality and completeness of 
in Medicaid using 
the national Medicaid claims databasethe Transformed Medicaid Statistical 
T-MSIS is not yet 
Information System (T-MSIS)we assessed the completeness of variables needed to 
possible because 
monitor national opioid prescribing in Medicaid.  We assessed variables needed to 
not all at-risk 
identify (1) beneficiaries at risk of opioid misuse or overdose (i.e., variables needed to 
beneficiaries and 
calculate beneficiaries total opioid dosage, and diagnosis codes to exclude patients 
providers can be 
for whom higher doses of opioids may be appropriate) and (2) the National Provider 
identified. 
Identifiers (NPIs) of providers that ordered and dispensed opioids (i.e., prescribers and 
 
pharmacies, respectively). 
 
Results  
Limitations of T-MSIS data impede identification  Nineteen States were missing pharmacy or 
of individual beneficiaries for national opioid  prescriber NPImost frequently, pharmacy NPI. 
analysis. 
A given Medicaid beneficiary can have multiple IDs 
within a State (e.g., if he/she disenrolled and later 
re-enrolled) and across States.  (Because Medicaid IDs 
are assigned at the State level, a beneficiary gets 
a new ID if he/she moves to another State.)  If 
a beneficiary has multiple IDs, the prescriptions 
dispensed to those IDs would erroneously appear 
to be for multiple people, not one person.  As 
a result, beneficiaries total opioid dosages would be  NOTE: Three States were missing both types of NPIs. 
undercounted.  Source: OIG analysis of T-MSIS data, 2019. 
Thirty-two States were missing NPI, diagnosis  Examples of reasons States were missing data: 
code, or quantity.    Did not require NPI to be collected 
  Have NPI in their State data but (1) submit it to 
the wrong field or file in T-MSIS or (2) are not 
able to transmit it to T-MSIS because they are 
operating with an outdated system 
  Do not report diagnosis codes for all services 
NOTE: Five States were missing NPI AND diagnosis code.  even though the variable is required 
Source: OIG analysis of T-MSIS data, 2019. 
Data Snapshot can be found at oig.hhs.gov/oei/reports/oei-05-18-00480.asp                1 
  Why This Matters 
Until T-MSIS data are complete in all States and limitations across States are addressed, it will not be possible 
to conduct a national evaluation of Medicaid beneficiaries at risk of opioid misuse or overdose.  According to 
CMS, Medicaid covered over 31 million prescriptions for opioids in 2017.2   
The data we reviewed are critical for nationally quantifying the opioid crisiss impact on Medicaid and for 
monitoring the crisis, as well as for conducting general program integrity efforts across States. 
 Without a unique beneficiary ID, it is not possible to identify all at-risk beneficiaries in need of
opioid-related treatment and to take appropriate action, or to monitor utilization of services to protect
beneficiaries from poorly coordinated care.
 Without a provider NPI, it is not possible to identify all providers who may be overprescribing opioids
and take appropriate action, or to identify providers for investigations of fraud, waste, or abuse.
 Without a diagnosis code, it is not possible to exclude all patients with cancer diagnoses for whom
higher doses of opioids may be appropriate, or to identify patients medical conditions to determine
medical necessity for services.
In August 2018, the Centers for Medicare & Medicaid Services (CMS) announced that all States were 
submitting T-MSIS data, that CMS was prioritizing T-MSIS data quality, and that CMS would have 
research-ready files available in 2019.3  Since then, CMS has been working with States to improve the quality of 
their data submissions, so some States data may have improved since we pulled our data in December 2018.  
Also, in May 2019, CMS added three of the variables we revieweddiagnosis code, drug quantity, and 
pharmacy NPIto its priorities for data quality.4  
What OIG Recommends 
To ensure the identification of at-risk beneficiaries and providers who may be overprescribing, CMS should: 
Work to ensure that individual  Ensure the correct submission of prescriber NPIs 
beneficiaries can be uniquely identified  CMS should prioritize State reporting of prescriber NPIs.  
at a national level using T-MSIS  CMS recently prioritized completeness of pharmacy NPIs, 
but not that of prescriber NPIs. 
CMS should work with States to address 
instances in which a single beneficiary has  CMS concurred with this recommendation and will prioritize 
more than one Medicaid ID within a State.   completeness of prescriber NPIs. 
Additionally, CMS should work to ensure that 
in cases in which a beneficiary was enrolled in 
more than one State over time, claims for 
individual beneficiaries can be linked across 
States.  Clarify requirements for diagnosis codes 
CMS should issue guidance to clarify which services require 
CMS concurred with this recommendation and 
a diagnosis code.  CMS recently prioritized completeness of 
will implement a process to enable IDs to be 
diagnosis codes, but some States are unsure whether 
linked.  CMS will also issue guidance to States 
a diagnosis code is required for all services. 
on assignment and coding of unique IDs, and 
to data users on identification of individual  CMS concurred with this recommendation and will revise 
beneficiaries at the national level.  guidance to clarify requirements. 
Data Snapshot:  National Review of Opioid Prescribing in Medicaid Is Not Yet Possible   2   Data: Percentage missing for each variable, by State 
NOTE: Cells highlighted in blue indicate variables for which 100 percent of the corresponding data were missing.  Cells highlighted in gray indicate 
variables for which the percentage of corresponding data missing was greater than 10 percent but less than 100 percent.   
*We averaged the percentage missing for beneficiary ID across all claims files.
Source: OIG analysis of T-MSIS data, 2019.
Data Snapshot:  National Review of Opioid Prescribing in Medicaid Is Not Yet Possible   3   Methodology 
We asse ssed the completeness of the T-MSIS variables that would be needed to monitor national opioid 
 prescribing in Medicaid: presc ription information, provider NPIs, and diagnosis codes.   
 We did not assess the completeness of the 46 variables that can be used to identify hospice care.
 Review period: We reviewed the December 2018 data for claims with dates of service between
January 2017 and March 2018.
 We categorized variables as missing in a State if the corresponding data fields were blank for more
than 10 percent of the States claims in our review period.
 We excluded certain claims:
o denied claims,
o financial transactions (i.e., capitation payment, supplemental payment, and service tracking
claims), and
o claims in which the variables we selected were not required (e.g., we excluded claims that do not
require a diagnosis code, such as claims for durable medical equipment, laboratory services, and
transportation services)
 We conducted interviews about missing data with 10 States Medicaid officials and T-MSIS staff to find
out why they were missing data.
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. 
Acknowledgments 
Hilary Slover served as the team leader for this study, and Joy Rooney served as the lead analyst.  Others in the 
Office of Evaluation and Inspections who conducted the study include Nicole Hrycyk and Lisa Minich.  Office of 
Evaluation and Inspections staff who provided support include: Clarence Arnold, Randi Hall, Althea Hosein, 
Kevin Manley, Christine Moritz, Kayla Phelps, and Keirsha Thompson.  We would also like to acknowledge the 
contributions of other OIG staff, including Mandy Brooks and Jessica Swanstrom.  This report was prepared 
under the direction of Thomas Komaniecki, Regional Inspector General for Evaluation and Inspections in the 
Chicago regional office, and Laura T. Kordish and Kelly Waldhoff, Deputy Regional Inspectors General. 
To obtain additional information concerning this report or to obtain copies, contact the Office of Public Affairs 
at Public.Affairs@oig.hhs.gov.    
Sources 
1 OIG, Opioids in Ohio Medicaid: Review of Extreme Use and Prescribing, OEI-05-18-00010, July 2018; OIG, Status Update: T-MSIS Data 
Not Yet Available for Overseeing Medicaid, OEI-05-15-00050, June 2017; OIG, Early Outcomes Show Limited Progress for the Transformed 
Medicaid Statistical Information System, OEI-05-12-00610, September 2013; OIG, MSIS Data Usefulness for Detecting Fraud, Waste, and 
Abuse, OEI-04-07-00240, August 2009.  
2 CMS, Medicaid Opioid Prescribing Mapping Tool, April 23, 2019.  Accessed at https://www.cms.gov/Research-Statistics-Data-and-
Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/OpioidMap_Medicaid_State.html on June 14, 2019. 
3 CMS, State Health Official letter SHO # 18-008, August 10, 2018.  Accessed at https://www.medicaid.gov/Federal-Policy-
Guidance/downloads/SHO18008.pdf on February 5, 2019.   
4 CMS, CMS Guidance: Overview of Data Quality Top Priority Items, May 2019.  Accessed at https://www.medicaid.gov/medicaid/data-
and-systems/macbis/tmsis/tmsis-blog/?entry=51423 on May 21, 2019. 
Data Snapshot:  National Review of Opioid Prescribing in Medicaid Is Not Yet Possible   4   Agency Comments 
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