Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
CM  S R R
  EGULARLY  EVIEWS 
 
  P C R
ART    EPORTING 
 
R   D , B
EQUIREMENTS  ATA   UT 
 
I F U
TS  OLLOWUP AND  SE OF 
D A L  
THE  ATA  RE  IMITED 
 
Daniel R. Levinson   
Inspector General  
 
March 2014  
OEI-03-11-00720   
   
EXECUTIVE SUMMARY:  CMS Regularly Reviews Part C Reporting 
Requirements Data, But Its Followup and Use of the Data Are Limited 
OEI-03-11-00720 
 
WHY WE DID THIS STUDY 
 
In 2012, 27 percent of Medicare beneficiaries were enrolled in Medicare Advantage 
(MA) plans. The Centers for Medicare & Medicaid Services (CMS) has collected data 
from MA organizations under the Part C Reporting Requirements since 2009.  These data 
are intended to serve as a resource for CMS to conduct the oversight, monitoring, 
compliance, and auditing activities that are necessary to ensure the quality of benefits that 
MA plans provide to enrollees. CMS contracted with Acumen to review and analyze all 
Part C Reporting Requirements data submitted by MA organizations, identify data issues, 
and notify affected MA organizations. The Part C Reporting Requirements data are a 
significant resource for oversight and improvement of the MA program because they 
pertain to the performance of MA organizations and often are not available to CMS from  
other sources. 
 
HOW WE DID THIS STUDY  
 
We reviewed the extent and types of data issues that Acumen identified for Part C 
Reporting Requirements measures that were active in 2010 and 2011.  We determined the 
steps that Acumen took to identify these data issues and the steps CMS took to address 
them.  We reviewed the extent to which CMS used the Part C Reporting Requirements 
data to monitor and assess MA organizations performance.   
 
WHAT WE FOUND 
 
CMS implemented regular and extensive reviews of the Part C Reporting Requirements 
data, but it conducted minimal followup on data issues identified for 2010 and 2011.  
MA organizations that submitted outlier data values accounted for most of the data issues 
that Acumen identified.  Other issues included inconsistent and overdue data.  CMS did 
not contact any MA organizations to determine whether outliers reflected inaccurate 
reporting or atypical performance, or to ensure that inconsistent data were corrected.  
Despite its investments in contractor reviews of the data, CMS has made limited use of 
the Part C Reporting Requirements data.   
 
WHAT WE RECOMMEND  
 
Our findings indicate that additional effort is needed to ensure appropriate oversight and 
use of these data. We recommend that CMS (1) determine whether outlier data values  
submitted by MA organizations reflect inaccurate reporting or atypical performance, (2) 
use appropriate Part C Reporting Requirements data as part of its reviews of MA 
organizations performance, and (3) establish a timeline for releasing Public Use Files for 
the Part C Reporting Requirements data.  CMS concurred with our recommendations. 
     
   
TABLE OF CONTENTS 
 
Objectives ....................................................................................................1 

Background..................................................................................................1 

Methodology................................................................................................8 

Findings......................................................................................................11 
 
CMS implemented regular and extensive reviews of the Part C 

data, but it conducted minimal followup on data issues identified   

for 2010 and 2011 ..........................................................................11 
 
CMS has made limited use of the Part C data despite its 

investments in contractor reviews of the data ................................14 

Conclusion and Recommendations ............................................................18 

    Agency Comments and Office of Inspector General Response .....19 

Appendixes ................................................................................................21 

A: Descriptions of the Part C Reporting Requirements     

Measures ........................................................................................21 

B: Agency Comments  ...................................................................24 

Acknowledgments......................................................................................27 

 
     
   
OBJECTIVES 
1. 	  To review the number and types of issues with Medicare Advantage 
(MA) organizations submissions of Part C Reporting Requirements 
data and the extent to which the Centers for Medicare & Medicaid 
Services (CMS) addressed these issues.  
2. 	  To review the extent to which CMS has used the data analysis results 
and data validation audit findings for the Part C Reporting 
Requirements data to improve the quality of these data and to review 
the extent to which CMS has used these data to monitor, assess, and 
improve MA organizations performance. 
BACKGROUND 
The Medicare Advantage Program 
Under Medicare Part C, private insurance companies, known as 
MA organizations, contract with CMS to provide coverage of Medicare 
services under managed care arrangements.  MA organizations can offer 
one or more MA plans that provide all Medicare Part A and B services and  
may provide additional services, such as enhanced benefits and Part D 
prescription drug coverage. In 2012, 27 percent of Medicare beneficiaries 
were enrolled in MA plans.1 Of the $537 billion in total Medicare 
expenses in fiscal year 2012, $134 billion was expended under the 
MA program.2      
Part C Reporting Requirements 
Federal regulations at 42 CFR  422.516(a) establish data-reporting 
requirements for MA organizations.  The regulations specify that 
MA organizations must have effective procedures to develop, compile, 
evaluate, and report statistics and other information to CMS, enrollees, 
and the public regarding (1) utilization, accessibility, and acceptability of 
services; (2) enrollee health status; (3) operational costs; and (4) other 
matters CMS may require.  The Part C Reporting Requirements are a 
group of measures that CMS lists in annual technical specifications 
 
1 Kaiser Family Foundation (KFF),  Medicare  Advantage Fact Sheet, November 2012.  
Accessed at http://kff.org/medicare/fact-sheet/medicare-advantage-fact-sheet/ on 
August 29, 2013.   
2 CMS, CMS Financial  Report Fiscal Year 2012, November 2012, p.  5.  Accessed at  
http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-
Reports/CFOReport/ on  April 1, 2013. 
CMSs Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720)       1   
   
documents.3, 4 Beginning January 1, 2009, CMS required MA  
organizations to collect data elements under 13 measures: 
   Benefit Utilization,  
   Procedure Frequency,  
   Serious Reportable Adverse Events (Adverse Events),  
   Provider Network Adequacy, 
   Grievances, 
   Organization Determinations and Reconsiderations, 
   Employer Group Plan Sponsors, 
   Private Fee-for-Service Plan Enrollment Verification Calls, 
   Private Fee-for-Service Provider Payment Dispute Resolution 
Process,  
   Agent Compensation Structure, 
   Agent Training and Testing, 
   Plan Oversight of Agents, and 
   Special Needs Plans Care Management.5   
Appendix A contains descriptions of each of these Part C Reporting 
Requirements measures. 
The measures are each composed of specific data elements that 
MA organizations must report to CMS.  For example, the Adverse Events 
measure is made up of 21 different data elements, including the number of 
surgeries on the wrong body part and the number of surgeries with a 
foreign object left in the patient.  
Some measures are reported at the level of the MA contract (i.e., at the 
level of the MA organizations contract with CMS), and other measures 
are reported at the level of the MA  plan offered under a given contract.6 In 
addition, CMS requires some measures to be reported annually and others 
quarterly.  Not all measures are required to be reported for all plan types. 
 
3 In addition to the Part C Reporting Requirements data, CMS requires MA  organizations 
to report other sets of data, such as the Healthcare Effectiveness Data and Information Set  
and the Medicare Health Outcomes Survey. 
4 CMS now refers to Part C Reporting Requirements measures as reporting sections.   
The term measures was used  during the period of our review.  Therefore, we use this 
term throughout the report. 
5 CMS, Medicare Part C Plan Reporting Requirements Technical Specifications  
Document, April 20, 2009, pp. 57.  

6 CMS, 2011 Medicare Part C Plan Reporting  Requirements Technical Specifications 
 
Document,  December 2011, pp. 78.  Accessed at  http://www.cms.gov/Medicare/Health-
Plans/HealthPlansGenInfo/ReportingRequirements.html on  April 10, 2013. 

CMSs Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720)       2   
   
Throughout this report, we will use the term Part C data to refer to the 
data submitted by MA organizations under the Part C Reporting 
Requirements.  CMS collects and manages these data in the Health Plan 
Management System (HPMS).7  MA organizations can submit their data to 
this system electronically through online data-entry pages and file uploads.  
In 2010, 611 MA contracts submitted Part C data to HPMS.  In 2011, 
575 MA contracts submitted such data.  For both years, all MA  
organizations that were required to submit Part C data eventually did so.  
CMS has suspended reporting requirements for 6 of the original 
13 measures:  Benefit Utilization, Procedure Frequency, Provider Network 
Adequacy, Agent Compensation Structure, Agent Training and Testing, 
and Plan Oversight of Agents.8  Two of these measuresAgent 
Compensation Structure and Agent Training and Testingwere suspended 
after 2009, the first year of Part C reporting.  For all of the suspended 
measures except Plan Oversight of Agents, CMS has indicated that it will 
derive these data from other sources.  For the Plan Oversight of Agents 
measure, CMS plans to revise the set of data elements and resume its 
collection in 2014.9  
Significance of Part C Reporting Requirements Data 
The data collected under the Part C Reporting Requirements pertain to the 
performance of MA organizations and often are not available to CMS 
from other sources.  In a June 2008 Federal Register notice regarding 
Part C data collection, CMS stated that the data will be an integral 
resource for oversight, monitoring, compliance, and auditing activities 
that are necessary to ensure the quality of benefits that MA plans provide 
to enrollees.10    
To obtain the required Federal approval for collecting the Part C data from 
MA organizations, CMS submitted justifications for the Reporting 
Requirements measures.  For example, for the Adverse Events measure, 
CMS indicated that reliable and valid reporting about the occurrence of 
[adverse] events ... is necessary so that the causes of these events can be 
identified and processes of care improved.  For the Grievances measure, 
 
7 The purpose of HPMS is to collect and maintain information on MA and  Part D plans.  
This information includes, but is not limited to, beneficiaries use of services, the MA 
and Part D contractor application process, plan  oversight, and the tracking of complaints 
reported to 1-800-Medicare.  73 Fed. Reg. 2257  (Jan. 14, 2008). 
8 CMS, Medicare Part C Plan Reporting Requirements Technical Specifications  
Document Contract Year  2013, February 13, 2013, p. 2.   Accessed  at 
http://www.cms.gov/Medicare/Health-Plans/HealthPlansGenInfo/ 

ReportingRequirements.html  on April 2, 2013. 

9 Ibid.  

10 73 Fed. Reg. 36329  (June 26, 2008). 

CMSs Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720)       3   
   
CMS stated that it needed these data to determine if there are issues that 
are troubling to enrollees and may adversely affect their privacy, access to 
care, satisfaction with their plan, and the quality of care they are 
receiving.11   
As recently as June 2013, CMS stated that it needs the Part C data to 
respond to questions about beneficiary use of available services, patient 
safety, grievance rates, and other factors pertaining to performance of 
MA plans that could not be answered prior to collection and reporting of 
these data.12  CMS also noted that less frequent collection [of the Part C 
data] would severely limit CMS ability to oversee and monitor 
MA benefits. 
CMS has not included any of the Part C Reporting Requirements measures 
in its calculation of star ratings for MA plans.  (These ratings are posted 
for consumers on the Medicare Plan Finder Web site and used to award 
value-based bonus payments to MA plans.)  However, in April 2013, CMS 
stated that it was considering adding the Special Needs Plans Care 
Management measure to the 2015 ratings.13      
As of May 2013, CMS had posted selected data for the Grievances and 
Special Needs Plans Care Management measures on the Part C and D 
Performance Data page of CMS.gov.  Although CMS indicated that it was 
considering including data related to the Adverse Events measure on the 
CMS.gov page in 2013, it had not posted any such data as of September 
2013.14      
 
11 CMS, Supporting Statement for Paperwork Reduction Act  Submissions:   Part C  
Medicare Advantage Reporting Requirements and Supporting Regulations in  42 CFR 
 422.516(a), November 17, 2008, pp. 5 and 8.  Accessed at  
http://www.reginfo.gov/public/do/PRAViewDocument?ref_nbr=200810-0938-009 on  
July 23, 2013. 
12 CMS, Supporting Statement for Paperwork Reduction Act  Submission:  Part C  
Medicare Advantage Reporting Requirements and Supporting Regulations in  42 CFR 
 422.516(a), CMS-10261, June 21, 2013, pp. 78.   Accessed at 
http://www.cms.gov/Regulations-and-
Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing.html on July 18, 
2013. 
13 CMS,  Announcement of Calendar Year (CY) 2014 Medicare Advantage Capitation Rates 
and Medicare Advantage and Part D Payment Policies and Final Call Letter, April 1, 2013, 
p. 110. Accessed at http://www.cms.gov/Medicare/Health-
Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2014.pdf on June 27, 2013. 
14 CMS,  Announcement of Calendar Year (CY) 2013 Medicare Advantage Capitation Rates 
and Medicare Advantage and Part D Payment Policies and Final Call Letter, April 2, 2012, 
p. 83.  Accessed at http://www.cms.gov/medicare/health-
plans/healthplansgeninfo/downloads/2013-call-letter.pdf on April 24, 2013. 
CMSs Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720)       4   
   
Analysis of Part C Reporting Requirements Data 
CMS contracted with Acumen to validate, prepare, and analyze Medicare 
Parts C and D Reporting Requirements data  that MA contracts began to 
report in 2009.15 CMS intended for the services provided under the 
Acumen contract to (1) enable it to monitor and measure the compliance 
of MA organizations with Federal regulations and (2) help it to ensure that  
beneficiaries receive quality care. CMS paid Acumen $242,583 to 
perform these services in 2012. 
Some of the tasks that CMS specified in Acumens Statement of Work 
were: 
   monitoring the completeness of MA contracts submissions of 
Part C data, 
 	  identifying MA contracts that are potential outliers or may have 
submitted inconsistent data for selected Part C Reporting 
Requirements measures, 
 	  performing quantitative analysis of submitted data, and 
 	  creating Public Use Files for the Part C data.  
Since 2009, Acumen has downloaded Part C data from HPMS and 
reviewed all MA contracts data submissions.  For each reporting period,  
Acumen created methodology documents describing how it reviewed the 
Part C data. Acumen identified MA  contracts that did not submit data by 
the due date, submitted data that contained placeholders, submitted data 
that were inconsistent, or submitted outlier data values.16  Acumen sent 
email and Web notifications to these MA contracts.  Before sending these 
notifications, Acumen provided lists of the MA contracts to CMS for 
review and approval. CMS has not required Acumen to determine, on a 
regular basis, whether MA contracts resubmitted their data in response to 
the notifications or to follow up with MA contracts regarding identified 
data issues. Table 1 on the following page lists the data reviews that CMS 
required Acumen to perform for each Part C Reporting Requirements 
measure for 2010 and 2011. 
 
15 CMS, Statement of  Work for  Contract GS-10F-0133S, Task Order 
HHSM-500-2008-00428G, September 16, 2008.   
16 An MA contract is considered to have submitted Part C data that contain placeholders 
if it submitted values of zero for two  or more measures in a single reporting period.  An  
MA contract submitted inconsistent data if it submitted data values for a measure that 
contradict one  another.  For example, data submitted by an MA contract for the Plan  
Oversight of Agents measure would be inconsistent if the number of sales agents 
investigated  on the basis of complaints exceeded the total number of sales agents for that 
MA contract.  An outlier data value is an individual data value that falls outside a 
specified range of reported  values, or  falls above or  below a predetermined benchmark 
value.  
CMSs Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720)       5   
   
Since 2010, Acumen has provided CMS with annual reports of the results 
of its quantitative analyses of the Part C data submitted by MA contracts.  
These reports include a descriptive summary of the data submitted for 
each measure, including ranges and means; analyses of the data by data 
element and type of MA contract; and characteristics of MA contracts with 
outlier data values. Acumen has also produced ad hoc reports at CMSs 
request, including reports that summarize the data submitted for specific 
measures, focus on data submitted by selected MA contracts, and identify  
data trends across multiple years.  
 
Table 1: Data Reviews Performed by  Acumen on Part C Reporting Requirements for 2010 
and 2011  
Measure   Measure   Measure   Measure  
Reviewed for   Reviewed for   Reviewed for   Reviewed for  
Measure  
Overdue  Placeholder  Inconsistent  Outlier Data 
Data   Data   Data    Values 
Benefit Utilization   1   1     1  
Procedure Frequency   
Adverse Events  2 
Provider Network Adequacy 
 
Grievances    
Organization Determinations 
       
and Reconsiderations  
Employer Group Plan 
       
Sponsors  
Private Fee-for-Service Plan    1    1  
Enrollment Verification Calls 
Private Fee-for-Service 
Provider Payment Dispute    1    1  
Resolution Process 
Plan Oversight of Agents 
Special Needs Plans Care 
    2    
Management  
Source: Office of Inspector General (OIG) review  of Part C Reporting Requirements Methodology Documents provided by 
 
Acumen. 

1 Measure reviewed for 2010 only.  CMS suspended the Benefit Utilization measure after 2010.  Acumen did not review the 

Private Fee-for-Service measures for placeholder data or outlier data values for 2011; CMS specified that these measures 

would be used for monitoring only.
  
2 Measure reviewed for 2011 only.  Acumen did not review  the Adverse Events and Special Needs Plans Care Management 

measures for inconsistent data for 2010.
  
CMSs Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720)       6   
   
Beginning in September 2010, CMS added a plan-monitoring task to 
Acumens contract.  This requires Acumen to create performance metrics 
for MA organizations using Part C data related to access to care and 
quality of care. As specified in the Statement of Work, the purpose of this 
task is to help CMS proactively identify MA organizations with potential 
program compliance issues.  In January 2012, Acumen provided CMS 
with performance scores for 548 MA contracts on the basis of the Part C  
data submitted for 2010. 
Data Validation Audits of Part C Reporting Requirements Data 
In 2010, CMS amended 42 CFR  422.516 to state that each MA contract 
is subject to an independent yearly audit of data submitted for the Part C 
Reporting Requirements.  The audits were designed to uncover 
deficiencies in MA contracts reporting practices and to verify that the 
Part C data values that MA contracts submit to CMS are supported by 
documentation and data files.  As part of the rationale for this amendment, 
CMS specified that the retrospective data validation audits will focus on 
how each MA organization collects, reports, and stores its data; takes into 
account appropriate data exclusions; and verifies its calculations.17    
CMS requires all MA contracts to hire an independent, external entity to 
perform the required audits.  These data validation auditors conduct the 
audits for selected Part C Reporting Requirements measures in accordance 
with procedures and standards developed by CMS.18, 19  Auditors may 
review either a sample or all of the Part C data reported for an 
MA contract, in addition to policies, procedures, and source documents.  A  
data validation audit of an MA contract does not take into account the data 
issues that Acumen identified for that contract.   
CMS assigns a score to each MA contract on the basis of the audit 
findings. CMS establishes an overall score threshold that it uses to 
determine whether an MA contract receives a Pass (for a score that 
meets or exceeds the threshold) or a Not Pass (for a score that falls 
 
17  75  Fed.  Reg. 19678, 1976019761 (April 15, 2010). 

18 For 2011, the first year of data validation audits, CMS included  data elements under 

five of the Part C Reporting Requirements measures:  Provider Network Adequacy, 

Grievances, Organization Determinations and Reconsiderations, Employer Group Plan
  
Sponsors, and  Plan  Oversight of Agents.  CMS, Medicare  Part C and Part D Reporting 

Requirements Data Validation Procedure Manual, December 2010, p. 3. 
  
19 For the 2012 audits, CMS added data elements under three additional Part C Reporting 
 
Requirements measures:  Procedure Frequency,  Adverse Events, and Special Needs Plans 

Care Management.  CMS,  Medicare  Part  C and Part D Reporting  Requirements  Data
  
Validation Procedure Manual, Version 2.0:  December 2011, p. 3.  Accessed at 

http://www.cms.gov/Medicare/Prescription-Drug-
Coverage/PrescriptionDrugCovContra/Downloads/DVProcedureManualVer2.pdf on 
  
June 26, 2013. 

CMSs Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720)       7   
   
below the threshold).20  For the audits performed in 2011, the score 
threshold was 70 percent.  For the audits performed in 2012, CMS raised 
the score threshold to 90 percent. CMS issues a report to all MA contracts 
to notify them of their audit scores.  CMS requires any MA contract that 
scored below the threshold to submit a corrective action plan.   
METHODOLOGY 
Scope 
We reviewed the extent and types of issues with Part C data that Acumen 
identified for measures that were active in 2010 and 2011.  We determined 
the steps that  Acumen took to identify these data issues and the steps that 
CMS took to address them.  We reviewed how CMS has used the Part C 
data; the analyses and reports provided by Acumen; and the results of the 
data validation audits to monitor and assess MA organizations  
performance.   
We excluded demonstration and cost contracts from our review.  We also 
did not include in our analysis any data issues related to the Benefit 
Utilization measure, as CMS suspended collection of data for this measure 
for the 2011 reporting period.  In addition, we did not include in our 
review of outlier issues the measures Private Fee-for-Service Plan 
Enrollment Verification Calls or Private Fee-for-Service Provider Payment 
Dispute Resolution Process because  Acumen calculated outlier issues for 
these two measures for the 2010 reporting period, but not for 2011.   
Data Collection 
Acumen.  We requested that Acumen provide spreadsheet files containing 
all Part C data issues that it identified for reporting periods in 2010 and 
2011.21  We asked Acumen to include in these files all of the information it 
had provided to CMS regarding the data issues, such as the MA contract 
name, the contract number, the reporting period, the reporting measure, 
the submission due date, and the data issue identified.  We also asked 
Acumen to include the dates when CMS approved sending notices 
regarding data issues and the dates when Acumen issued the notices to the 
MA contracts.  We asked Acumen to provide the methodology documents 
it created for its analyses of 2010 and 2011 Part C data.   
 
20 CMS, Medicare Part C and Part D Reporting Requirements Data Validation  
Procedure Manual, Appendix  K:  Pass/Not Pass Determination  Methodology  
Version 2.0, p. 1. Accessed at http://www.cms.gov/Medicare/Prescription-Drug-
Coverage/PrescriptionDrugCovContra/PartCDDataValidation.html on April  11, 2013.  
21 Acumen identified MA contracts that did  not submit data by the due date, submitted  
data that contained placeholders, submitted inconsistent  data, or submitted outlier data 
values.  
CMSs Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720)       8   
   
We requested that Acumen complete a survey about its processes for 
reviewing and analyzing data, and about its interactions with CMS 
regarding MA contracts/plans that did not submit data by the due date, 
submitted data that contained placeholders, submitted inconsistent data, or  
submitted outlier data values.  We asked Acumen to provide  
documentation to support its survey responses.   
CMS.  We collected data from CMSs Medicare Drug Benefit and C and D 
Data Group within its Center for Medicare.  We sent CMS the spreadsheet 
files that  Acumen provided to us and asked CMS for additional 
information for each data issue listed in the spreadsheet.  Specifically, we  
asked CMS whether it had contacted the MA contract about the data issue, 
and if so, how many times; how the MA contract responded; and whether 
the MA contract had addressed the data issue.  We also asked CMS 
whether it had collected supporting documentation from the MA contract 
to confirm that the original Part C data that the MA contract had submitted 
had either been accurate or had been corrected and resubmitted.  If CMS 
did not contact the MA contract about the data issue that  Acumen 
identified, we asked CMS why it did not do so.   
We surveyed CMS about its review of information that Acumen provided, 
its processes and actions with regard to the data issues that Acumen 
identified, and its use of reports on the Part C Reporting Requirements 
data that Acumen provided.  We inquired about CMSs use of the results 
of the Part C Reporting Requirements data validation audits.  We also 
inquired about CMSs use of the Part C data to monitor and assess 
MA organizations performance.  We asked CMS to provide 
documentation to support its survey responses.   
Analysis    
We reviewed and summarized Acumens survey responses and supporting 
documentation regarding its processes and interactions with CMS 
concerning Part C data issues.  We reviewed and summarized CMSs 
survey responses and supporting documentation regarding its review and 
use of the information provided by Acumen, its use of data validation 
audit results, and its use of the Part C data to evaluate MA contracts  
performance. 
We reviewed the spreadsheet files that Acumen provided and summarized 
the number of data issues it identified for 2010 and 2011.  We grouped the 
data issues by type and calculated the total number of issues of each type 
and for each Part C measure.  We analyzed the data issues by MA contract 
and determined whether an MA contract had the same type of issue for 
multiple measures.  We also determined whether an MA contract had data  
issues with the same measure for both 2010 and 2011.   
CMSs Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720)       9   
   
We reviewed the additional information that CMS provided for each data 
issue in the spreadsheet files.  We summarized the numbers and types of 
data issues for which CMS contacted MA contracts.  We also summarized 
the actions that CMS took in response to these data issues. 
Limitations 
We did not validate Acumens analyses of submissions of 2010 and 2011 
Part C data. We did not contact MA contracts about the Part C data issues 
that Acumen identified for 2010 and 2011.  We did not evaluate the quality 
or sufficiency of the data validation audits and did not validate the audit 
results provided to CMS. We also did not verify the survey responses that 
CMS and Acumen provided.  
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency. 
   
CMSs Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720)       10   
   
FINDINGS 
CMS implemented regular and extensive reviews of 
the Part C data, but it conducted minimal followup on 
data issues identified for 2010 and 2011    
CMS requires Acumen to conduct thorough reviews and analyses of all 
Part C data submitted by MA contracts.  CMS designed these reviews to 
identify MA contracts that did not submit data by the due date, submitted 
data that contained placeholders, submitted data that were inconsistent, or  
submitted outlier data values.  Acumen has performed the required 
reviews and supplied both CMS and MA contracts with information about 
the data issues it identified.  Acumen has also provided CMS with Part C 
data analysis reports and performance metrics for MA contracts. 
For 2010 and 2011, 638 MA contracts submitted Part C data to CMS. 
Acumen identified 2,134 data issues across 513 of these 
638 MA contracts. Acumen provided CMS with information about each 
data issue it identified before notifying the MA contracts on CMSs behalf.  
Specifically, the data issues included 1,904 outlier incidents, 147 incidents 
of overdue data, 50 incidents of inconsistent data, and 33 incidents of 
placeholder data.22  
CMS did not contact any MA organizations to determine the cause of the 
outlier data values identified by Acumen or to ensure that inconsistent data 
were corrected. CMS also did not follow up with MA organizations to 
address data submitted with placeholder values.  CMS has not required 
Acumen to conduct these types of followup activities.   
CMS followed up with MA organizations only regarding overdue Part C 
data. Specifically, CMS issued noncompliance notices to four 
MA contracts for eight incidents of overdue data.  These incidents made 
up less than 1 percent (8 of 2,134) of all data issues that Acumen identified 
for 2010 and 2011. 
   
 
22 For explanations of the terms outlier data, inconsistent  data, and placeholder 
data, see footnote 16.  
CMSs Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720)       11   
   
Many MA contracts received notices about submissions of 
outlier data, but CMS did not determine whether outliers 
reflected inaccurate reporting or atypical performance  
Of the 513 MA contracts with data issues, 490 submitted Part C data that 
contained outliers. Specifically, Acumen identified 1,904 outlier data 
values across 7 Part C Reporting Requirements measures for 2010 and 
2011, using indicators that it calculated for each of the 7 measures.23 For 
example, Acumen calculated an indicator for the Grievances measure 
equal to the number of reported grievances per 1,000 MA plan enrollees.  
Acumen used the indicator data to identify MA plans that submitted values  
that were below the 5th percentile or above the 95th percentile. Table 2 
lists the Part C Reporting Requirements measures that Acumen reviewed 
for outlier data values, the number of outlier data values that it identified 
for these measures for 2010 and 2011, and the number of outlier indicators 
that it calculated for each measure.   As shown in Table 2, Acumen 
identified far fewer outlier data values for the Organization 
Determinations and Reconsiderations measure in 2011 than in 2010.  This 
reduction accounted for a 40-percent drop in the total number of outlier 
data values from 2010 to 2011.   
Table 2: Part C Reporting Requirements Measures Reviewed for Outlier Data Values, 2010 and 2011  
Number of  Number of  Total Number  Number of 
Reporting  Outlier Values   Outlier Values   of Outlier  Calculated 
Measure  
Frequency   in Reporting  in Reporting  Values for  Outlier 
Year 2010   Year 2011   2010 and 2011  Indicators 
Organization Determinations 
Quarterly  894  365  1,259  41 
and Reconsiderations  
Grievances  Quarterly  151  177  328  1 
Plan Oversight of Agents  Annual   68  72  140  1 
Provider Network Adequacy  Annual   32  13  45  3 
Adverse Events   Annual   29  28  57  2 
Procedure Frequency  Annual   21  23  44  1 
Special Needs Plans Care 
Annual   19  12  31  2
Management  
     Total  1,214  690  1,904  
Source: OIG analysis of Part C Reporting Requirements data files and Methodology Documents that Acumen provided. 
1 Acumen calculated five outlier indicators for the 4th quarter 2011 data submitted for the Organization Determinations and Reconsiderations 
measure.  
 
23 For the 2010 and 2011 reporting  periods, Acumen calculated  outlier data values for the 
measures Procedure Frequency; Adverse Events;  Provider Network Adequacy;  
Grievances; Organization Determinations and Reconsiderations; Plan Oversight  of  
Agents; and Special Needs Plans Care Management. 
CMSs Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720)       12   
   
Acumen notified all of the MA contracts that they had submitted outlier 
data values and requested that they review the data to confirm their 
accuracy.  However, CMS did not contact any of these MA contracts to 
gather more information about these outliers.  Therefore, CMS did not 
determine whether the outliers reflected inaccurate reporting or atypical 
performance. 
In the preamble to an April 2010 final rule regarding policy and technical 
changes to the Part C and Part D programs, CMS stated that analyzing 
reported data for outliers identifies potential noncompliance and the need 
for further investigation and is a valuable tool to monitor and compare 
contracting organizations in a timely and effective manner.24 In response 
to the Office of Inspector Generals (OIG) inquiry as to whether CMS had 
contacted MA contracts that submitted outlier data, CMS staff stated:  
[A]n outlier doesnt mean [an MA contract] submitted inaccurate 
data. As a result, outlier data do not trigger any action except that 
plans/contracts are contacted and informed that they have 
submitted outliers and that they should verify/review their data 
submission.25    
CMS did not require MA contracts to respond to Acumens outlier notices 
or to provide any documentation that they verified the accuracy of their 
data. In addition, CMS did not require Acumen to check for 
resubmissions of Part C data in HPMS or to follow up with MA contracts 
to inquire about outlier data values. 
MA contracts submitted outlier values for successive years and multiple 
Part C Reporting Requirements measures. Acumen determined that 
490 MA contracts had submitted data that contained outliers for 2010 and 
2011.  Twenty-two percent of the 490 MA contracts (110 of 490) 
submitted such data for the same Reporting Requirements measure in both 
2010 and 2011.   
Forty percent of the 490 MA contracts (198 of 490) submitted data that 
contained outlier values for two or more Part C Reporting Requirements 
measures during the 2-year review period.  Of these 198 MA contracts, 
56 submitted outlier data values for three or more measures, including 
3 contracts that submitted outlier data values for 5 of the 7 Part C 
Reporting Requirements measures.   
   
 
24 75 Fed. Reg. 1968619687  (April 15, 2010). 

25 CMS, response to OIG survey:  Medicare Advantage Organizations Part C Reporting 
 
Requirements, January 2013. 

CMSs Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720)       13   
   
CMS did not follow up to ensure that inconsistent data 
identified by its contractor were corrected   
Acumen conducted consistency checks on data submitted for four of the 
Part C Reporting Requirements measures it reviewed.  Data submitted for  
two of these measuresProvider Network Adequacy and Special Needs 
Plans Care Managementcontained inconsistencies.  For data submitted 
in 2010 and 2011, Acumen identified 50 instances of inconsistent data 
values for 41 MA contracts.  Acumen notified these MA  contracts of the 
inconsistent data. However, CMS did not contact the MA contracts to 
confirm that the issues were corrected or to determine why the issues 
occurred. In addition, CMS has not required Acumen to track whether an 
MA contract resubmits Part C data in HPMS in response to notices of 
inconsistent data.   
Ten of the forty-one MA contracts were identified as having inconsistent 
data for the Special Needs Plans Care Management measure.  Acumen 
routinely performs two consistency checks of data submitted for this 
measure.  For example, Acumen reviews the data to ensure that the 
number of new Special Needs Plans enrollees receiving an initial 
assessment does not exceed the total number of new enrollees reported.  
Acumen sent spreadsheet reports to CMS listing the inconsistent data it 
identified for this measure for 2011 and received approval from CMS to 
notify the 10 MA contracts that submitted these data.  When OIG 
requested specific information from CMS on Part C data issues, CMS 
responded that it believed HPMS had already been rejecting submissions 
with inconsistent data. In January 2013, during the course of OIGs 
review, CMS submitted a Change Request to modify HPMS to prevent the 
submission of Special Needs Plans Care Management data that would fail 
the two consistency checks. 
Thirty-one MA contracts were identified as having inconsistent data for 
the Provider Network Adequacy measure.  For one of the two consistency 
checks of the data for this measure, Acumen determines whether the 
number of specialists participating in the network for the entire plan year 
exceeds the number of specialists participating at the start of the plan year.   
One of the thirty-one contracts was identified as having the same  
inconsistency in both 2010 and 2011.   
CMS has made limited use of the Part C data despite 
its investments in contractor reviews of the data 
CMS has contracted with Acumen to review, analyze, and report on the 
Part C data, but CMS has not used these data or the analyses that Acumen 
generated to review MA contracts performance.  Since 2010, CMS has 
CMSs Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720)       14   
   
required that each MA contract undergo an independent yearly audit of 
data submitted for the Part C Reporting Requirements.  Most 
MA organizations have scored well on these audits.  Although CMS has 
used the Part C data to respond to inquiries, it has not yet released these 
data to the public, as specified in Acumens Statement of Work. 
CMS has not used the quantitative analyses of Part C data that 
Acumen produced to review MA contracts performance 
CMS has indicated that it reviews the quantitative analysis reports that 
Acumen created, which include outlier analyses.  Acumen has also 
calculated performance scores for MA contracts at CMSs request.26   
However, CMS has not used this information to inform the selection of  
MA contracts for audits or to issue compliance notices to MA contracts for 
performance concerns. 
Part C regulations specify that CMS has the authority to find an 
MA organization out of compliance with contract requirements when the 
organizations performance represents an outlier relative to the 
performance of peer organizations.27  More than 500 MA contracts have 
submitted Part C data for each reporting period since 2009.  However, in 
response to OIGs inquiry, CMS staff stated that a limitation in using the 
Part C data to monitor and assess MA contracts performance is that there 
is little comparative data available for [the Part C Reporting Requirements 
measures] ... to establish benchmarks for good or poor performance. 
CMS also stated that it did not use the Part C data to assess 
MA organizations continued participation in the MA program because 
there are factors much larger than just Part C Reporting Requirements 
data on which to base decisions about program participation.  
MA contracts scored well on the data validation audits that 
CMS required 
Only 3 percent of MA contracts failed to pass their independent data 
validation audits for 2010 and 2011. Data validation audits for the Part C 
Reporting Requirements were first required in 2011 to review individual 
MA contracts 2010 data submissions for five measures.  For each 
MA contract, these retrospective audits were designed to uncover 
deficiencies in reporting practices and verify that the Part C data values 
submitted to CMS are supported by documentation and data files.   
 
26 Acumen calculated performance scores for all MA contracts that passed the data 
validation audits.  For each MA contract, Acumen calculated performance scores for 
indicators for three Part C Reporting Requirements measures as well as a composite 
performance score.    
27 42 CFR   422.504(m)(2).  
CMSs Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720)       15   
   
For 2010 and 2011, CMS required any MA contract that failed to pass its 
data validation audit to submit a corrective action plan.  However, CMS 
did not require MA contracts to submit any documentation to confirm that 
they resolved the issues that the audits had identified. 
In fall 2012, CMS performed a limited review of data validation 
workpapers to ensure that the audits were meeting their goal of improving 
the accuracy and validity of the Part C data.28 The only finding of this 
workpaper analysis was that some data validation auditors started their 
audit activities before the specified review period.  CMS concluded that 
the audits were meeting the initial goal of data validation. 
CMS used the Part C data to respond to a small number of 
inquiries, but it has not released the data to the public as 
intended 
In published program documents, CMS has stated that it uses the Part C 
data to respond to inquiries from  Congress, oversight agencies, and the 
public regarding MA organizations performance.29 CMS has used the 
Part C data reported for two measures to respond to two specific inquiries.   
CMS received a complaint about one MA organizations Special Needs 
Plansspecifically, about the performance of initial and annual health risk 
assessments.  CMS analyzed data for the Special Needs Plans Care 
Management measure for 2010.  CMSs analysis confirmed that the 
MA organization in question reported performing health risk assessments 
for only 22.6 percent of new enrollees in 2010, which was significantly 
below the average of 47.2 percent for all MA Special Needs Plans.  CMS 
requested that the MA organization confirm the accuracy or inaccuracy 
of the numbers reported for the Special Needs Plans Care Management 
measure and explain the low numbers of health risk assessments that the 
organization reported having performed.   
In another inquiry, the Government Accountability Office (GAO) asked 
CMS about actions the agency had taken in response to a recommendation 
in a December 2008 GAO report.  GAO recommended that CMS 
investigate the extent to which beneficiaries in private fee-for-service 
 
28 CMS requested 2012  data validation workpapers for three MA contracts to conduct a 
workpaper analysis.  Workpapers were requested for one Part C Reporting Requirements 
measure and four Part D Reporting Requirements measures. 
29 CMS, Medicare Part C and Part D Reporting Requirements Data Validation  
Procedure Manual, Version 2.0:  December 2011, p. 1.  Accessed at 
http://www.cms.gov/Medicare/Prescription-Drug-
Coverage/PrescriptionDrugCovContra/Downloads/DVProcedureManualVer2.pdf on   
June 26, 2013.  
CMSs Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720)       16   
   
plans face unexpected costs.30 In response to GAOs inquiry, CMS 
reported that it analyzed the data that MA plans submitted for the 
Organization Determinations and Reconsiderations measure for 
2009 and 2010. CMS compared the data submitted by private 
fee-for-service plans to the data submitted by other types of MA plans.   
CMSs analysis determined that private fee-for-service plans were not 
outliers compared to other types of MA plans for the numbers of 
determinations and reconsiderations reported for 2009.  However, for 
2010, CMS found that private fee-for-service plans generally had lower 
rates of decisions that were favorable and partially favorable to the 
beneficiary compared to other types of MA plans.   
CMS has not decided when Part C Reporting Requirements Public Use 
Files (PUFs) will be created or released to the public.  In Acumens 
Statement of Work, CMS stated that one purpose of the contract was to 
create Part C Reporting  Requirements PUFs.  CMS indicated that Acumen 
should create the PUFs quarterly, using final Part C data, beginning in 
August 2009. CMS also specified that the files should be 
consumer-friendly and should be posted on CMSs Web site with a link to 
Data.gov. As of January 2013, CMS indicated that it had not required 
Acumen to create PUFs because the Part C data were too new.  As of 
May 2013, CMS had posted selected data for two measuresGrievances 
and Special Needs Plans Care Managementon CMS.govs Part C 
and D Performance Data page. 
   
 
30 GAO,  Medicare Advantage Characteristics, Financial Risks, and Disenrollment Rates  
of Beneficiaries in Private Fee-for-Service Plans, GAO-09-25, December 2008.  
Accessed at http://www.gao.gov/assets/290/284340.pdf on  April 9, 2013. 
CMSs Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720)       17   
   
CONCLUSION AND RECOMMENDATIONS 
In 2012, 27 percent of Medicare beneficiaries were enrolled in MA plans.  
The data collected under the Part C Reporting Requirements pertain to the 
performance of MA organizations and often are not available to CMS 
from other sources. 
CMS implemented an extensive plan to ensure that MA contracts Part C 
data submissions are reviewed and that data issues are uncovered.  CMSs 
contractor, Acumen, has consistently notified both CMS and 
MA organizations regarding these data issues.  However, CMS has not 
required Acumen to follow up with MA organizations to determine the 
reasons for the data issues that Acumen has identified. 
For 2010 and 2011, Acumen identified 2,134 data issues with 
MA organizations Part C data submissions.  In response, CMS issued 
noncompliance notices to four MA contracts for eight incidents of overdue 
data, but did not follow up with any other MA contracts to determine the 
causes of the data issues or to ensure that the issues were addressed.  
Specifically, CMS did not determine whether outlier data values reflected 
inaccurate reporting or atypical performance and did not ensure that 
inconsistent data were corrected.  
CMS has required that Acumen and independent auditing firms play key 
roles in the review and analysis of the Part C data.  However, CMS has 
made limited use of the Part C data despite its investments in these 
contractors reviews.  CMS has not used the Part C data as part of its 
reviews of MA organizations performance, nor has it made public all of 
the data as intended. 
Our findings indicate that additional effort is needed to ensure that 
identified data issues are investigated and addressed, that the data are 
considered in reviews of MA contracts performance, and that the data are 
publicly available.    
We recommend that CMS: 
Determine whether outlier data values submitted by  
MA contracts reflect inaccurate reporting or atypical 
performance 
CMS has contracted with Acumen to provide regular review and analysis 
of the Part C data submitted by MA contracts.  Although having outlier 
data values does not necessarily indicate that an MA contract is a poor 
performer, MA contracts that repeatedly submit data that contain outliers 
may be reporting or performing differently than their counterparts.  It is 
important that CMS communicate with MA contracts to determine the 
CMSs Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720)       18   
   
nature of outlier data values and to ensure that reporting errors or 
performance issues are addressed. 
Use appropriate Part C data as part of its reviews of 
MA contracts performance 
CMS has invested in contractor reviews to ensure the completeness, 
accuracy, and validity of the Part C data.  These data provide insight into 
how an MA organization is providing services to Medicare beneficiaries.  
OIG understands that CMS considers many factors in its assessment of an 
MA contracts performance.  However, data for the Part C Reporting 
Requirements measures are not collected through other means and may be 
an important source of information for MA contract oversight.   
Establish a timeline for releasing the Part C Reporting 
Requirements PUFs 
CMS specified its intent to create Part C Reporting Requirements PUFs 
in 2009. OIG understands that CMS is reluctant to publicly release data 
before they have been properly reviewed and validated.  However, the 
Part C data have been reviewed by Acumen since 2009 and have 
undergone 2 years of independent validation audits.  Using the 
information that Acumen regularly provides along with the results of data 
validation audits, CMS should be able to determine a timeline for 
releasing these data to the public.  
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
CMS concurred with all of OIGs recommendations.  In its comments on 
the draft report, CMS acknowledged that the Part C Reporting 
Requirements data are an important source of information...about 
beneficiary use of available services, patient safety, grievance rates, and 
other factors pertaining to the performance of Medicare Advantage plans 
that [was not available] prior to collection and reporting of these data. 
CMS concurred with our first recommendation, stating that it can do more 
to determine whether outlier data values submitted by MA organizations 
reflect inaccurate reporting or atypical performance.  CMS stated that it 
will require MA organizations with outlier data to report to CMS whether  
these data were reported inaccurately or reflect atypical performance.  For 
inaccurate data, CMS will continue to require MA organizations to correct 
and resubmit these data.  For data that an MA organization confirms are 
accurate, CMS stated that it will follow up with the MA organization if the 
data indicate potential problems in performance or for patient safety.   
CMSs Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720)       19   
   
CMS concurred with our second recommendation. CMS acknowledged 
that the Part C data have typically not been leveraged enough in CMS 
components reviews of MA organizations.  CMS stated that it will send 
the annual reports and appropriate ad hoc reports prepared by Acumen to 
all group and division directors involved in reviews of MA organizations.  
CMS will request that the directors indicate the usefulness of these Part C 
data reports every time the reports are issued. 
CMS concurred with our third recommendation.  CMS stated that it will 
begin releasing PUFs for the Part C Grievances and Special Needs Plans  
Care Management data in the second quarter of 2014.  CMS stated that 
additional PUFs for the Part C reporting sections will be made available 
as the data achieve a degree of reporting reliability and validity that CMS 
considers appropriate for public reporting. 
The full text of CMSs comments is provided in Appendix B. 
   
CMSs Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720)       20   
   
APPENDIX A 
Descriptions of the Part C Reporting Requirements 
Measures 
The Part C Reporting Requirements measures described here are the 
original 13 measures established by CMS. 
Benefit Utilization  
This measure was composed of 138 data elements reported by 
MA contracts, including utilization, payment, and cost-sharing 
information for different types of Part A and Part B services.  MA  
contracts reported this measure annually for each MA plan.  CMS 
suspended data collection for this measure after 2010. 
Procedure Frequency 
This measure was composed of 23 data elements reported by 
MA contracts regarding the number of unique enrollees who received 
specific medical procedures, such as cardiac catheterizations, joint 
replacements, and organ transplants.  MA contracts reported this measure 
annually.  CMS suspended data collection for this measure after 2012. 
Serious Reportable Adverse Events 
This measure is composed of 21 data elements reported by MA contracts 
regarding the number of specific types of adverse events and 
hospital-acquired conditions that occurred in acute-care hospitals or after 
discharge from acute-care hospitals.  Examples include the number of 
surgeries on the wrong body part, the number of surgeries with a foreign 
object left in the patient, and the number of catheter-associated urinary 
tract infections. MA contracts report this measure annually. 
Provider Network Adequacy 
This measure was composed of 96 data elements reported by 
MA contracts regarding the number of different types of providers that 
were in the MA contracts network during the reporting period.  Examples  
include the number of primary care internal medicine physicians in the 
network on the first day of the reporting period and the number of 
cardiologists accepting new patients at the start of the reporting period.  
MA contracts reported this measure annually.  CMS suspended data 
collection for this measure after 2012. 
   
CMSs Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720)       21   
   
Grievances 
This measure is composed of seven data elements reported by 
MA contracts regarding the number of different types of grievances filed 
by enrollees and completed during the reporting period.  MA contracts 
report this measure quarterly for each MA plan.  
Organization Determinations and Reconsiderations 
This measure is composed of six data elements reported by MA contracts 
regarding the number and type of determinations made in response to 
enrollee requests for coverage of items or services, and the number and 
type of reconsiderations resulting from MA contracts reviews of 
determinations.  MA contracts report this measure quarterly. 
Employer Group Plan Sponsors 
This measure is composed of nine data elements reported by 
MA contracts. For each MA plan, MA contracts report information about 
the employer groups that have arrangements with the plan to provide 
health benefits to their group members.  This measure is reported 
annually. 
Private Fee-For-Service Plan Enrollment Verification Calls 
This measure is composed of three data elements reported by private 
fee-for-service MA contracts regarding the number of telephone contacts 
made and educational letters sent to prospective enrollees in response to 
enrollment requests.  MA contracts report this measure annually for each 
private fee-for-service plan. 
Private Fee-For-Service Provider Payment Dispute Resolution 
Process 
This measure is composed of three data elements reported by private 
fee-for-service MA contracts regarding the number of provider payment 
appeals and denials during a reporting period.  MA contracts report this 
measure annually for each private fee-for-service plan.  
Agent Compensation Structure 
This measure was composed of six data elements reported by 
MA contracts. The type of information collected included the number of 
licensed independent agents selling plans in the reporting period and the 
compensation that these agents received during the reporting period.  
MA contracts reported this measure annually.  CMS suspended data 
collection for this measure after 2009. 
   
CMSs Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720)       22   
   
Agent Training and Testing 
This measure was composed of eight data elements reported by 
MA contracts regarding the number of sales agents who completed 
training and the number of agents who took and passed tests.  
MA contracts reported this measure annually.  CMS suspended data 
collection for this measure after 2009. 
Plan Oversight of Agents 
This measure was composed of six data elements reported by 
MA contracts regarding complaints and disciplinary actions involving 
agents licensed to sell plans on behalf of the MA organizations during the 
reporting period. This measure was reported annually.  CMS suspended 
data collection for this measure after 2012 and plans to resume data 
collection in 2014. 
Special Needs Plans Care Management 
This measure is composed of four data elements reported by MA contracts 
regarding the initial health risk assessments and annual reassessments 
performed on enrollees in MA contracts Special Needs Plans.   
MA contracts report this measure annually for each Special Needs Plan. 
   
CMSs Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720)       23  APPENDIX 8 
Agency Comments 
(  f 
".,..,.4"'"''"',
DEPARTMENT OF HEALTH & HUMAN SERVICES  Centers for Medicare & Medicaid Services 
-;,,.,_~ 
Administrator 
Washington, DC 20201 
DATE: 
JAN 16 2014 
TO: 	 Daniel R. Levinson 

Jnspector'neneral 

FROM: 	 Maril\yn Tavetmer 

Administrato'J:. 

SUBJECT: 	 Office oflnspector General (OJG) Draft Report: "CMS Regularly Reviews Part 
C Reporting Requirements Data but CMS's Follow-up and Use of the Data are 
Limited" (OEI-03-11-00720) 
Thank you for the opportunity to review and comment on the OIG draft report titled above. The 
OIG reviewed the extent and types of Part C Reporting Requirements data issues identified by 
Acumen for measures (now called "reporting sections") that were active in 2010 and 2011, In 
addition, the OIG reviewed documentation supplied by CMS in an attempt to determine the steps 
taken by Acumen to identify data issues and steps CMS took to address them. 1 
The data provided to CMS through the Part C reporting requirements are an important source of 
information for CMS to provide information about beneficiary use of available services, patient 
safety, grievance rates, and other factors pertaining to the performance of Medicare Advantage 
(MA) plans that could not be answered prior to collection and reporting of these data. 
We appreciate OIG's efforts in working with CMS to ensure that the Part C reporting 
requirements data are more widely distributed and used to assess performance of MA plans. Our 
response to each of the 010 recommendations follows: 
Recommendation: 
The OIG recommends CMS determine whether outlier data values submitted by Medicare 
Advantage (MA) contracts reflect inaccurate reporting or atypical performance. 
CMS Response: 
The CMS concurs that it can do more to determine whether outlier data values submitted by MA 
organizations reflect inaccurate reporting or atypical performance. 
1 Acumen is a CMS contractor that reviews and analyzes all Part C Reporting Requirements data submitted by MA 
organizations (MA only contracts and MA-PD contracts), identifies data issues, and notifies affected MA 
organizations. 
CMS's Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720)  24   
   
 
   
CMSs Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720)       25   
   
   
CMSs Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720)       26   
   
ACKNOWLEDGMENTS 
This report was prepared under the direction of Robert Vito, Regional 
Inspector General for Evaluation and Inspections in the Philadelphia 
regional office, and Linda Ragone, Deputy Regional Inspector General.  
Amy Sernyak served as team leader for this study.  Other Office of 
Evaluation and Inspections staff from the Philadelphia regional office who 
conducted this study include Joanna Bisgaier and Conswelia McCourt.  
Central office staff who provided support include Meghan Kearns, 
Christine Moritz, and Rita Wurm. 
CMSs Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720)       27   
   
Office of Inspector General
http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as  
amended, is  to protect the integrity of the Department of  Health and Human Services  
(HHS)  programs, as well as the health and welfare of beneficiaries  served by those 
programs.  This statutory mission  is  carried  out through  a nationwide network  of  audits, 
investigations, and inspections conducted by the  following operating components: 
Office of Audit Services 
The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit work done by others.  Audits  
examine the performance of HHS programs and/or its grantees and contractors in carrying  
out their respective responsibilities and are intended  to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections 
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of  fraud and misconduct  related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office of Counsel to the Inspector General 
The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
OIG, rendering  advice and opinions on HHS programs and operations and  providing all  
legal support for OIGs  internal operations.  OCIG represents  OIG in all civil and 
administrative fraud and  abuse cases involving HHS programs, including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In  connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program  guidance, publishes fraud alerts, and provides other  
guidance  to  the health care industry concerning the anti-kickback statute and other  OIG  
enforcement authorities.