MEDICARE 

ADVANTAGE 

Limited Progress 

Made to Validate 

Encounter Data Used 

to Ensure Proper 

Payments 

Report to Congressional Requesters

January 2017

GAO-17-223

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-17-223, a report to 

congressional requesters

January 2017

MEDICARE ADVANTAGE

Limited Progress Made to Validate Encounter Data 

Used to Ensure Proper Payments 

What GAO Found

Since GAO issued its July 2014 report, the Centers for Medicare & Medicaid 

Services (CMS) within the Department of Health and Human Services (HHS) has

made limited progress to validate the completeness and accuracy of Medicare 

Advantage (MA) encounter data. CMS collects encounter data—detailed 

information about the care and health status of MA enrollees—to determine 

payments to MA organizations (MAO). These entities received approximately 

$170 billion to provide coverage to nearly one-third of all Medicare beneficiaries 

in 2015. The agency uses a risk adjustment process to account for differences in 

enrollees’ expected health care costs relative to an average beneficiary. Without 

complete and accurate encounter data, CMS cannot appropriately risk adjust 

MAO payments. CMS has begun compiling basic statistics on the volume and 

consistency of data submissions and preparing automated summary reports for 

MAOs indicating diagnosis information used for risk adjustment. However, CMS 

has yet to undertake activities that fully address encounter data accuracy, such 

as reviewing medical records. (See figure.) Furthermore, some health insurance 

and provider trade associations GAO interviewed voiced concerns about CMS’s 

ability to properly identify diagnoses used for risk adjustment. CMS officials noted 

that they are working with MAOs to refine how the methodology used to obtain 

diagnoses data is applied. To the extent that CMS is making payments based on 

data that have not been fully validated for completeness and accuracy, the 

soundness of billions of dollars in Medicare expenditures remains 

unsubstantiated. Given the agency’s limited progress, GAO continues to believe 

that CMS should implement GAO’s July 2014 recommendation that CMS fully 

assess data quality before use. 

Change in Status of the Centers for Medicare & Medicaid Services’ Actions to Validate 

Medicare Advantage (MA) Encounter Data, from July 2014 to October 2016

Since the July 2014 report, CMS has made progress in developing plans to use 

MA encounter data for risk adjustment, but has not specified plans and time 

frames for most other purposes, such as conducting program evaluations and 

supporting public health initiatives. CMS began phasing in patient diagnosis 

information from encounter data in its risk adjustment process in 2015 and 

Why GAO Did This Study

CMS collects MA encounter data to 

help ensure the proper use of federal 

funds by improving risk adjustment in 

the MA program—the private health 

plan alternative to traditional 

Medicare—and for other potential 

purposes. CMS’s ability to make 

proper payments depends on the 

completeness and accuracy of MA 

encounter data. In July 2014, GAO 

reported that CMS had taken some, 

but not all, appropriate actions to 

validate the completeness and 

accuracy of encounter data and had 

not fully developed plans for using 

them. 

GAO was asked to provide an update 

on its July 2014 findings. In this report, 

GAO identifies (1) steps CMS has 

taken to validate MA encounter data, 

and (2) CMS’s plans and time frames 

for using MA encounter data—as well

as stakeholder perspectives on these 

steps and plans. 

To do this work, GAO compared CMS 

activities with the agency’s protocol for 

validating Medicaid encounter data—

comparable data collected and 

submitted by entities similar to 

MAOs—and federal internal control 

standards. In addition, GAO reviewed 

relevant agency documents and 

interviewed CMS officials on MA 

encounter data collection and 

reporting. GAO also reviewed 

comments in response to CMS’s 2014 

proposed rule and reports from 

stakeholder organizations. GAO also 

interviewed a non-generalizable 

selection of 11 stakeholders including 

health insurance and provider trade 

associations and research 

organizations. HHS provided technical 

comments on this report that were 

incorporated as appropriate.

 

 

View GAO-17-223. For more information, 

contact James Cosgrove at (202) 512-7114 or 

cosgrovej@gao.gov.
Highlights of GAO-17-223 (Continued)

United States Government Accountability Office

intends to rely completely on those data by 2020. Because it has primarily focused on collecting comprehensive 

encounter information for risk adjustment purposes—which is key to ensuring proper payments—CMS officials told GAO 

that the agency has largely deferred planning for additional uses of the data. Some stakeholder organizations have 

objected to the risk adjustment transition time frame, asserting that it does not allow sufficient time for a successful 

transition. According to CMS, the multiyear transition time frame is reasonable. Some stakeholders also were concerned 

that releasing data to external entities could compromise the confidentiality of proprietary information, such as payments 

to providers. CMS officials said that they intend to use data protections similar to those used with other Medicare data. In 

the absence of planning for all of the authorized uses, the agency cannot be assured that the amount and types of data 

being collected are necessary and sufficient for specific purposes. Given the agency’s limited progress, GAO continues to 

believe that CMS should implement GAO’s July 2014 recommendation that CMS fully develop plans for the additional 

uses of encounter data.
Page i GAO-17-223 Medicare Advantage Encounter Data

Letter 1

Background 6

CMS Has Made Limited Progress since July 2014 to Validate MA 

Encounter Data; Stakeholder Organizations Questioned the 

Effectiveness of CMS Efforts 8

CMS Has Detailed Plans for Using MA Encounter Data for Risk 

Adjustment but Not for Other Purposes, Creating Unease 

among Some Stakeholder Organizations 15

Agency Comments 21

Appendix I GAO Contact and Staff Acknowledgments 23

Table

Table 1: Key Characteristics of the Medicare Advantage (MA) Risk 

Adjustment Processing System (RAPS) Data and 

Encounter Data 7

Figures

Figure 1: Centers for Medicare & Medicaid Services’ Medicare 

Advantage Encounter Data Submission Process 8

Figure 2: Change in Status of the Centers for Medicare & 

Medicaid Services’ Actions to Validate Medicare 

Advantage (MA) Encounter Data, from July 2014 to 

October 2016 9

Figure 3: Centers for Medicare & Medicaid Services’ Transition 

from Risk Adjustment Processing System (RAPS) Data to 

Medicare Advantage (MA) Encounter Data for Risk Score 

Calculation 16

Contents
Page ii GAO-17-223 Medicare Advantage Encounter Data

Abbreviations

CMS Centers for Medicare & Medicaid Services

FFS fee-for-service

HHS Department of Health and Human Services

MA Medicare Advantage

MAO Medicare Advantage organization

RAPS Risk Adjustment Processing System

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Page 1 GAO-17-223 Medicare Advantage Encounter Data

441 G St. N.W.

Washington, DC 20548

January 17, 2017

The Honorable Kevin Brady

House of Representatives

The Honorable Sander M. Levin

House of Representatives

The Honorable Fred Upton

House of Representatives

In the Medicare program, paying for care in a way that contains costs and 

maintains quality requires that the Centers for Medicare & Medicaid 

Services (CMS)—the agency that administers Medicare—develop sound 

data and payment methods. Whereas Medicare pays fee-for-service 

(FFS) providers who submit claims for reimbursement after services have 

been rendered, Medicare pays Medicare Advantage (MA) organizations 

(MAO) a predetermined, fixed monthly amount per enrollee.1 This 

payment does not vary on the basis of the number or cost of health care 

services an enrollee uses. Instead, CMS uses a process known as risk 

adjustment to pay MAOs more for enrollees who are predicted to have 

higher medical costs and less for those predicted to have lower costs. 

The purpose of risk adjustment is to pay MAOs fairly and accurately, 

thereby decreasing incentives for MAOs to avoid enrolling sicker 

beneficiaries. MAOs can incur losses if aggregate costs exceed payments 

but can retain savings if aggregate costs are less than payments.

CMS adjusts payments for the health status of an enrollee using a risk 

score, which indicates how costly the enrollee is expected to be relative to 

the national average beneficiary. CMS calculates the risk score on the 

basis of an enrollee’s demographic characteristics (such as age and sex) 

and health status (diagnoses). For example, an MAO receives a higher 

 1

The MA program is a private plan alternative to the Medicare FFS program. CMS 

contracts with MAOs to provide covered health care services to plan enrollees. MA plans 

must cover all Medicare Part A and Part B services except for hospice care. Part A 

includes inpatient care in hospitals and skilled nursing facilities and certain home health 

care services. Part B includes physician services, outpatient care, certain home health 

care services, and durable medical equipment. In addition, MA plans usually offer 

prescription drug coverage and may offer extra benefits, such as vision, hearing, and 

dental coverage. In 2015, Medicare paid approximately $170 billion to MAOs to provide 

coverage for nearly 17 million beneficiaries, almost one-third of all Medicare beneficiaries.

Letter
Page 2 GAO-17-223 Medicare Advantage Encounter Data

risk-adjusted payment for an enrollee with diabetes or heart disease than 

for an otherwise identical enrollee without those conditions. CMS cannot 

accurately risk adjust MAO payments if they are based on diagnosis data 

that are incomplete and inaccurate.2

Since 2004, CMS has used an abbreviated set of MAO diagnostic data 

collected through the Risk Adjustment Processing System (RAPS) to 

calculate MA enrollee risk scores.3 The agency relies on diagnosis 

information in RAPS data along with FFS claims data to determine the 

relative cost for treating beneficiaries with various diagnoses. In 2012, 

CMS began collecting MA encounter data—data roughly equivalent to 

FFS claims data. Replacing RAPS with encounter data requires MAOs to 

submit more information about enrollees, providers, dates of service, 

diagnoses, treatments, and payments. CMS does not expect the 

diagnoses in MA encounter data to differ from those in RAPS.

In July 2014, we reported that CMS had taken some, but not all, 

appropriate actions to ensure the completeness and accuracy of MA 

encounter data.4 We compared CMS’s activities to the principal activities 

identified in its protocol for validating—ensuring the completeness and 

accuracy of—Medicaid encounter data that states receive from managed 

care organizations, which are entities that provide Medicaid benefits in 

exchange for a fixed monthly payment. The protocol outlines a series of 

steps for validating encounter data from Medicaid managed care 

organizations.5 Because of the similarities in the type of data and the 

entities gathering the data—managed care entities—we referred to this 

 2

Completeness refers to the data representing all encounters for all enrollees and 

accuracy refers to the data representing a correct record for all encounters that occurred.

3

CMS calculates a risk score for every Medicare beneficiary, including those in the FFS 

program and those in MA. To identify a FFS beneficiary’s diagnoses, CMS uses claims 

data received directly from providers. To identify an MA enrollee’s diagnoses, CMS uses 

information transmitted by MAOs.

4

GAO, Medicare Advantage: CMS Should Fully Develop Plans for Encounter Data and 

Assess Data Quality before Use, GAO-14-571 (Washington, D.C.: July 31, 2014).

5

Certain state Medicaid agencies that have relied on managed care organizations to 

provide Medicaid services have been collecting and using encounter data for many years. 

State Medicaid agencies that contract with managed care organizations generally must 

ensure than an independent external quality review organization review each managed 

care organization annually. CMS developed protocols for external quality review 

organizations, including one that can be used to evaluate encounter data submissions. 

Centers for Medicare & Medicaid Services, EQR Protocol 4: Validation of Encounter Data 

Reported by the MCO (Baltimore, Md.: September 2012).
Page 3 GAO-17-223 Medicare Advantage Encounter Data

protocol in assessing CMS’s actions to validate MA encounter data.6 We 

found that CMS had

• established timeliness and frequency requirements for data 

submissions,

• certified nearly all MAOs to transmit encounter data, and

• performed automated checks to determine whether key data elements 

were completed and values were reasonable.

However, we also found that CMS had not

• developed requirements for data completeness and accuracy,

• performed statistical analyses to detect certain data validity issues,

• reviewed medical records to verify diagnoses and services listed in 

encounter data, or

• reported what it had learned about data quality to MAOs.

In addition, we found that CMS had not fully developed plans for using 

MA encounter data. While the agency had announced plans to use 

diagnoses from both RAPS and encounter data to risk adjust payments 

beginning in 2015, it had not established time frames or specific plans to 

use encounter data for other intended purposes as of July 2014.7 In light 

of these findings, in July 2014, we recommended that, to ensure that MA 

encounter data are of sufficient quality for their intended purposes, CMS

• complete all the steps necessary to validate the data before using 

them to risk adjust payments or for other intended purposes and

 6

Because the CMS encounter data protocol was developed for external quality review 

organizations reviewing the quality of Medicaid encounter data, we adapted it to assess 

activities that CMS could take to validate MA encounter data. Specifically, we modified the 

first step, “to review” requirements for collecting and submitting encounter data, to be “to 

establish” such requirements. We also divided the third step calling for analyzing 

electronic encounter data into two activities: performing automated checks and conducting 

statistical analyses. The Medicaid encounter data validation protocol is consistent with 

GAO’s data validation standards.

7

Centers for Medicare & Medicaid Services, Announcement of Calendar Year (CY) 2015 

Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment 

Policies and Final Call Letter (Apr. 7, 2014), https://www.cms.gov/Medicare/HealthPlans/MedicareAdvtgSpecRateStats/Downloads/Announcement2015.pdf. 
Page 4 GAO-17-223 Medicare Advantage Encounter Data

• establish specific plans and time frames for using MA encounter data 

for all intended purposes in addition to risk adjusting payments to 

MAOs.

Since our July 2014 report, CMS finalized its proposal to expand the 

allowable uses of encounter data from five to nine purposes, including 

risk adjustment, quality review and improvement activities, public health 

initiatives, and program integrity activities.8 CMS also finalized its 

proposal to allow external entities, such as other federal agencies and 

private research organizations, to use MA encounter data under specified 

conditions and consistent with the nine purposes.9 In the preamble to the 

final rule, CMS also summarized and responded to comments from 

numerous stakeholder organizations surrounding the agency’s use and 

the release of MA encounter data.10

You asked us to provide an update on CMS’s efforts to validate MA 

encounter data and its plans and time frames for using these data. In this 

report, we identify

1. CMS steps, if any, to validate MA encounter data taken since our July 

2014 report, and describe related stakeholder perspectives, and

2. CMS plans and time frames, if any, for using MA encounter data 

developed since our July 2014 report, and describe related 

stakeholder perspectives.

To identify any CMS steps to validate MA encounter data taken since our 

July 2014 report, and describe related stakeholder perspectives, we 

compared the agency’s activities to the principal activities identified in its 

Medicaid encounter data validation protocol, the same criteria we used for 

our July 2014 report.11 We reviewed relevant agency documents and 

 8

79 Fed. Reg. 49,854, 50,325-27 (Aug. 22, 2014). 

9

79 Fed. Reg. 49,854, 50,327-34 (Aug. 22, 2014).

10Id. at 50,324-34.

11CMS’s Medicaid encounter data validation protocol specifies certain steps for assessing 

the completeness and accuracy of encounter data that Medicaid managed care 

organizations are required to submit to state agencies. In the context of MA, these steps 

include (1) establishing requirements for collecting and submitting MA encounter data, (2) 

reviewing MAOs’ capability to collect and submit encounter data, (3) performing 

automated checks on submitted data for completeness and accuracy, (4) conducting 

statistical analyses on encounter data for completeness and accuracy, (5) reviewing 

medical records to verify encounter data, and (6) summarizing findings on encounter data 

completeness and accuracy to provide recommendations to MAOs. 
Page 5 GAO-17-223 Medicare Advantage Encounter Data

interviewed CMS officials regarding actions taken to ensure the 

completeness and accuracy of MA encounter data. Additionally, we 

interviewed 11 stakeholder organizations, including health insurance and 

provider trade associations, private research and consulting firms, and 

federal agencies.12 We selected stakeholder organizations on the basis of 

their prominence in the MA program and the specificity of their written 

comments on a 2014 proposed rule that addressed MA encounter data. 

Our findings cannot be generalized to all stakeholder organizations. 

However, our approach allowed us to obtain the perspectives of a diverse 

group of stakeholder organizations with direct experience collecting and 

using MA encounter data or with interest in using the data in the future.

To identify any CMS plans and time frames for using MA encounter data 

developed since our July 2014 report, and describe related stakeholder 

perspectives, we reviewed relevant regulations, agency guidance to 

MAOs, and documents available on CMS’s website, and interviewed 

agency officials. We assessed agency planning activities in light of 

relevant standards for internal control in the federal government.

13 Finally, 

we interviewed stakeholder organizations, as described above, and 

reviewed stakeholder comments on CMS’s 2014 proposed rule, public 

presentations, and reports related to MA encounter data.

We conducted this performance audit from June 2016 to January 2017 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

 12The stakeholder organizations we interviewed were as follows: (1) American Hospital 

Association, (2) America’s Health Insurance Plans, (3) Blue Cross Blue Shield 

Association, (4) CAPG (formerly the California Association of Physician Groups), (5) Case 

Mix Analysis, (6) Department of Health and Human Services’ Office of Inspector General, 

(7) Alliance of Community Health Plans, (8) Inovalon, (9) Medicare Payment Advisory 

Commission, (10) Moran Company, and (11) SNP Alliance. Individual MAOs and 

providers participated in several of our interviews with trade associations.

13GAO, Standards for Internal Control in the Federal Government, GAO/AIMD-00-21.3.1 

(Washington, D.C.: November 1999); and GAO, Standards for Internal Control in the 

Federal Government, GAO-14-704G (Washington, D.C.: Sept. 10, 2014, effective fiscal 

year 2016). Internal control is a process effected by an entity’s oversight body, 

management, and other personnel that provides reasonable assurance that the objectives 

of an entity will be achieved.
Page 6 GAO-17-223 Medicare Advantage Encounter Data

Compared with RAPS data, MA encounter data contain more data

elements, including data on diagnoses not used for risk adjustment. 

Specifically, MAOs may enter more diagnoses on each encounter data 

submission than on each RAPS data submission and may transmit 

encounter data more frequently than RAPS data. (See table 1.) Although 

there are a number of differences between RAPS data and encounter 

data, an important distinction is a shift in who is responsible for identifying 

diagnoses used for risk adjustment. Under RAPS data submissions, 

MAOs individually analyze all their claims data and only submit data with 

diagnoses that are relevant for risk adjustment. In contrast, for encounter 

data submissions, MAOs transmit data to CMS on all enrollee 

encounters, regardless of whether the encounter contains diagnoses 

used for risk adjustment.14

 14For risk adjustment, CMS focuses on clinically significant, costly medical conditions 

likely to be treated if they are found. These include, for example, coronary artery disease, 

rheumatoid arthritis, and cancer. However, CMS excludes from the risk adjustment model 

other conditions—such as osteoarthritis and muscle strain—that are not considered 

medically significant, or may be subject to discretionary medical coding or enhanced rates 

of diagnosis through population screening. 

Background
Page 7 GAO-17-223 Medicare Advantage Encounter Data

Table 1: Key Characteristics of the Medicare Advantage (MA) Risk Adjustment Processing System (RAPS) Data and 

Encounter Data

Characteristics RAPS data Encounter data

Number of data elements May contain between 24 and 86

data elements

May contain between 154 and 202 data elementsa

Types of data elements Diagnoses Diagnoses, procedures, items provided to enrollees, and costs

Maximum number of 

diagnoses

May include up to 10 diagnosis 

groupings

May include up to 12 diagnoses for professional service encounters 

and 25 diagnoses for institutional service encounters

Process for identifying 

diagnoses for risk 

adjustment purposes

Identified and submitted by MA 

organizations, and used for risk 

adjustment

Identified by the Centers for Medicare & Medicaid Services, which 

requires MA organizations to submit all encounters regardless of 

whether they contain diagnoses used for risk adjustment

Types of providers 

submitting data

Collected from physicians and 

hospital inpatient and outpatient 

facilities

Collected from physicians, hospital inpatient facilities, hospital 

outpatient facilities, ambulance providers, clinical laboratories, durable 

medical equipment suppliers, home health providers, mental health 

providers, rehabilitation facilities, and skilled nursing facilities

Frequency of data 

submission

Submitted at least quarterly by 

MA organizations

Submitted every week, every other week, or every month by MA 

organizations, depending on their number of enrolleesb

Source: GAO summary of Centers for Medicare & Medicaid Services information. | GAO-17-223

a

The number of data elements are within this range if MA organizations choose to submit encounter 

data records using CMS’s Minimum Data Elements, a subset of the total data elements used in the 

standard health care transaction claims format.

b

MA organizations with fewer than 50,000 enrollees submit encounter data monthly, those with 

between 50,000 and 100,000 enrollees submit the data every other week, and those with more than 

100,000 enrollees submit the data weekly.

In addition, the encounter data submission process involves a number of 

steps and exchanges of information between providers, MAOs, and CMS. 

First, MAOs collect encounter data—originating from an enrollee’s 

medical record—from providers to manage and process reimbursement 

for health care services and supplies for enrollees. After collecting and 

reviewing these data, MAOs submit the data to CMS through the 

Encounter Data System.15 CMS then processes and checks the data for 

problems. CMS designed the system to reject and return problematic data 

to MAOs for corrections.16 MAOs are expected to work with providers to 

correct the encounter files and resubmit the data to CMS. (See fig. 1.)

 15The Encounter Data System adopted the health insurance industry’s standard claims 

format so that CMS generally avoided placing a new requirement on MAOs. MAOs can 

choose to submit encounter data using the Minimum Data Elements, which is a subset of 

the total data elements that CMS created for the standard health care transaction claims 

format.

16CMS defines rejected claims as those that CMS is unable to process because of MAOs’ 

or other submitters’ formatting errors, invalid data, and invalid beneficiary information.
Page 8 GAO-17-223 Medicare Advantage Encounter Data

Figure 1: Centers for Medicare & Medicaid Services’ Medicare Advantage Encounter Data Submission Process

Since our July 2014 report, CMS has taken additional steps across 

several activities to ensure that MA encounter data are complete but has 

yet to fully address data accuracy. (See fig. 2)

CMS Has Made 

Limited Progress

since July 2014 to 

Validate MA 

Encounter Data; 

Stakeholder 

Organizations 

Questioned the 

Effectiveness of CMS 

Efforts
Page 9 GAO-17-223 Medicare Advantage Encounter Data

Figure 2: Change in Status of the Centers for Medicare & Medicaid Services’

Actions to Validate Medicare Advantage (MA) Encounter Data, from July 2014 to 

October 2016

The agency has taken the following steps, which address primarily the 

completeness of encounter data and provide feedback to MAOs on data 

submission:

• Creating a report card with basic statistics on the completeness 

of encounter data for MAOs. This step partially fulfills CMS’s 

Medicaid data validation protocol activity to conduct statistical 

analyses to assess completeness and accuracy. Analyzing values in 

specific data elements and generating basic statistics on the volume 

and consistency of data elements can help detect data validity issues. 

Agency officials told us they are using the report cards to encourage 

MAOs to submit data more frequently and completely.17 The report 

cards contain the following information:

• quarterly performance indicators. These indicators relate to 

submission frequency (such as the percentage of biweekly 

periods with submitted data), data volume (such as the numbers 

 17Agency officials told us they do not have a time frame of the frequency with which MAOs 

will receive these report cards but indicated that they are developing a schedule for 

routine dissemination of report cards.
Page 10 GAO-17-223 Medicare Advantage Encounter Data

of submitted encounters per 1,000 enrollees), and data quality 

(such as rejection rates of data submissions).

• comparisons with other MAOs. These MAO-specific 

comparisons display an MAO’s volume of encounters—overall 

and by service type (professional, inpatient, outpatient, and 

durable medical equipment)—alongside the regional and national 

averages for both MA encounter data submissions and Medicare 

FFS claims for each of the past 3 years.

• Developing an automated report for MAOs on diagnoses used for 

risk adjustment. This step partially fulfills the data validation protocol 

activity to summarize findings on encounter data completeness and 

accuracy to provide recommendations to MAOs. The automated 

report identifies diagnoses from MAO encounter data submissions 

that CMS will use to calculate risk scores for the next payment year. 

The report is primarily intended to help MAOs ascertain the basis of 

enrollee risk scores, though representatives from health insurance 

trade associations told us that they have also used the automated 

reports to prepare internal financial projections and compare patient 

diagnoses between encounter data and RAPS data submissions. 

MAOs first received these reports in December 2015, and since then, 

CMS has modified the report layout in response to MAO feedback. 

According to agency officials, CMS has finalized the initial version of 

the automated report and is distributing the automated reports to 

MAOs on a monthly basis. Further, the agency intends to make 

technical changes as necessary in the future.

According to agency officials, they finalized the protocol for validating MA 

encounter data in November 2016 and have begun implementing several 

parts of it.

18 In September 2016, CMS awarded a contract to update the 

protocol and report annually on the implementation and outcomes of 

protocol activities.19

The stakeholder organizations we interviewed raised several issues with 

CMS’s recent actions to ensure the completeness of MA encounter data. 

 18According to agency officials, the MA encounter data protocol is similar to the CMS 

developed Medicaid encounter data protocol.

19Other activities in this contract include conducting various operational analyses, 

including an assessment of encounter data completeness and quality using geographic, 

organizational, and other comparisons. The contractor is also expected to identify or 

develop key performance metrics, such as volume of submissions by type of service. 
Page 11 GAO-17-223 Medicare Advantage Encounter Data

The main issues mentioned by several stakeholder organizations 

included the following:

• Errors in identifying diagnoses used for risk adjustment.

Representatives from health insurance trade associations we 

interviewed criticized CMS’s process for identifying diagnoses that are 

relevant for risk adjustment. First, they stated that MAOs question the 

integrity of CMS’s data processing. They noted, for example, that the 

automated reports MAOs receive had missing procedure codes for 

some encounters where the original data submissions had included 

them. CMS told us that they are working with MAOs to make needed 

corrections to these reports. Second, representatives said that MAOs 

have been unable to replicate CMS’s analyses because CMS has 

made adjustments to how it identifies diagnoses eligible for risk 

adjustment using encounter data. As a result, they say, MAOs are 

unsure whether CMS is properly distinguishing diagnoses that are 

used for risk adjustment from those that are not used.20 When asked 

about this concern, CMS officials noted that they publicly announced 

how the agency intends to implement the risk adjustment transition in 

December 2015, and the methodology has not changed.21

• Inclusion of encounter data elements considered irrelevant.

Representatives we interviewed from some health insurance and 

provider trade associations questioned CMS’s inclusion and checks of 

data elements the agency does not use for risk adjustment and which 

they contend are irrelevant for the purposes enumerated in the August 

2014 final rulemaking.22 CMS’s Encounter Data System is designed to 

 20Stakeholders asserted that until CMS has finalized its approach for culling diagnoses 

from encounter data, the data should not be used for risk adjustment because doing so 

may result in substantial financial harm. Health insurance industry representatives cited a 

June 2016 analysis conducted by Inovalon, a data analytics company, which examined 

the implications of transitioning from RAPS data to encounter data. The analysis 

compared RAPS return files—which showed which data were rejected and accepted—

with CMS’s automated reports on diagnoses used for risk adjustment. It showed that the 

expanded use of encounter data decreased risk scores, partially because of “incomplete”

encounter data submissions.

21See Centers for Medicare & Medicaid Services, Final Encounter Data Diagnosis 

Filtering Logic, memorandum from Director, Medicare Plan Payment Group, to All 

Medicare Advantage Organizations (MAO), PACE Organizations, Medicare-Medicaid 

Plans, Section 1833 Cost Contractors and Section 1876 Cost Contractors, and certain 

Demonstrations.

22These data elements include, for example, an ambulance’s pick-up and drop-off 

locations and the distance an ambulance travels, which trade association representatives 

told us are not routinely collected for standard billing purposes.
Page 12 GAO-17-223 Medicare Advantage Encounter Data

reject erroneous information by applying a subset of the edits used to 

process FFS claims, which are not all relevant to MA encounter data, 

according to CMS officials. CMS requires MAOs to make corrections 

and resubmit the data for all rejected encounters. Representatives 

stated that both MAOs and providers must dedicate significant 

resources to meet CMS requirements. In particular, they said MAOs 

must alter their data systems and submit numerous requests to 

providers for data corrections and medical record reviews. When 

asked about this comment, CMS officials noted that the agency wants 

encounter data elements to be comparable to FFS claims data. 

Although not all of the encounter data elements are used for risk 

adjustment purposes, CMS noted that they should be reliable, 

comprehensive, and complete in the event they are used for any 

authorized purposes.

• Technical problems with encounter data submission.

Representatives we interviewed from several health insurance and 

provider trade associations reported that MAOs have experienced 

difficulties with certain data submissions. They cited, for example, 

difficulty with submitting encounters for recurring services, such as 

physical therapy. While MAOs and providers typically record such 

services as a single encounter, they must submit multiple separate 

encounters to CMS for recurring services. Agency officials told us they 

had not heard about this problem from MAOs. In addition, stakeholder 

representatives mentioned challenges resulting from frequent, 

randomly scheduled changes to data submission requirements, which 

they say generate costs and confusion.23 CMS stated that technical 

changes occur quarterly, which is typical for other CMS data collection 

efforts. Agency officials pointed out that CMS has worked with some 

of the larger MAOs to address data submission issues.

• Inadequate CMS communication with individual MAOs. Although 

some researchers praised CMS officials for their assistance and 

support, representatives from several health insurance trade 

associations told us that their members are dissatisfied with CMS’s 

communication efforts. Representatives noted that CMS’s webinars 

are not designed to facilitate a conversation between the agency and 

MAOs, and that the email address CMS set up to handle questions 

from MAOs does not produce responses that can be shared across 

 23MAO trade associations we interviewed said that they would like the ability to view and 

verify their data submissions throughout the validation process so that they can monitor 

their data and alert CMS if there are any inaccuracies.
Page 13 GAO-17-223 Medicare Advantage Encounter Data

MAOs in a timely fashion.24 CMS officials told us that its response 

time for emailed questions on MA encounter data largely depends on 

the complexity of the issue. They said that the agency has not been 

able to provide individualized assistance because of resource 

limitations, but has recently contracted with an external organization 

to provide on-site assistance to MAOs to improve their data 

submission processes.

Although CMS has taken several steps to ensure the completeness of MA 

encounter data, as of October 2016, the agency had yet to take a number 

of other important steps identified in the agency’s Medicaid protocol.

Steps CMS has not taken include the following:

• establish benchmarks for completeness and accuracy. This step 

would address the data validation protocol activity to establish 

requirements for collecting and submitting MA encounter data. 

Without benchmarks, CMS has no objective standards against which 

it could hold MAOs accountable for complete and accurate data 

reporting.

• conduct analyses to compare against established benchmarks.

This step would address the data validation protocol activity to 

conduct statistical analyses to ensure accuracy and completeness. 

Without such analyses, CMS is limited in its ability to detect potentially 

inaccurate or unreliable data.

• determine sampling methodology for medical record review and 

obtain medical records. This step would address the data validation 

protocol activity to review medical records to ensure the accuracy of 

encounter data. Without medical record reviews, CMS cannot 

substantiate the information in MAO encounter data submissions and 

lacks evidence for determining the accuracy of encounter data.25

 24Representatives suggested that CMS offer more training opportunities for MAOs, 

convene technical workgroups where CMS staff could work directly with MAOs, and host 

interactive question and answer sessions with knowledgeable CMS staff. 

25CMS has indicated that it plans to subject the diagnoses in encounter data to the same 

risk adjustment data validation process as the diagnoses in RAPS data. In conducting risk 

adjustment validation audits for RAPS data, it reviews a sample of medical records. 

However, in an earlier report, we recommended that the Department of Health and Human 

Services (HHS) improve its processes for selecting contracts to include in the audits, and 

enhance the timeliness of the audits, among other things. See GAO, Medicare Advantage: 

Fundamental Improvements Needed in CMS’s Effort to Recover Substantial Amounts of 

Improper Payments, GAO-16-76 (Washington, D.C.: Apr. 8, 2016).
Page 14 GAO-17-223 Medicare Advantage Encounter Data

• summarize analyses to highlight individual MAO issues. This step 

would address the data validation protocol activity to provide 

recommendations to MAOs for improving the completeness and 

accuracy of encounter data. Without actionable and specific 

recommendations from CMS, MAOs might not know how to improve 

their encounter data submissions.

To the extent that CMS is making payments based on data that have not 

been fully validated for completeness and accuracy, the soundness of 

billions of dollars in Medicare expenditures remains unsubstantiated. 

Given the limited progress CMS has made, we continue to believe that 

the agency should complete all the steps necessary to validate the data 

before using them to risk adjust payments or for other intended purposes, 

as we recommended in our July 2014 report.26

 26See GAO-14-571.
Page 15 GAO-17-223 Medicare Advantage Encounter Data

Since our July 2014 report, CMS has made progress in defining its 

objectives for using MA encounter data for risk adjustment purposes and 

in communicating its plans and time frames to MAOs.27 Although 

additional work is needed, CMS has improved its ability to manage a key 

aspect of the MA program.

In April 2014, CMS announced that it would begin incorporating patient 

diagnoses from MA encounter data submissions into risk score 

calculations. For 2015 MAO payments, CMS used encounter data 

diagnoses as an additional source of diagnoses to compute risk scores.28

CMS supplemented the diagnoses from each enrollee’s RAPS data file 

 27As discussed in our July 2014 report, CMS had not fully developed plans for using MA 

encounter data. While the agency had announced plans to use diagnoses from both 

RAPS and encounter data for risk adjustment purposes beginning in 2015, it had not 

established time frames or specific plans to use encounter data for other potential 

purposes. In light of these findings, we recommended that CMS establish specific plans 

and time frames for using MA encounter data for all intended purposes in addition to risk 

adjusting payments to MAOs. See GAO-14-571.

28Risk scores that CMS uses to adjust MA payments are based on diagnosis data from 

services provided the previous year. For example, MAO payments made in 2015 reflect 

risk scores calculated using diagnoses rendered during 2014. 42 CFR § 422.310(g)

CMS Has Detailed 

Plans for Using MA 

Encounter Data for 

Risk Adjustment but 

Not for Other 

Purposes, Creating 

Unease among Some 

Stakeholder 

Organizations

CMS Plans to Fully 

Transition to Using MA 

Encounter Data for Risk 

Adjustment Purposes by 

2020, Generating Mixed 

Reactions from Some 

Stakeholder Organizations
Page 16 GAO-17-223 Medicare Advantage Encounter Data

with the diagnoses from each enrollee’s MA encounter data file.29 For 

2016, CMS used a different process that increased the importance of 

encounter data in computing risk scores. Specifically, CMS calculated risk 

scores as follows:

• CMS determined two separate risk scores for each enrollee. CMS 

based one risk score on the diagnoses from each enrollee’s RAPS 

data file and the other risk score on the diagnoses from each 

enrollee’s encounter data file.

• CMS combined the two risk scores, weighting the RAPS risk score by 

90 percent and the encounter data risk score by 10 percent.

CMS intends to increase the weight of encounter data in the risk score 

calculation in the next 4 years so that encounter data will be the sole 

source of diagnoses by 2020. (See fig. 3.)

Figure 3: Centers for Medicare & Medicaid Services’ Transition from Risk Adjustment Processing System (RAPS) Data to

Medicare Advantage (MA) Encounter Data for Risk Score Calculation

While some stakeholder organizations we interviewed supported CMS’s 

time frame for transitioning from RAPS data to encounter data for risk 

score calculation, others raised objections to CMS’s planned timeline. 

Representatives from several stakeholder organizations we interviewed—

 29Under CMS’s data submission requirements for payment purposes, MAOs have until the 

final risk adjustment data submission deadline, as determined by CMS, to submit their 

encounter data for a payment year. See 42 C.F.R. § 422.310(g). After this deadline, CMS 

recalculates beneficiary risk scores and determines if adjustments to MA payments are 

necessary. For example, for 2015 payments adjusted with risk scores from 2014 dates of 

services, MAOs had until February 1, 2016 to submit encounter data records for 2014 

dates of services. Additionally, the agency plans to re-run the risk adjustment 

methodology with all MAOs for risk scores developed in 2015 and 2016 to account for 

changes in how CMS incorporates encounter data in risk score development.
Page 17 GAO-17-223 Medicare Advantage Encounter Data

primarily research firms and a health insurance trade association—said 

that CMS’s time frame was appropriate and that MAOs had adequate 

time to adjust their data submission processes. However, representatives 

from several health insurance and provider trade associations we 

interviewed said that many MAOs and providers are apprehensive about 

CMS’s time frame because it does not allow sufficient time for a 

successful transition. They told us that many MAOs and providers are still 

configuring their encounter data systems. In a December 2015 memo to 

all MAOs, CMS noted that, since 2016 will be the fourth year of collecting 

encounter data, the transition time frame is a reasonable, modest step 

toward ultimately relying exclusively on encounter data as the source of 

diagnosis information in risk adjustment.30 The agency noted that it has 

worked with MAOs to correct issues with how the agency applies the 

methodology for identifying diagnoses for risk adjustment is applied.

Although the agency has formulated general ideas of how to use MA 

encounter data for some purposes besides risk adjustment, CMS has not 

determined specific plans and time frames for most of the additional 

purposes for which the data may be used, namely (1) to update risk 

adjustment models; (2) to calculate Medicare disproportionate share 

hospital percentages; (3) to conduct quality review and improvement 

activities; (4) for Medicare coverage purposes; (5) to conduct evaluations 

and other analysis to support the Medicare program (including 

demonstrations) and to support public health initiatives and other health 

care-related research; (6) for activities to support the administration of the 

Medicare program; (7) for activities to support program integrity; and (8) 

for purposes authorized by other applicable laws.31 CMS officials 

explained that their main priority to date has been to use MA encounter 

data for calculating risk scores and that they plan to use the data for other 

purposes at a future time. However, this is inconsistent with federal 

internal control standards relating to risk assessment and information and 

communication that call for clearly defining objectives and communicating 

those objectives to key external organizations.32

 30Centers for Medicare & Medicaid Services, Final Encounter Data Diagnosis Filtering 

Logic.

3142 C.F.R. § 422.310(f)(1) (2016).

32GAO-14-704G.

CMS’s Plans and Time 

Frames for Using MA 

Encounter Data for Other 

Authorized Purposes 

Remain Undeveloped, 

Creating Unease among 

Some Stakeholder 

Organizations
Page 18 GAO-17-223 Medicare Advantage Encounter Data

In addition to articulating plans for using encounter data for risk 

adjustment, CMS has indicated its interest in using MA encounter data for 

additional purposes. As of October 2016, CMS has begun planning for 

two of the eight remaining authorized uses:

• quality review and improvement activities. In April 2016, CMS 

awarded a contract to develop quality metrics that represent care 

coordination using encounter data.33 As of September 2016, the 

contractor had developed some plans for using encounter data to 

develop the metrics but testing and analyzing the data are ongoing.

• program integrity activities. CMS officials told us they anticipate 

including MA encounter data in the Fraud Prevention System to help 

identify abusive billing practices, but have yet to fully develop plans for 

this proposed use. To date, CMS officials reported that the Center for 

Program Integrity has begun using encounter data to determine 

improper payments to providers. It conducted a study of the number 

of services both paid as FFS claims and submitted as MA encounters. 

Additionally, it used encounter data to identify MA providers that were

not enrolled in Medicare.

For the remaining authorized uses of encounter data, CMS reportedly has 

developed general ideas, but not specific plans and time frames. For 

example, CMS officials told us the CMS Innovation Center has plans to 

use MA encounter data to evaluate three demonstration models.34

Because these efforts are in their infancy, the officials could not provide 

details or specific time frames for these applications of encounter data. In 

addition, CMS has released MA encounter data to the Medicare Payment 

Advisory Commission and the Department of Health and Human 

Services’ Office of Inspector General for research purposes using 

standard protocols for releasing FFS data to those agencies. However, 

 33The care coordination measures are designed to provide comparative information on 

care coordination services—like communication across providers and service follow-up—

provided to Medicare beneficiaries enrolled in MA plans. CMS officials told us that the

contractor is testing and validating care coordination measures using the encounter data 

and intends to complete this by September 28, 2017.

34The CMS Innovation Center supports the development and testing of innovative health 

care payment and service delivery models. Demonstration models that will use MA 

encounter data for evaluation purposes include the Medicare Advantage Value-Based 

Insurance Design Model, the Medicare-Medicaid Financial Alignment Model, and the 

Accountable Health Communities Model.
Page 19 GAO-17-223 Medicare Advantage Encounter Data

CMS has not yet released the data to other organizations or finalized 

protocols for doing so.35

Stakeholder organizations we interviewed acknowledged that the agency 

has the authority to collect MA encounter data, but some indicated 

unease about CMS’s expansion of allowable uses of the data. In addition, 

some were concerned about the potential for future expansions because 

CMS has not fully defined its plans and time frames for other applications. 

In contrast, representatives from both health insurance and provider trade 

associations and research organizations noted that the authorized 

purposes are within CMS’s purview and that the agency already uses 

FFS data for similar purposes. CMS officials told us that some of the 

authorized uses are purposefully broad because they want to have some 

flexibility to expand their uses of encounter data in the future.

A common point made by all of the stakeholder organizations we 

interviewed was the importance of privacy protections for releasing MA 

encounter data to researchers and other interested parties. Many 

organizations were concerned that CMS might release commercially 

sensitive information to external entities.36 A few also highlighted the 

importance of protecting patient privacy.37 To protect proprietary 

information and patient privacy, stakeholder organizations offered the 

following suggestions:

 35CMS officials told us that they anticipate using the same processes researchers 

currently use to access FFS data, such as data use agreements and submitting a request 

to the Research Data Assistance Center—a CMS contractor that provides free assistance 

to academic and non-profit researchers using Medicare FFS data for research purposes—

to ensure that external entities use encounter data appropriately. 

36In the May 2014 proposed rule, CMS proposed aggregating payment data to protect 

commercially sensitive data before any release to external entities. See 79 Fed. Reg. 

27,978, 28,283 (proposed May 15, 2014). That protection was clarified and finalized in the 

August 2014 final rule. See 79 Fed. Reg. 49,854, 50,327-34 (Aug. 22, 2014) (codified at 

42 C.F.R. § 422.310(f)(2)(iv) (2016)).

37The August 2014 rule finalized a prohibition against any public disclosure of beneficiary 

identifying information. See 79 Fed. Reg. 49,854, 50,328 (Aug. 22, 2014) (codified at 42 

C.F.R. § 422.310(f)(2)(iii)(A) (2016). CMS also told us that public data releases will not 

contain any individually identifying information about Medicare beneficiaries, but will 

instead be de-identified to ensure compliance with the Health Insurance Portability and 

Accountability Act. Additionally, regulations only permit the release of beneficiary 

information to authorized external entities under certain circumstances. See 42 C.F.R. § 

422.310(f)(2) (2016). 
Page 20 GAO-17-223 Medicare Advantage Encounter Data

• Aggregate the data. Representatives from some health insurance 

trade associations said aggregating the data on a geographic level, 

such as the county or state level, would generally allow MAOs to 

remain anonymous. One MAO stated that aggregating the data at the 

physician group level would be appropriate. In the preamble to its final 

rule, CMS clarified that payment data released to external entities 

would be aggregated at the level necessary to protect commercially 

sensitive information, such as proprietary payment rates between 

plans and providers.38

• Deny or delay the release of certain data. Representatives from 

health insurance and provider trade associations were opposed to 

releasing encounter data elements—such as payment or utilization 

data—that could be used for anti-competitive behavior. They 

proposed delaying the release of encounter data by several years to 

protect proprietary information. In the preamble to its final rule, CMS 

stated that such delays in releasing the data to external entities would 

defeat the purposes of improving transparency in the Medicare 

program.39

• Limit data access. Representatives from health insurance and 

provider trade associations and research organizations emphasized 

that CMS should implement appropriate safeguards for releasing MA 

encounter data to external entities similar to those protections used 

for Medicare FFS data. Representatives from three trade associations 

argued that encounter data should not be made available to 

researchers and other interested parties until the data quality is 

assured. In the preamble to its final rule, CMS stated that making 

encounter data available to researchers using a process similar to that 

applied to FFS data would enhance transparency in the MA 

program.40

To the extent that specific plans for using the MA encounter data remain 

undeveloped, CMS is unable to communicate a set of well-defined 

 38See 79 Fed. Reg. 49,854, 50,328-29 (Aug. 22, 2014). 

39CMS will not release risk adjustment data until the risk adjustment reconciliation period 

has been completed for that payment year, except under extraordinary circumstances. 

See 42 C.F.R. 422.310(f)(3) (2016). According to the preamble to the final rule, CMS has 

indicated that the reconciliation period provides MAOs an opportunity to identify and 

correct errors in data they have submitted for that data collection year and ensures that 

the risk adjustment data is complete and accurate. See 79 Fed. Reg. 49,854, 50,331 

(Aug. 22, 2014).

4079 Fed. Reg. 49,854, 50,329-30 (Aug. 22, 2014). 
Page 21 GAO-17-223 Medicare Advantage Encounter Data

objectives to stakeholders. Furthermore, in the absence of planning for all 

of the authorized uses, the agency cannot be assured that the amount 

and types of data being collected are necessary and sufficient for specific 

purposes. Given the agency’s limited progress on developing plans for 

additional uses of encounter data, we continue to believe that CMS 

should establish specific plans and time frames for using the data for all 

intended purposes, in addition to risk adjusting payments to MAOs, as we 

recommended in our July 2014 report.41

We provided a draft of this report to the Department of Health and Human 

Services (HHS) for comment. HHS provided technical comments, which 

we incorporated as appropriate. 

 41GAO-14-571.

Agency Comments
Page 22 GAO-17-223 Medicare Advantage Encounter Data

As agreed with your offices, unless you publicly announce the contents of 

this report earlier, we plan no further distribution until 30 days from the 

report date. At that time, we will send copies to the appropriate 

congressional committees and the Secretary of Health and Human 

Services. In addition, the report will be available at no charge on the GAO 

website at http://www.gao.gov.

If you or your staffs have any questions about this report, please contact 

me at (202) 512-7114 or cosgrovej@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this report. Major contributors to this report are listed in 

appendix I.

James Cosgrove

Director, Health Care
Appendix I: GAO Contact and Staff 

Acknowledgments

Page 23 GAO-17-223 Medicare Advantage Encounter Data

James Cosgrove, (202) 512-7114 or cosgrovej@gao.gov

In addition to the contact named above, Rosamond Katz (Assistant 

Director), Manuel Buentello, David Grossman, and Jessica Lin made key 

contributions to this report. Also contributing were Muriel Brown, Christine 

Davis, Elizabeth Morrison, and Jennifer Rudisill.

Appendix I: GAO Contact and Staff 

Acknowledgments

(100938)

GAO Contact

Staff 

Acknowledgments
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