Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

CMS REGULARLY REVIEWS 

PART C REPORTING 

REQUIREMENTS DATA, BUT 

ITS FOLLOWUP AND USE OF 

THE DATA ARE LIMITED 

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-andReports/CFOReport/ on April 1, 2013. 

CMS’s 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 organization’s 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. 5–7. 6

 CMS, 2011 Medicare Part C Plan Reporting Requirements Technical Specifications
 

Document, December 2011, pp. 7–8. Accessed at http://www.cms.gov/Medicare/HealthPlans/HealthPlansGenInfo/ReportingRequirements.html on April 10, 2013. 

CMS’s 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 measures—Agent 

Compensation Structure and Agent Training and Testing—were 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). 

CMS’s 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. 7–8. Accessed at 

http://www.cms.gov/Regulations-andGuidance/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/HealthPlans/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/healthplans/healthplansgeninfo/downloads/2013-call-letter.pdf on April 24, 2013. 

CMS’s 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 Acumen’s 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. 

CMS’s Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720) 5 
 

 

 

2

 

 

1

1

 

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 CMS’s 

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 

Reviewed for 

Overdue 

Data 

Measure 

Reviewed for 

Placeholder 

Data 

Measure 

Reviewed for 

Inconsistent 

Data 

Measure 

Reviewed for 

Outlier Data 

Values 

Benefit Utilization 1 1 1 

Procedure Frequency 

Adverse Events 

Provider Network Adequacy 

Grievances 

Organization Determinations 

and Reconsiderations 

Employer Group Plan 

Sponsors 

Private Fee-for-Service Plan 

Enrollment Verification Calls 

1 

Private Fee-for-Service 

Provider Payment Dispute 

Resolution Process 

1 

Plan Oversight of Agents 

Special Needs Plans Care 

Management 2 

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.
 

CMS’s 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 

Acumen’s 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, 19760–19761 (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-DrugCoverage/PrescriptionDrugCovContra/Downloads/DVProcedureManualVer2.pdf on
 

June 26, 2013. 

CMS’s 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-DrugCoverage/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. 

CMS’s 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 CMS’s 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 CMS’s use of the results 

of the Part C Reporting Requirements data validation audits. We also 

inquired about CMS’s 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 Acumen’s survey responses and supporting 

documentation regarding its processes and interactions with CMS 

concerning Part C data issues. We reviewed and summarized CMS’s 

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. 

CMS’s 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 Acumen’s 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. 

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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 CMS’s 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. 

CMS’s 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 

Measure Reporting 

Frequency 

Number of 

Outlier Values 

in Reporting 

Year 2010 

Number of 

Outlier Values 

in Reporting 

Year 2011 

Total Number 

of Outlier 

Values for 

2010 and 2011 

Number of 

Calculated 

Outlier 

Indicators 

Organization Determinations 

and Reconsiderations Quarterly 894 365 1,259 41 

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 

Management Annual 19 12 31 2

 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. 

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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 General’s (OIG) inquiry as to whether CMS had 

contacted MA contracts that submitted outlier data, CMS staff stated: 

[A]n outlier doesn’t 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 Acumen’s 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. 19686–19687 (April 15, 2010). 

25 CMS, response to OIG survey: Medicare Advantage Organizations’ Part C Reporting
 

Requirements, January 2013. 

CMS’s 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 measures—Provider Network Adequacy and Special Needs 

Plans Care Management—contained 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 OIG’s 

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 

CMS’s 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 Acumen’s 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 CMS’s 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 

organization’s 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 OIG’s 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). 

CMS’s 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 organization’s Special Needs 

Plans—specifically, about the performance of initial and annual health risk 

assessments. CMS analyzed data for the Special Needs Plans Care 

Management measure for 2010. CMS’s 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-DrugCoverage/PrescriptionDrugCovContra/Downloads/DVProcedureManualVer2.pdf on 

June 26, 2013. 

CMS’s Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720) 16 
 

 

 

plans face unexpected costs.30 In response to GAO’s 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. 

CMS’s 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 Acumen’s 

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 CMS’s 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 measures—Grievances 

and Special Needs Plans Care Management—on CMS.gov’s “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. 

CMS’s 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. CMS’s 

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 

CMS’s 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 contract’s 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 OIG’s 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. 

CMS’s 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 CMS’s comments is provided in Appendix B. 

CMS’s 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 contract’s 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. 

CMS’s 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. 

CMS’s 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. 

CMS’s Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720) 23 
APPENDIX 8 

Agency Comments 

( •".,..,.4"'"''"'•, f 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 
 

 

 

CMS’s Followup and Use of Part C Reporting Requirements Data Are Limited (OEI-03-11-00720) 25 
 

CMS’s 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. 

CMS’s 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 OIG’s 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.