OIG: CMS anti-fraud efforts failing for lack of prompt claims analysis

Since 1999, states have been required to use the Medicaid Statistical Information System (MSIS) to report fee-for-service Medicaid claims. The MSIS reporting program was designed to help both Medicare and Medicaid detect fraud and abuse more effectively.

However, it seems that CMS isn't doing enough to take advantage of the data this program supplies, and states aren't meeting their deadlines either, according to a new report from the HHS Office of the Inspector General. The OIG looked at more than 3,000 quarterly data files submitted by states from fiscal year 2004 to FY 2006. As of June 2007, only 54 percent of those files had been quality checked, validated and released for public use, the IG found. In other words, CMS seems quite backlogged on this front.

Generally speaking, the OIG concluded, it took 18 months for quarterly data to move from submission to the MSIS public database. Adding to the problem were issues with state data submission; states contributed six months to the delay because of late CMS submissions, the IG found.

The bottom line, the IG said, is that as of June 2009, "the MSIS had not captured many data elements that can assist in fraud, waste and abuse detection." Seems like a real missed opportunity here--while old-fashioned police-style detective work seems to have resulted in some major busts lately, less-glamorous data crunching can be a big help, too.

To learn more about the report:
- read this iHealthBeat piece