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CMS cancels release of MA encounter data

For the first time this week, the Centers for Medicare and Medicaid Services was scheduled to make public encounter data on Medicare Advantage plans.

Susan Morse, Senior Editor

For the first time this week, the Centers for Medicare and Medicaid Services was scheduled to make public encounter data on Medicare Advantage plans during an AcademyHealth conference in New Orleans.

At the last minute, CMS cancelled the session, surprising many including some CMS officials, according to ProPublica.

AcademyHealth‏ tweeted at #ARM17 "Session Update: 'Analysis of 2014 Medicare Advantage Encounter Data' scheduled for Sunday 6/25 @ 10:30am has been cancelled

Through Twitter, Niall Brennan, a former chief data officer for CMS called the decision hugely disappointing and said he hoped CMS was not backsliding on open data.

CMS said by statement that the data was not complete enough to support its use in research.

"After evaluating the quality of the 2014 encounter data, CMS ultimately determined that it cannot be used to independently establish either the range of diagnoses for Medicare Advantage enrollees or to determine the services provided by Medicare Advantage organizations and therefore should not be released for research use," a CMS spokesman said. "After further analyzing the 2014 encounter data, CMS has determined that the data are not complete enough to support research use. MS is still evaluating the quality of the 2015 encounter data and has not made a determination about whether this data will be released to researchers." 

Insurers have long been concerned about the accuracy of encounter data, CMS's use of it in calculating risk scores and its subsequent  potential to impact payment.

[Also: CMS lifts enrollment, marketing sanctions against Cigna's Medicare Advantage, drug plans]

Encounter data is generated by providers. It documents both the clinical conditions of patients and the services delivered to treat those conditions.

CMS began collecting encounter data from Medicare Advantage plans in 2012.

Starting in 2016, CMS began to use encounter data in determining risk scores.

That year, it based 10 percent of a Medicare Advantage enrollee risk score on encounter data. The other 90 percent was based on diagnoses submitted by MA plans through the Risk Adjustment Processing System, or RAPS.

In 2017, CMS proposed a blend of 75 percent RAPS, and 25 percent encounter data and said in February it would use the same figures for 2018.

However, after receiving numerous letters of concern from insurers, in April, CMS set the blend at 85 percent to 15 percent for 2018.

[Also: Two Medicare Advantage insurers settle whistleblower lawsuit for $32M]

America's Health Insurance Plans released a report in February expressing concern about encounter data's ability to effect payment because studies have shown risk scores based on encounter data came in at 4 to 16-percent lower than those based on RAPS scores.

AHIP cited a Government Accountability Office report that said CMS had yet to undertake activities to fully address encounter data accuracy, such as reviewing medical records.

Then there's Department of Justice concerns about private insurers such as UnitedHealth overcharging the MA program by inflating risk scores to boost revenue.

[Also: UnitedHealthcare wins first round in MA payments case, readies lawsuit against HHS]

Earlier this year, the Department of Justice joined a whistleblower lawsuit against UnitedHealth Group and subsidiary WellMed Medical Management, claiming the insurer allegedly defrauded Medicare of hundreds of millions in risk adjustment payments.

Twitter: @SusanJMorse

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