How MCO rules update could lead to better data collection, better care

Standardized encounter data currently lacking for Medicaid managed care organizations
Tools

The proposed update to Medicaid managed care organization (MCO) rules would standardize data collection across the program, allowing Medicaid to "fill substantial gaps" in its understanding of how to serve its ever-growing member population, according to an opinion piece published in the Journal of the American Medical Association.

About 74 percent of Medicaid enrollees are part of an MCO, but standardized encounter data are scarce for the populations these programs serve.

The Centers for Medicare & Medicaid Services (CMS) announced updates to its MCO rules in late May, saying its proposal will "better align regulations and best practices to other health insurance programs, including the private market and Medicare Advantage plans," FierceHealthPayer has reported.

In fact, Medicare Advantage has required its plan sponsors to report encounter data, including diagnoses and the amounts charged and paid for services, since 2008, the opinion piece notes. In contrast, CMS currently allows states to decide what types of MCO encounter data they will provide, leading to major gaps in the type and quality of data different states provide.

The current situation is even problematic from a fraud standpoint, an Office of Inspector General report pointed out in July, leading the agency to call for better oversight from CMS to ensure all managed care entities are accounted for in each state.  

But CMS' proposed rule would "harmonize" the Medicare and Medicaid managed care requirements for data reporting, which will allow the Medicaid programs to better fulfill their role as health policy laboratories and take part in comparative effectiveness research, the article argues.

Still, implementing the new regulations will not be easy. Standardized data collection has in the past faced political hurdles, with some MCOs worried that data release will put them at a competitive disadvantage. MCO programs and states must also contend with limited resources and technical capacity.

However, if CMS and the states are able to work together to enhance their current data systems, "none of these challenges is insurmountable," the article concludes.

To learn more:
- here's the opinion piece

Related Articles:
CMS updates Medicaid managed care organization rules
3 key reasons CMS overhauled MCO rule
States still fail to report managed care encounter data to prevent fraud
GAO: Medicaid managed care needs better watchdogs