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GAO-14-56R 1 (2014-01-06)

handle is hein.gao/gaobaahnk0001 and id is 1 raw text is: G A O U.S. GOVERNMENT ACCOUNTABILITY OFFICE 441 G St. N.W. Washington, DC 20548 January 6, 2014 Congressional Committees Medicaid: Use of Claims Data for Analysis of Provider Payment Rates Within the Medicaid program, federal law requires that state Medicaid payments to providers be consistent with efficiency, economy, and quality of care; and be sufficient to enroll enough providers so that services are available to beneficiaries at least to the extent that they are available to the general population in the same geographic area.1 Two frequently cited studies of Medicaid payments have been conducted by the American Academy of Pediatrics (AAP) and the Urban Institute, both of which obtained state-specific fee schedule data for selected services and procedures through surveys of state Medicaid officials and from state websites.2 These studies shed some light on potential Medicaid payments for selected services; however, they provide little information on the extent to which states vary their payment for a service based on the circumstances in which that service was provided-such as whether the state pays a different amount depending on characteristics of the provider, setting, or beneficiary. These studies also provide little information on how often the payment rates they selected from the fee schedules were actually used in practice. Without such information, it may be difficult for the Centers for Medicare & Medicaid Services (CMS)-the agency within the Department of Health and Human Services that oversees the joint federal-state Medicaid program-or other policy makers to fully assess the adequacy of Medicaid payments. One potentially useful source of more comprehensive information on provider payments is claims data. Assessing Medicaid fee schedules against Medicaid claims data can serve to cross validate both data sources, and provide new insights into the robustness of claims data for payment analyses. We prepared this report under the authority of the Comptroller General to conduct work on GAO's initiative to assist Congress with its oversight responsibilities for the Medicaid program. In this report, we provide information on: (1) the extent to which state Medicaid programs vary the rates paid to providers for a given service and the basis for the variation; and (2) the extent to which Medicaid provider payment rates calculated from claims data confirm rates reported in studies of states' fee schedules. Scope and Methodology To conduct this work, we examined 2010 Medicaid fee-for-service (FFS) claims data for selected professional services and states. We selected 35 professional services from among those included in the studies by the AAP and the Urban Institute. The services were chosen to represent a range of professional service categories-including evaluation and management, imaging, laboratory, and maternal health. We selected 9 states from among the 26 states with available 2010 claims data as of October 2012. We chose states that represented different regions of the country and that served 1See 42 U.S.C. § 1396a(a)(30)(A). 2American Academy of Pediatrics, Medicaid Reimbursement Survey, 2010/11, American Academy of Pediatrics (Elk Grove, IL, 2011). Zuckerman S. et al., Trends in Medicaid Physician Fees, 2003-2008, (Washington, D.C.: Health Affairs, Vol. 28, No.3, 2009), w510-w519. GAO-14-56R Medicaid Payment Rates Page 1

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