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CMS sees possible insurer PPACA data integrity problems

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A federal agency wants some health insurers to explain, in writing, why data reports for different Patient Protection and Affordable Care Act (PPACA) “three R’s” risk-management programs appear to tell conflicting stories.

The Centers for Medicare & Medicaid Services (CMS) talks about what it believes to be big differences between health insurers’ risk corridors program data submissions and data the insurers filed for the PPACA reinsurance program and the PPACA risk-adjustment program.

Insurers with units that sell qualified health plans (QHPs) through the PPACA public exchange system will have to complete a new checklist to attest that their data filings comply with PPACA risk corridors program rules, CMS officials say in a paperwork change notice.

If companies have big differences in the data they filed for the risk corridors program and the data they filed for the PPACA risk-adjustment program, or for the PPACA reinsurance program, “CMS is requiring that issuers quantify these differences, and provide a written explanation of the magnitude of the discrepancy,” CMS officials say. “We require these descriptions to be approved by an actuary.”

The PPACA risk corridors program is supposed to use cash from PPACA public exchange plan issuers with good results in 2014, 2015 and 2016 to help issuers with poor results in years. Some have questioned whether enough insurers did well enough in 2014 to make good on risk corridors program obligations to the insurers that did poorly.

See also: What if CMS risk-adjustment bill collectors fail?

The PPACA risk-adjustment program is supposed to use cash from issuers with relatively low-risk enrollees to help issuers with high-risk enrollees, to keep insurers from outperforming competitors by finding ways to push away high-risk enrollees.

The PPACA reinsurance program is supposed to use a broad-based fee to pay a portion of the cost of individual coverage holders who file catastrophic claims in 2014, 2015 or 2016.

The 250 affected health insurers were supposed to provide the data needed to run the risk corridors program in their PPACA medical MLR data filings. The MLR data filings were due July 31.

CMS required top company executives to attest to the completeness and accuracy of the data filings.

See also: 3 ways a PPACA lifeboat form is spamming the CEOs

The U.S. Government Accountability Organization (GAO) reported that insurers complained of having problems with getting explanations from CMS about how to collect and file the three R’s program data.

CMS gave insurers preliminary reinsurance and risk-adjustment program cash transfer estimates June. 30. Originally, the agency said it would try to give insurers risk corridors program estimates Aug. 14. The agency announced Aug. 10 that it would put off providing risk corridors transfer estimates because of concerns about insurer data submissions.

See also: Feds question insurers’ PPACA aid program filings

“While conducting program integrity reviews of submitted data, CMS has identified a number of significant discrepancies in the 2014 benefit year submissions that issuers made for MLR and risk corridors on July 31,” officials say. “CMS also identified a number of common errors that may lead to submissions that do not comply with CMS regulations and guidance.”