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3 ways the PPACA data filing mess makes insurers want to SCREAM

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The Centers for Medicare & Medicaid Services (CMS) usually doesn’t get much of a response from the public when it puts new “information collection requirements” through the standard federal review process.

When CMS put an emergency addition to the data collection process for the new Patient Protection and Affordable Care Act (PPACA) “three R’s” risk-management programs through a review, health insurers howled.

Anthony Barrueta replied on behalf of Kaiser Permanente.

Matt Eyles of America’s Health Insurance Plans (AHIP) and Kris Haltmeyer of the Blue Cross and Blue Shield Association sent in a joint letter on behalf of the U.S. health insurer community.

CMS officials were supposed to give an estimate of how much time insurers would spend checking and explaining their three R’s data submissions, and the health insurer representatives strained to find ways to tell CMS how wrong they think the CMS burden estimates were.

“We believe CMS grossly underestimates the magnitude of the work associated with completing the checklist” and explaining what CMS sees as data problems, Barrueta writes in the Kaiser Permanente letter.

CMS and insurers are battling over the data submissions because drafters of PPACA created three huge new programs for insurers — a temporary reinsurance program, a permanent risk-adjustment program, and a temporary risk corridors program — in effort to protect insurers against the risk that giant, unexpected, PPACA-related swings in claims risk would kill commercial health insurers.

See also: Feds: “We’ll send some PPACA lifeboat money in December”

CMS is using a broad insurer fee to fund the reinsurance program, but the risk-adjustment program requires insurers with enrollees with low risk scores to send cash to competitors with enrollees with high risk scores, and the risk corridors program requires insurers with good underwriting results to send cash to competitors with poor underwriting results.

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

CMS has been using different types of data to run each program and it required high-level health insurance company executives to attest to the completeness and accuracy of the data submitted. But CMS officials reported in August that the differences between the data reports insurers filed for each of the three R’s are so great that it will require many insurers to go through a long checklist to verify the data, verify that the information is correct, and explain why what CMS is seeing as discrepancies exists. The data validation reports were due Sept. 14.

CMS has published preliminary three R’s data in ways that make it difficult to analyze how three R’s problems could affect insurers, but officials seem to have hinted that the impact could be big enough to do significant harm to some insurers’ finances.

For more details about what insurers are saying about the data discrepancy fight, read on.


1. The time needed to explain what CMS officials think are weird data discrepancies could take 100 times as long as CMS officials estimated.

CMS originally calculated an insurer would need about 8 hours to handle the data validation request.

Kaiser Permanente believes the true number is closer to 800 staff hours, Barrueta says.

CMS officials say, in a written response to the comments, that they can’t push back data validation deadlines because they have their own “significant regulatory timelines” to meet.

Insurers also asked, for example, that CMS set up the data validation submission they’re supposed to use in such a way that they can upload stored files into the system, or in such a way that the system itself can save the data entered, to keep the data from vanishing if the system crashes.

“Because of the urgency of the timelines involved, and because of our efforts to provide issuers as much time as possible to provide the explanations, CMS has not been able to take the time to build a data intake system with such functionality,” officials say.

See also: CMS sees possible insurer PPACA data integrity problems


2. Insurers think that, if CMS wants to know who’s responsible for any “discrepancies,” it should try going through the procurement process for a mirror. And a clue. 

Eyles and Haltmeyer note that CMS had insurers submit the data for the risk corridors program and for the other programs using “separate and distinct data fields, instructions, requirements and time frames.”

“The data in those two submissions are not comparable and differences — potentially of a significant magnitude — should be expected,” the insurer reps say.

See also: CMS posts PPACA risk corridors program form

Unhappy woman

3. CMS seems to have developed more overlapping, conflicting processes that are bound to lead to MORE discrepancies.

The insurer reps note that the current data validation mess could affect the consumer rebates made through the PPACA medical loss ratio (MLR) program, the schedule for when insurers will pay and receive risk corridors program transfers, and a coming wave of audits.

CMS has established one audit process for reviewing PPACA program payments, and a similar, but different process, for another, related data validation effort, the reps warn.

See also: What the PPACA exchange cops hope to bag


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