Part 1 of this article appeared in the December 2017 issue of
Part 1 of this article presented an overview of the recently overhauled Medicaid managed care program
regulations and the need to conduct
pre-submission diligence to validate the accuracy, completeness, and truthfulness of the
certified data submissions. To help meet the
new requirements, a data validation and testing process should be integrated into existing
managed care compliance programs.
Part 2 presents two examples of implementing a pre-submission data diligent
review, testing, and validation process.
The examples illustrate how a Compliance
review process can promote Medicaid
program compliance and integrity,
lessen regulatory sanctions, and pro-
tect against potential claims under the
False Claims Act.
Pre-review diligence examples
Consider two examples of how a diligent data review and testing process may be
used to promote Medicaid program compliance and integrity, lessen regulatory sanctions,
and help build a protective moat against
potential claims under the False Claims Act.
The first example involves a network adequacy
data submission and the second pertains to an
encounter data submission. These data submissions are essential to state monitoring and
administration of major Medicaid program
requirements and activities and are subject to
close regulatory scrutiny by the state.
by Jay Davis, JD, CHC, CHPC, CCEP, CIPP/US, CIPM
Certifying Medicaid program
data, Part 2: Pre-data
» Accurate, complete, and truthful certified data submissions are essential to state monitoring and administration of major Medicaid
program requirements and activities.
» The Compliance department should establish a diligent‑review audit protocol to test and validate the accuracy and completeness of
the submission before the data is certified.
» Encounter data submissions are integral to Medicaid program administration, are subject to close regulatory scrutiny, and merit
special attention in the pre‑submission review and testing process.
» Overutilization and underutilization affect the accuracy, completeness, and utility of encounter data for Medicaid program oversight
and integrity, and they may indicate or identify provider fraud, waste, and abuse.
» Data certifications play an integral role in furthering Medicaid program integrity when supported by well‑conceived pre‑submission
review and testing protocols.
Jay Davis ( firstname.lastname@example.org) is an Attorney focusing in privacy,
ethics, compliance, and healthcare, practicing in the greater Los Angeles area.