What Newly Launched Medicaid Information Do and Don’t Inform Us

The Facilities for Medicare and Medicaid Companies (CMS) is concentrated on addressing “fraud, waste and abuse” in Health applications together with Medicaid. Efforts span throughout several types of Health protection and throughout all supplier and repair varieties. In November 2025, CMS issued a letter to states describing alternatives for federal and state governments to work collaboratively. Efforts to handle fraud, waste and abuse are usually not new. The Center for Program Integrity (CPI), inside CMS, was established in 2010 to coordinate program integrity efforts and transfer from a “pay and chase” mannequin to greater reliance on knowledge analytics to detect and stop fraud. CPI has labored with states to supply coaching by way of the Medicaid Integrity Institute and entry to broad units of full knowledge to assist promote program integrity efforts.

On February 14, 2026, CMS released a dataset with provider-level spending knowledge that the company suggests may very well be used to establish uncommon billing patterns for particular companies, states, or suppliers. This coverage watch describes what the info embody, what they exclude, and the way they may probably result in mistaken conclusions given the restrictions of the info.

What do the info embody and exclude?

The brand new dataset contains seven forms of knowledge:

•  The nationwide supplier identifier (NPI) for the billing supplier,
• The NPI of the servicing supplier (which can be a person or an organizational entity),
• The process code (also referred to as the healthcare widespread process coding system or HCPCS code),
• The month and 12 months,
• The variety of beneficiaries seen,
• The variety of procedures delivered (the rely of claims), and
• The overall quantity paid for the companies.

The totals embody information of outpatient companies paid for by Medicaid instantly (“fee-for-service”) and people paid for by Medicaid managed care organizations on behalf of enrollees between 2018 and 2024.

The information exclude all institutional information and all Information about prescribed drugs, that are vital shares of Medicaid spending, with hospital care accounting for 37% and being the only largest supply of Medicaid spending. Past excluding total classes of companies, the info omit a number of forms of Information which are vital in evaluating the reasonableness of service quantity and spending:

• Enrollment. The quantities of companies used rely on how many individuals are eligible to obtain the companies, which varies primarily based on state insurance policies, the economic system, and folks’s demographics. Variations in service use over time or between geographic areas will not be comparable with out accounting for the variety of Medicaid enrollees and their age and Health standing.
• Advantages and Protection. The quantity of companies used additionally relies on what companies states elect to supply and the way they decide who’s eligible to make use of these companies, options which will change over time.
• Cost charges. Spending on companies relies on how a lot states are paying for every service, which may rely on the native value of residing in addition to state choices about how a lot fee charges ought to be to make sure affordable entry to care.
• Diagnoses. The information don’t embody any Information to point what situation the procedures are used to deal with.
• Place of service and different modifiers. The information exclude Information about the place the companies had been carried out (together with whether or not they had been offered in-person or remotely) and different modifiers which are used to establish traits of the companies.

How would possibly the info result in mistaken conclusions?

Though knowledge analytics could be a highly effective software to establish probably problematic patterns, they may result in mistaken conclusions if utilized in isolation. A couple of particular shortcomings of the brand new Medicaid knowledge stand out.

• The reported procedures are usually not all the time comparable to one another. The information present counts of sufferers, companies, and Medicaid spending for every process, however the procedures are usually not in all circumstances comparable to one another. Some are very narrowly outlined whereas others embody a wide selection of procedures. In CMS’ instance of how the info may very well be used, spending on private care seems to be a big outlier and the only largest supply of Medicaid spending. Nonetheless, the “process” for private care features a vary of doable companies lasting from quarter-hour as much as a whole day. In distinction, there are a number of separate procedures for psychotherapy that every correspond to go to size (half-hour, 45 minutes, 60 minutes, and so on.). Equally, there are a number of procedures for emergency division visits and workplace visits that correspond to the complexity of the case on a scale from one to 5. Private care wouldn’t be the most important class of spending if institutional spending had been additionally included.
• Suppliers are usually not all the time comparable to one another. The information present counts of sufferers, companies, and Medicaid spending for every supplier, however a few of the suppliers are people whereas others are group practices, clinics, and even total county and state Health departments. In CMS’ instance of how the info may very well be used to have a look at spending by supplier, 10 of the 20 largest “suppliers” are state or native authorities businesses that each administer and ship Medicaid advantages somewhat than Health Care suppliers. States’ approaches to delivering Medicaid advantages fluctuate broadly, however typically, state or native Health departments contribute by paying suppliers to ship companies and by offering companies instantly (significantly within the case of companies for individuals with behavioral Health wants and developmental disabilities).
• There may be restricted Information concerning the strategies used to create the dataset or the underlying knowledge high quality. The information don’t point out how underlying Medicaid knowledge had been aggregated to create the abstract file. In addition they don’t deal with points associated to the standard of the underlying knowledge, which come from the Information-solution/transformed-medicaid-statistical-Information-system-t-msis”>Reworked Medicaid Statistical Information System or T-MSIS. T-MSIS is a wealthy supply of information, however generally there are points with the info in particular states for particular matters. CMS maintains a rigorous “data quality atlas” that helps “insightful, methodologically sound evaluation” of the info. The atlas gives a wealth of Information about potential knowledge issues. IT’s unclear how CMS dealt with these points when producing the recently-released knowledge. For instance, CMS reports that within the 2024 knowledge, there have been six states with unusable Information about whole spending for the companies included within the knowledge; and an extra 16 states the place the info had been of excessive concern. IT is unknown whether or not CMS included the unusable knowledge within the public file or whether or not the general public knowledge mirror a distinct model of T-MSIS.

Past these knowledge points, the info are lacking context about how Medicaid spending and use of care modified between 2018 and 2024. The COVID-19 pandemic, which started in 2020, resulted in main modifications to Medicaid spending that resulted from elevated enrollment in the course of the steady enrollment interval and elevated consciousness of unmet wants for behavioral Health and long-term care. As states elevated entry to these companies, use of these companies and related spending grew because of modifications in states’ insurance policies relating to protection, eligibility, and supplier fee charges.