Transcript Slide 1

PHDSC
Payer Type Work Group
Joint NUBC / NUCC Meeting
Baltimore, Maryland
February 1, 2006
PHDSC Payer Type Work Group
Organized July 20, 2000
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Co-Chairs:
Amy Bernstein, Sc.D.
Chief
Analytic Studies Branch/Office of Analysis and Epidemiology
Centers for Disease Control and Prevention (CDC)
National Center for Health Statistics (NCHS)
[email protected]
Judy Parlato, M.B.A., B.S.N., R.N.
Clinical Advisor
Massachusetts Division of Health Care Finance & Policy
[email protected]
PHDSC Payer Type Work Group
Goals of the Committee
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To create a payer type standard for reporting payer data for
health care services.
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The payer standard will allow for consistent comparison of the
payment category from various data sets and across different
types of providers.
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The payer type standard will be flexible, expandable and allow
for different levels of detail.
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The payer standard will be one that all providers can use.
PHDSC Payer Type Work Group
Need for Payer typology
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There is currently no national standard for reporting and
classifying source of payment data.
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Existing ASC X12N 837 categories in the subscriber section
are currently neither mutually exclusive nor comprehensive.
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Ability to compare source of payment data across databases is
critical to policymakers and researchers examining effects of
payment policy.
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PlanID is not expected to meet the Committee’s goals.
PHDSC Payer Type Work Group
Current Claim Filing Indicator List
used in 837 implementation
Guides
09
10
11
12
13
14
15
16
AM
BL
Self-pay
Central Certification
Other Non-Federal Programs
Preferred Provider
Organization (PPO)
Point of Service (POS)
Exclusive Provider
Organization (EPO)
Indemnity Insurance
Health Maintenance
Organization (HMO)
Medicare Risk
Automobile Medical
Blue Cross/Blue Shield
CH
CI
DS
HM
LI
LM
MA
MB
MC
OF
TV
VA
WC
ZZ
Champus
Commercial Insurance Co.
Disability
Health Maintenance Organization
Liability
Liability Medical
Medicare Part A
Medicare Part B
Medicaid
Other Federal Program
Title V
Veteran Administration Plan
Workers’ Compensation Health
Claim
Mutually Defined / Unknown
PHDSC Payer Type Work Group
Current Situation
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This is reportable as the Claim Filing Indicator in
SBR09 in the Subscriber and Patient Loops
There are major problems with that list
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Definitional ambiguities
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Overlapping issues
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What is Central Certification (code 10)?
How do you distinguish a Medicare or Medicaid Managed Care
Plan from a private Managed Care Plan?
Analysis Problems
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current categories are not organized in a way to
facilitate analysis of payer policies or issues
difficult and in some cases impossible with Medicare
and Medicaid managed care to analyze payment
issues within states or across states
PHDSC Payer Type Work Group
Current Situation
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Maintenance to the ANSI ASC X12 list
requires a change to the standard.
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That adds to the complexity of maintaining a
list that meets industry needs in a timely
manner.
Commonly used data element by states, but
improvements would be welcomed.
PHDSC Payer Type Work Group
Accomplishments to Date
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Developed a flexible and expandable Payer typology for reporting and
analyzing payer data called “Possible Source of Payment typology”
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main category with sub-categories containing finer detail, allowing
sub-categories to be rolled up if necessary.
Refinement of the Payer Typology.
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Collaboration with The Agency for Healthcare Research and
Quality (AHRQ) Hospital Cost and Utilization Project (HCUP)
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AHRQ/HCUP review of current state Payer reporting practices for
33 states using the Typology as the framework.
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Modifications made to the PHDSC Payer Typology based on
review.
PHDSC Payer Type Work Group
Example from the typology
01 MEDICARE (SBR09 value - MA or MB)
1. Medicare (managed care)
1 Medicare HMO (SBR09 value - 16)
2 Medicare PPO
3 Medicare POS
9 Medicare managed care other
2. Medicare (non-managed care)
1 Medicare FFS
2 Medicare drug benefit
3 Medicare Medical Savings Account (MSA)
4 Medicare drug benefit (Part D)
9 Medicare non-managed care other
PHDSC Payer Type Work Group
Final Thoughts
 Updated Payer Typology available on PHDSC website at:
http://phdatastandards.info/about/committees/payer.htm
 National Center for Health Statistics will be responsible for
maintaining the list.
 The PHDSC payer work group committee will be developing a
guidelines and definition document.
 Respond to NPRM PlanID when released for comment:
 incorporate PHDSC’s Typology into mechanics of PlanID system
 leveraging support from Consortium members in this effort.
 Continue outreach to the industry on viability of typology.
(Note: Georgia is first state planning to pilot this typology)
 Propose a change to the standards.
 An external code source for X12 standards to be appended
to the SBR segment
 a Code-Code-Value on the UB-04
PHDSC Payer Type Work Group
Questions?
PHDSC Payer Type Work Group