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Maine All Provider/All Payer Claims Database (What You Need To Know But Were Too Afraid To Ask)
www.maine.gov/mhdowww.healthweb.maine.govwww.mhdpc.org
Alan M. Prysunka
Maine Health Data Organization
October, 2010
Legal Framework
Maine Health Data Organization (MHDO) established as an independent executive agency in June, 1996 to continue collection of hospital inpatient, outpatient, and financial data
Legislation passed in June, 2001 creating the Maine Health Data Processing Center (MHDPC) and amending MHDO’s statutes to collect data directly from carriers and TPA’s
MHDO health care claims data collection rules (Chapter 243) finalized in July, 2002 (modified June, 2003; December, 2005; July, 2006; April, 2009)
Legal Framework (continued)
MHDO designated as Public Health Authority by Maine Office of Attorney General under HIPAA Privacy Rules (45 CFR, Subpart E §164.501)
Public Health Authority can compel Covered Entities to submit Protected Health Information without the written authorization of patients or members (45 CFR, Subpart E §164.512)
ME TPA claimed ERISA preemption in 2003 and sought order from Federal Court to exclude TPA’s from data submission requirements
Federal Court ruling on March 24, 2004 stipulated health care claims data held by TPA’s not plan assets - must be provided to the MHDO under Maine law
Legal Framework (continued)
MHDO data release rules (Chapter 120) amended in January, 2007 to allow for direct identification of health care practitioners
MHDO statutes amended June, 2007 to include pharmacy benefits managers, Medicare Part D sponsors, and non-ME licensed carriers under definition of payer
Legal Framework - Compliance
MHDO statutes establish schedule of fines for failure to submit data, failure to pay assessments, failure to safeguard identity of patients (all civil violations):
$1,000/day for health care facility, carrier, TPA, PBM – not to exceed $25,000
$100/day for all other health care providers – not to exceed $2,500 per occurrence
$500,000 maximum for intentional misuse of data for commercial advantage, pecuniary gain, or malicious harm
Legal Framework – Data Release
MHDO rules (Ch. 120) establish terms and conditions of data release:
No direct/indirect identification of members/patients – unless MHDO Board grants exception to DHHS for public health study
Identity of practitioners performing abortions protected
No release of data deemed confidential or privileged by MHDO – data providers may challenge designation
No release of data that places data provider at a competitive economic disadvantage (negotiated discounts)
Data providers may review all data requests, require additional information, and/or require further review prior to data release
Mandatory advisory committees required for all data requests containing identifiable practitioner data elements and group numbers
Legal Framework – Data Collection
MHDO rules (Ch. 243) specify terms and conditions of commercial claims data collection, including the submission of the following:
Paid medical, dental, pharmacy claims files for all covered services rendered to publicly (Medicare Part C and D) and privately insured Maine residents
Eligibility/membership file
Health care service provider files
Home grown procedure and taxonomy code files
Medicare Part A and B and Medicaid files submitted under DUA’s approved by CMS and ME Office of MaineCare Services
Included Information
Information included in the database:
Type of product (HMO, POS, Indemnity, etc.) Type of contract (single person, family, etc.) Coverage type (self-funded, individual, small group, etc.) Encrypted subscriber/member social security
numbers/names Dates (birth/service/paid) Patient demographics (age, gender, residence, relationship
to subscriber) Revenue/diagnosis/procedure/drug codes (ICD, E-codes CPT,
HCPC, NDC, CDT) Service/prescribing provider (name, tax id, payer ID, NPI,
specialty code, city, state, zip code) Billing provider (name, payer ID, NPI) Plan (primary/secondary) and member (co-pay, coinsurance,
deductible) payments Facility/bill type
Excluded Information
Information presently excluded from the database: Services provided to uninsured (except ME Partners) Denied claims Workers’ compensation claims Services by ME providers for non-Maine residents Premium information Capitation/administrative fees Referrals Test results from lab work, imaging, etc. Provider affiliation with group practice Provider networks
Missing Data Sources
Tricare and Federal Employees Health Benefit Program data not presently in database:
14,000 federal employees in ME Both are proprietary and under the auspices of the
federal government Will attempt to secure in 2010
ERISA preempted: Self-funded / self-administered ERISA programs (e.g. –
WalMart) ERISA fiduciaries Unions; private purchasing alliances
Governance
MHDO governed by 21 member policy board representing: 4 consumers 3 employers 2 third-party payers 9 providers (2 hospital; 2 physician; 1 chiropractor; 1
pharmacist; 1 ambulatory care; 1 home health care; 1 mental health)
3 state agencies (1 DHHS; 1 Dirigo Health; 1 Professional & Financial Regulation)
Duties include: Oversight of data collection, distribution, and analysis Promulgation of all rules under MHDO authority
Financing
Annual MHDO revenue derived equally from health care providers and payers in the following percentages: 38.5% hospitals (based upon net patient service
revenue) 11.5% non-hospital providers (based upon fixed
categorical assessments) 38.5% carriers (based upon premiums written) 11.5% TPA’s (based upon claims paid for plan
sponsors)
Additional revenue derived from: Sale of data ($100,000/year) Prescription privacy fees ($300,000/year)
MHDO Expenditures
Legislatively authorized total expenditures/assessment cap: FY2008 - $1,794,412 FY2009 - $1,966,297 FY2010 - $2,154,613
Staff: 10 FTE’s (3.5 FTE’s full time claims database)
Funds not expended must be carried forward to reduce following FY assessment
Maine Health Data Processing Center
Legislation passed in June of 2001 creating the Maine Health Data Processing Center (MHDPC) - a public/private partnership between the Maine Health Data Organization (MHDO) and Onpoint Health Data (f/n/a the Maine Health Information Center)
MHDPC defined as a non-profit corporation with a public purpose with powers deemed as essential government functions
Primary functions: collection and processing of claims data submitted by third-party payers with edited data files provided to the MHDO for storage and distribution
MHDPC Expenditures
MHDPC standard processing costs funded by MHDO and Onpoint Health Data in the following manner:60% MHDO / 40% Onpoint
3.65 FTE’s at the MHDPC assigned to processing MHDO claims data and producing provider linkage tables
MHDPC Expenditures
Maine Health Data Processing CenterAnnual Budget
Funds: FY 2010 FY 2009 FY 2008 FY 2007
MHDO (60%) $119,856 $140,145 $ 195,111
MHDO (100%) 169,760 185,450 146,155
Onpoint (40%) 79,917 93,430 130,074
Total Funds $369,533 $419,025 $471,340
$146,150
$217,500
$97,433
$461,083
Maine Claims Data Flow
Commercial Payers
MHDO
MHDPC
Data RequestorsData/Reports
Data Feeds/Resubmissions
Edited/UpdatedData
EditReports
Governmental Payers MappedFiles
DataFiles
Issues / Problems
HIPAA implementation delays have caused additional problems:
National patient ID does not exist - using encrypted SSN’s and names for subscribers /members
National payer ID not yet established (difficult to track mergers, buy outs, DBA’s) – using NAIC codes for carriers and home grown codes for TPA’s and PBM’s
Issues / Problems (continued)
National provider ID implementation issues have resulted in additional complexities and expenses ($200,000+ / year) requiring:
Stripping information out of the claims and creating separate service provider files
Linking data using all possible data points and conducting manual review
Mapping individual payer provider specialty codes to national specialty taxonomy codes
Identifying substitution of service provider with billing provider
Verifying accuracy of prescribing physicians due to replacement of DEA# with NPI
Uses of Claims Data
Uses (continued)
Uses (continued)
Uses (continued)
Payer Distribution by Weighted Discharges (from Inpatient Data) and Case Mix Adjusted Average Commercial Paid Amount per Weighted Discharge (from Commercial Inpatient Data and Commercial Claims Data) 2007 -
Sorted by Medicare
% Medicare
% MaineCare
% Commercial
% Other
$5,511
$3,779
$4,387
$5,129
$7,289
$5,940
$4,660
$5,293
$6,523
$4,560
$6,233
$6,863
$6,052
$5,256$5,339
$5,383
$7,158
$6,309$6,279
$5,310
$9,997
$5,939
$4,804
$7,605
$5,098
$4,363
$4,888
$9,013
$4,638
$9,897
$6,173
$5,174
$5,769
$4,824
$5,427
$5,915
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
St A
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MC
St M
arys
Maine Acute Care Hospitals
Pa
ye
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y P
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t o
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eig
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Dis
ch
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$3,500
$4,500
$5,500
$6,500
$7,500
$8,500
$9,500
$10,500
Cas
e M
ix A
dju
sted
Ave
. Pai
d P
er W
eig
hte
d
Dis
char
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% Medicare % MaineCare % Commercial % Other
Uses (continued)
Correlation Between Percent Medicare as Payer and Case Mix Adjusted Average Commercial Paid Amount per Weighted Discharge, Critical Access Hospitals
Highlighted, Inpatient and Claims 2007 Data
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
$0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000
Paid Amount Per Weighted Discharge
Pe
rce
nt
of
We
igh
t D
isc
ha
rge
s P
aid
by
Me
dic
are
High % Medicare - Low Paid
High % Medicare - High Paid
Low % Medicare - Low Paid
Low % Medicare - High Paid
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