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Maine All Provider/All Payer Claims Database ( What You Need To Know But Were Too Afraid To Ask). Alan M. Prysunka Maine Health Data Organization. www.maine.gov/mhdo www.healthweb.maine.gov www.mhdpc.org. October, 2010. Legal Framework.
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Maine All Provider/All Payer Claims Database (What You Need To Know But Were Too Afraid To Ask) Alan M. Prysunka Maine Health Data Organization www.maine.gov/mhdo www.healthweb.maine.gov www.mhdpc.org 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
MHDPCExpenditures Maine Health Data Processing Center Annual Budget
Maine Claims Data Flow Commercial Payers Data Feeds/Resubmissions Edit Reports MHDPC Governmental Payers Mapped Files Edited/Updated Data Data Files Data Requestors MHDO Data/Reports
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