Brief History of Maine All ProviderAll Payer
y Claims Database
Alan M. Prysunka
Maine Health
l h Data Organization
O
June, 2010
www.maine.gov/mhdo
www.healthweb.maine.gov
h lh b
i
www.mhdpc.org
Milestones

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
July, 2002 (modified June
June, 2003; December,
December 2005;
July, 2006; April, 2009)
Milestones
(continued)

Data submissions begin January, 2003

First iteration (eighteen months 1/03 – 6/04) of data released
April, 2005

MHDO data release rules (Chapter 120) amended in January,
2007 to allow for direct identification of health care practitioners
p

MHDO statutes amended June, 2007 to include pharmacy benefits
managers, Medicare
M di
Part
P t D sponsors, and
d non-ME
ME licensed
li
d
carriers under definition of payer
Legal Framework

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
d Maine
M i law
l
Financing

Annual MHDO revenue derived equally from health care
providers and payers in the following percentages:
 38.5%
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
MHDO Expenditures
p

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
MHDPC Expenditures
p

MHDPC funded by MHDO and Onpoint Health Data, a
private non-profit

Funding: 60% MHDO / 40% Onpoint

3.65 FTE’s at the MHDPC assigned to processing
MHDO claims data and provider linkage
MHDPC Expenditures
Maine Health Data Processing Center
Annual Budget
F d
Funds:
FY 2010
FY 2009
FY 2008
FY 2007
MHDO (60%)
$146,150
$119,856
$140,145
$ 195,111
MHDO (100%)
$217,500
169,760
185,450
146,155
Onpoint (40%)
$97,433
79,917
93,430
130,074
$461,083
$369,533
$419,025
$471,340
Total Funds
Claims Database Structure

Database contains:





Paid medical, dental, pharmacy claims files for all covered
services rendered to publicly (Medicare Part A, B, C, D and
Medicaid) and privately insured Maine residents
Eligibility / membership file
Health care service provider files
Home grown procedure and taxonomy code files
Standard format utilized:


HIPAA standard codes
HIPAA transaction set data elements (ASC X12N 270/271
eligibility, 835 remittance, 837 claims)
Included Information

Information included in the database:









Type of product (HMO,
(HMO POS,
POS Indemnity,
Indemnity etc.)
etc )
Type of contract (single person, family, etc.)
Coverage type (self-funded, individual, small group, etc.)
Encrypted subscriber/member social security numbers/names
Patient demographics (date of birth, gender, residence,
relationship to subscriber)
Diagnosis codes (including E-codes)
E codes)
Procedure codes (ICD, CPT, HCPC, CDT)
Groupers (DRG, APC)
NDC
C code
d / generic indicator
d
Included Information










(
(continued)
)
Revenue codes
Service dates
Service provider (name,
(name tax id,
id payer ID,
ID NPI
NPI, specialty code
code,
city, state, zip code)
Billing provider (name, payer ID, NPI)
Prescribing physician
Plan payments
Member payment responsibility (co-pay,
(co pay, coinsurance,
deductible)
Date paid
Type of bill
Facility type
Claims
C
a s Data
ata Submission
Sub ss o Status
Data Submitters:
Carriers - 53
TPA’s/PBM’s - 45
Dental Carriers - 18
AR
AZ
CA
CO
CT
DC
FL
GA
IA
IL
IN
KS
MA
MD
ME
MI
2
3
6
4
8
1
5
1
2
14
4
1
15
2
10
1
MN
MO
NE
NH
NJ
NY
OH
PA
SC
TN
TX
VA
VT
WA
WI
WV
8
2
8
10
6
9
6
6
4
1
8
1
4
1
7
2
Maine Claims Data Flow
Commercial Payers
Data Feeds/Resubmissions
Edit
Reports
MHDPC
Governmental Payers
Mapped
pp
Files
Edited/Updated
Data
Data
Files
Data Requestors
MHDO
Data/Reports
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
C it ti / d i i t ti fees
Capitation/administrative
f
Referrals
Test results from lab work, imaging, etc.
Provider affiliation with group practice
Provider networks
Missing
g Data


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
p
purchasing
p
g alliances
Issues / Problems

HIPAA implementation delays have caused additional
problems:


National patient ID does not exist (using encrypted SSN’s
SSN s
and names for subscribers / members)
Nationall payer ID not yet established
bl h d (difficult
(d ff l to trackk
mergers, buy outs, DBA’s)
Issues / Problems

((continued))
National provider ID implementation issues have
resulted in additional complexities and expenses
($200 000+ / year)) requiring:
($200,000+
i i




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
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
100%
% Other
$10,500
$9,897
% Com m ercial
80%
$9,500
$9,013
70%
$8,500
% MaineCare
60%
$7,605
40%
$6,279
$6,309
$6,173
$5,915
$
,
$5,939
$5,769
$5
769
$5,427
$5,174
30%
20%
$4,824
$5,098
$4,888
$4,638
$5,310
$6,863
$6,052
$5,383
$5,339
$5,256
$6,523
$6,233
$5,293
$4,560
% Medicare
10%
$6,500
$5,940
$5,9
0
$4,804
$4,363
$7,500
$7,289
$7,158
50%
$5,511
$5,129
$5,500
$4,660
$4,387
$4,500
$3,779
$3,500
drew
s
M illi n
oc ke
t
MDI
Seb a
st ico
ok
St J o
Red- s eph
F airv
iew
CA
Dea n
NMM
C
M iles
Cary
Rum
for
Park d
vi ew
ME C
oas t
Houl
ton
Pen
Vall e
y
TAM
C
Pen
Bay
Cala
is
Wal d
o
Dow
n Ea
st
Good
all
York
Brid g
ton
M ayo
Ste p
hen s
In lan
d
SM M
C
M GM
C
Merc
y
Blu e
Hil l
EM M
C
Fra n
kl in
CMM
C
M id C
oa st
M MC
St M
ary s
0%
M aine Acute Care Hospitals
% Medicare
% MaineCare
% Commercial
% Other
Case Mix
x Adjusted Ave. Paid Per Weighted
Discharge
$9 997
$9,997
St An
Payer by Percent of Weigh
ht Discharges
90%
Uses (continued)
(
)
90%
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
High % Medicare Low Paid
High % Medicare High Paid
Low % Medicare Low Paid
Low % Medicare - High
Paid
Percent of Weigh
ht Discharges Paiid by Medicare
80%
70%
60%
50%
40%
30%
20%
10%
0%
$0
$2,000
$4,000
$6,000
$8,000
Paid Amount Per Weighted Discharge
$10,000
$12,000