Hospital Claims Data FAQ
For Super-Utilizer Interventions
What is hospital claims data?
Hospitals collect data related to the billable activities the hospital system performs
for its patients. Hospital claims data includes total hospitalization costs (what is
billed and what is reimbursed), date of admission, date of discharge, diagnosis codes
related to the hospitalization, insurance, address, and date of birth for each patient
and each hospitalization.
Hospital claims data is historical data. It takes weeks for the hospital to enter and
assemble claims data related to individual hospitalizations.
How will having access to hospital claims data help a super-utilizer
intervention?
When you are just starting a super-utilizer intervention, hospital claims data will
help you understand the hospital utilization background of the patients you are
working with. If you can review 6-12 months of hospital claims data for each of the
patients in the intervention, you can identify:
 total costs of care for each patient before your intervention and compare it
with costs during/after your intervention
 the diagnoses and treatments each patient recently received
 how long your super-utilizer patient has stayed in the hospital before your
intervention or how often the patient was readmitted
These data points can help direct your intervention with each patient and begin to
develop larger lessons for your work with super-utilizers.
If you are able to collect 6-12 months of hospital claims data for an entire hospital or
entire community, you can begin to understand community-level patterns,
including:
 total costs of care for super-utilizing patients in your community
 common diagnoses for super-utilizing patients in your community
 how long super-utilizer patients have stayed in the hospital or how often
super-utilizers have been readmitted.
Community level data is important to developing the broad story about what is
happening with super-utilization in your area, how it affects overall care and costs,
and what kinds of providers/partners needs to collaborate to address the issue(s).
Hospital claims data will not help you identify potential patients for your
intervention. In order to identify patients for an intervention you need close to realtime data so that you can identify and intervene with patients who are in the
hospital or very recently discharged. You can get real-time data either through a
health information exchange (HIE) or through the ADT
(admission/discharge/transfer) feeds from your partnering hospital(s).
What is the process for obtaining hospital claims data?
Hospital claims data can be requested through individual patient consent or through
a comprehensive data sharing agreement with a hospital.
When making a hospital claims data request be sure to ask for total hospitalization
costs (what is billed and what is reimbursed), date of admission, date of discharge,
diagnosis codes related to the hospitalization, insurance, address, and date of birth
for each patient and each hospitalization.
1) Individual patient consent
The easiest way to get hospital claims data is to have patients enrolled in
your super-utilizer intervention collect their own claims data. Patients must
contact the billing department at each hospital they have visited and provide
whatever consent the hospital claims department requires.
Patients can also provide consent for someone else, such as a member of the
super-utilizer team, to access this information on their behalf.
Often there is no official form for the patient to complete; rather, the hospital
may ask for a written, signed letter that states the name of individual
authorized to receive claims data, the specific information being requested
and the period of claims sought.
2) Data sharing agreement with a hospital
Hospitals may enter into agreements that will allow the hospital to share its
claims data with a third party / outside organization that will coordinate care
for its super-utilizers. These agreements allow individual patient data to be
shared without an individual consent to be signed. Usually, a Memorandum
Of Understanding (MOU) or a Collaborative Services Agreement (CSA) is used
to describe and govern the super-utilizer care coordination activities that
will be undertaken, and the role each party will play.
If the hospital claims data, which includes protected health information
(PHI), will be shared electronically, a Business Associates Agreement may
also be necessary to ensure that the exchange of data will be fully compliant
with federal law (HIPAA).
Samples of these agreements are available on the Camden Coalition’s
website.1
3) Institutional Review Board (IRB)
Hospital claims data may also be made available through the hospital’s IRB
1
http://www.camdenhealth.org/about/resources-2/contracts/
2
approval process. In addition to permitting the exchange of hospital claims
information, an IRB agreement allows you to conduct research on your
super-utilizer intervention. Talk to your hospital partner(s) about how to
pursue IRB approval.
Why is it important for a hospital to share hospital claims data with a superutilizer intervention?
There are specific benefits to hospitals that can support a super-utilizer intervention
by providing data to the program. Super-utilizing patients who regularly cycle in
and out of the hospital are generally expensive for the hospital to treat, and they
divert resources from others who need emergency department and inpatient care. A
successful super-utilizer intervention will reduce these burdens on any
participating hospital. A super-utilizer intervention may also lower the hospital’s
30-day readmission rate, which will keep the hospital from losing Medicare funding.
Lastly, super-utilizers often visit more than one hospital in a community.
Identifying and intervening with super-utilizers is not something an individual
hospital. By sharing data with community-wide super-utilizer intervention, a
hospital can gain efficiencies and effective care that would be outside of its
individual capacity.
How does HIPAA impact the collection of hospital claims data?
HIPAA permits hospitals to use and disclose their patients’ protected health
information (PHI), including hospital claims data, for the purposes of treatment,
payment and healthcare operations without obtaining individual patient consent.
Most super-utilizer interventions are a form of “treatment” because they include
the “provision, coordination, or management of health care and related services
among health care providers or by a health care provider with a third party.” 2
If a hospital identifies your program as a third party that will coordinate care for its
super-utilizers, that hospital may share information, including hospital claims data,
about its patients who may be eligible for the intervention without obtaining prior
patient consent.
Does HIPAA require the protection of hospital claims data?
Your program should be careful to comply with HIPAA by safeguarding all patient
information. HIPAA protects all individually identifiable health information, known
as protected health information (PHI), which includes name, address, birth date,
Social Security number, information that relates to the individual’s physical or
For information about uses and disclosures for treatment, payment, and health care operations, see:
http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/usesanddisclosuresfortpo.
html.
2
3
mental health condition, and the provision of or payment for health care to the
individual.
To make sure that PHI is not disclosed improperly, only save PHI on an encrypted
hard drive, and send any electronic communications containing PHI through a
secure email server. Furthermore, any disclosure of PHI should be limited to
information that is necessary to carrying out the care coordination intervention.
The hospitals you work with are a terrific source of information about HIPAA.
Generally, a hospital will have a Director of Compliance who can explain their
policies regarding PHI.
4
Hospital Claims Data FAQ
For Super-Utilizer Interventions
Four Roles of Data in a Healthcare High Utilization Intervention
Quantify the high
utilizer problem
Can hospital claims
data help?
Yes. Claims data
includes records for
each visit to the
emergency room or
inpatient stay. The
data can be
reorganized in a way
that summarizes the
yearly utilization (#
ED and # IP visits),
charges and receipts
for each patient.
Analysis of this data
can be used to quantify
the number and cost of
high utilizers to the
local healthcare
system.
What specific claims
data variables are
essential to have for
this component?
Unique patient id is
needed in order to
take individual claims
records and turn them
into an aggregate
utilization history.
What are the specific
software needs?
 Data analysis and
visualization
software
 If data is being
merged from
multiple hospital
systems, master
patient index
software is
needed in order
merge patient
utilization from
multiple hospitals.
Develop
interventions to
target the high
utilizer problem
Yes. Further analysis
of the claims data can
be used to facilitate a
discussion on what
interventions are
needed and how many
patients a program
will need to serve in
order to significantly
reduce costs.
Identify and engage
patients needed a
high utilizer
intervention
No. In order to
identify patients for
an intervention you
need close to realtime data. For
example, the best time
to begin an
intervention with an
inpatient high utilizer
is when they are
currently in the
hospital. Claims data
is historical data and
cannot identify
current inpatients
with a history of high
utilization.*
Patient address is
necessary in order to
explore geographic
hotspots.
NA
 Data analysis and
visualization
software
 ArcGIS mapping
software
NA
*Real time data for identifying patients for an intervention can be gathered in one of two ways:
Evaluate the impact
of the intervention
on the problem
Yes. Identifying
historic claims data for
patients receiving an
intervention can be
used to evaluate
program impact. For
example, calculating a
patients total costs 6
months prior to
program enrollment
and 6 months post
enrollment can
quantify the impact on
that particular
patients. Aggregating
this information for all
program participants
will quantify the total
program impact.
Patient name and date
of birth from the
claims data is needed
in order to link the
claims data to patients
participating in the
intervention
 Data analysis and
visualization
software
1) If your community has a Health Information Exchange (HIE), the HIE data can be used to create a daily report of
current hospital inpatients classified as high utilizers. HIE’s provide a more accurate identification of high utilizers
because the system aggregates data across hospitals and thus can identify a patient classified as high utilizers when
aggregating utilization across hospitals.
2) If you do not have an HIE you can work with individual hospitals to generate a list of patients currently admitted
to that hospital that have been admitted to that particular hospital 2 or more time in the last 6 months. This option
would miss cross-hospital system high utilizers, but should provide an ample number of patients for potential
enrollment. They key component of this option is developing a partnership with the hospital to run this list daily
and provide access to the list.