Source of Payment Typology: A New National Standard Roxanne Andrews, PhD
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Source of Payment Typology:
A New National Standard
Roxanne Andrews, PhDChair, Source of Payment TypologySubcommittee
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Agenda
• Overview of Typology Subcommittee
• Overview of Typology
• Implementation of Typology
• Activities over the Coming Year
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THE SUBCOMMITTEE
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Source of Payment Tpology Subcommittee
• Subcommittee of the Data Standards Committee
• Purpose: to create and refine a standard to allow consistent reporting of payer data to public health agencies for health care services and research
• The Payer Typology is an early project for the Consortium (starting in 2000) with continual successes over the years
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Typology Subcommittee
Patricia Andrews
Louisiana State University Health Sciences Center
Louisiana Tumor Registry
Amy Bernstein*
CDC/NCHS
Robert Bolden
Georgia Hospital Association
Robert Davis
Consultant
Sheila Frank
Consultant
Regina Gibson
Blue Cross Blue Shield Michigan
Marjorie Greenberg
CDC/NCHS
Tammara Jean Paul
CDC/NCHS
Hetty Khan
CDC/NCHS
Starla Ledbetter
California Office of Statewide Health Planning and Development
Denise Love
National Association of Health Data Organizations (NAHDO)
Anna Orlova
Johns Hopkins School of Public Health
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Typology Sub-Committee
Charlotte Pease
Maine Health Data Organization
Barbara A. Rudolph
University of Wisconsin - Madison
Cristal Schoenfelder
CA Office for Statewide Health Planning and Development
Gale Scott
Tampa General Hospital
Castine Verrill
CDC/NCCDPHP
Michelle Williamson
CDC/NCHS
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SOP Typology Subcommittee Phases of Activities
• Developed standard payer codes, definitions & user guide
• Worked with national standards groups to have the SOP Typology accepted– ANSI X12– NUBC– HL7 (& PHIN)
Implementation & Education/OutreachMaintenance
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SOURCE OF PAYMENT
TYPOLOGY
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Importance of Source of Payment Data
• Source of payment data used for wide variety of public health and healthcare research
• Critical need for policymakers and researchers examining effects of payment policy to compare across databases
• Standardized source of payment data needed to monitor healthcare trends such as access to healthcare and treatment patterns across payer categories
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Payer Coding for National Quality Monitoring
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Risk-adjusted Inpatient Heart Attack Mortality
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Payer Coding for Tracking National Hospital Costs
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Issues with Payer in Administrative Data Collected Today
• No uniformity across states• NO DEFINITIONS FOR CONCEPTS• Missing Concepts
– For example: bad debt and charity care
• Overlapping Concepts– For example: Health Maintenance Organization
• Obscure Concepts– For example: Central Certification
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Current Claim Filing IndicatorList Used in 837 Implementation Guides
09 Self-pay10 Central Certification11 Other Non-Federal Programs12 Preferred Provider Organization (PPO)13 Point of Service (POS)14 Exclusive Provider Organization (EPO)15 Indemnity Insurance16 Health Maintenance Organization (HMO) Medicare RiskAM Automobile MedicalBL Blue Cross/Blue Shield
CH Champus CI Commercial Insurance Co.DS DisabilityHM Health Maintenance OrganizationLI LiabilityLM Liability MedicalMA Medicare Part AMB Medicare Part BMC MedicaidOF Other Federal ProgramTV Title VVA Veteran Administration PlanWC Workers’ Compensation Health ClaimZZ Mutually Defined / Unknown
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Solution:Source of Payment Typology
• Designed to improve the organization of the payment categories
• Provides robust definitions
• Hierarchical structure
• Definitions for ALL the concepts
• Companion User Guide for each version of the Source of Payment Typology
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Major Payer Categories
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Medicare
MedicaidOther Government (not Medicare, Medicaid or corrections)
Department of Corrections
Private Health Insurance
Blue Cross/Blue Shield
Managed Care, unspecified (*)
No payment from organization
Miscellaneous/other
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Source of Payment Typology Categories:
Major and Sub-classifications
1 MEDICARE
11 Medicare (Managed Care)
111 Medicare HMO
112 Medicare PPO
113 Medicare POS
119 Medicare Managed Care Other
12 Medicare (Non-managed Care)
121 Medicare FFS
122 Medicare Drug Benefit
123 Medicare Medical Savings Account (MSA)
129 Medicare Non-managed Care Other
19 Medicare Other
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Second Level Sub-classification
2 MEDICAID
21 Medicaid (Managed Care)
211 Medicaid HMO
212 Medicaid PPO
213 Medicaid PCCM (Primary Care Case Mgt)
219 Medicaid Managed Care Other
22 Medicaid (Non-managed Care Plan)
23 Medicaid/SCHIP
24 Medicaid Applicant
25 Medicaid - Out of State
29 Medicaid Other
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Third Level Sub-classification
2 MEDICAID
21 Medicaid (Managed Care)
211 Medicaid HMO
212 Medicaid PPO
213 Medicaid PCCM (Primary Care Case Management)
219 Medicaid Managed Care Other
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Additional Level Classification
32 Department of Veterans Affairs
321 Veteran care--Care provided to Veterans
3211 Direct Care--Care provided in VA facilities
3212 Indirect Care--Care provided outside VA facilities
32121 Fee Basis
32122 Foreign Fee/Foreign Medical Program(FMP)
32123 Contract Nursing Home/Community Nrsing Home
32124 State Veterans Home
32125 Sharing Agreements
32126 Other Federal Agency
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Additional Level Classification
8 NO PAYMENT from an Organization / Agency / Program / Private Payer Listed
81 Self Pay
82 No Charge
821 Charity
822 Professional Courtesy
823 Research / Clinical Trial
83 Refusal to Pay / Bad Debt
84 Hill Burton Free Care
85 Research / Donor
89 No Payment, Other
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IMPLEMENTATION I:Hospital Discharge
Data Systems
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States Using the Source of Payment Typology
• Georgia – 2007
• Oregon – 2008
• New York – 2009
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IMPLEMENTATION II:Quality eMeasures
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Supplemental Data Elements in eMeasures Include Payer
• Supplemental data elements are included in quality emeasures– To aggregate data to various subgroups– To compare quality across subgroups to
identify disparities
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CMS and National Quality Forum Use Typology as the Value Set for "Payer"
• CMS 2014 Meaningful Use Clinical Quality Measures (CQM) require 4 supplemental data: sex, race, ethnicity, payer
• NQF Measure Authoring Tool for emeasures includes "payer" as default supplemental data
• National Library of Medicine includes Typology in Value Set Authority Center for 2014 CQM
– Raised the issue of "intellectual property" for PHDSC Board 25
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ACTIVITIES OVER THE
COMING YEAR
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Maintenance Activities
• Annual maintenance meeting in spring– opportunity for public comments and requests
• Typology categories and / or definitions updated every October (as needed)
• Periodic Subcommittee conference call discussions of impact of insurance system changes on needed payer categories (e.g. from ACA)
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Education/Outreach
• Webinars, conference presentations, emails to target audiences– e.g., Webinar Nov 19
• Identify & take advantage of opportunities that arise– e.g., this year- PHDSC letter comments on
the proposed Federal rule on the health plan ID recommended the Typology be included in the CMS registry for the plan ID
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Questions
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