Maine all provider all payer claims database what you need to know but were too afraid to ask
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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. 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)

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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

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


  • 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


  • 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


Maine Health Data Processing Center

Annual Budget

Maine Claims Data Flow

Commercial Payers

Data Feeds/Resubmissions




Governmental Payers







Data Requestors



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)



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