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PHDSC Payer Type Work Group. Joint NUBC / NUCC Meeting Baltimore, Maryland February 1, 2006. PHDSC Payer Type Work Group Organized July 20, 2000. Co-Chairs: Amy Bernstein, Sc.D. Chief Analytic Studies Branch/Office of Analysis and Epidemiology

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phdsc payer type work group

PHDSC Payer Type Work Group

Joint NUBC / NUCC Meeting

Baltimore, Maryland

February 1, 2006

phdsc payer type work group organized july 20 2000
PHDSC Payer Type Work GroupOrganized July 20, 2000
  • Co-Chairs:

Amy Bernstein, Sc.D.

Chief

Analytic Studies Branch/Office of Analysis and Epidemiology

Centers for Disease Control and Prevention (CDC)

National Center for Health Statistics (NCHS)

ztl1@cdc.gov

Judy Parlato, M.B.A., B.S.N., R.N.

Clinical Advisor

Massachusetts Division of Health Care Finance & Policy

Judy.Parlato@hcf.state.ma.us

PHDSC Payer Type Work Group

goals of the committee
Goals of the Committee
  • To create a payer type standard for reporting payer data for health care services.
  • The payer standard will allow for consistent comparison of the payment category from various data sets and across different types of providers.
  • The payer type standard will be flexible, expandable and allow for different levels of detail.
  • The payer standard will be one that all providers can use.

PHDSC Payer Type Work Group

need for payer typology
Need for Payer typology
  • There is currently no national standard for reporting and classifying source of payment data.
  • Existing ASC X12N 837 categories in the subscriber section are currently neither mutually exclusive nor comprehensive.
  • Ability to compare source of payment data across databases is critical to policymakers and researchers examining effects of payment policy.
  • PlanID is not expected to meet the Committee’s goals.

PHDSC Payer Type Work Group

current claim filing indicator list used in 837 implementation guides
Current Claim Filing Indicator List used in 837 implementation Guides

CH Champus

CI Commercial Insurance Co.

DS Disability

HM Health Maintenance Organization

LI Liability

LM Liability Medical

MA Medicare Part A

MB Medicare Part B

MC Medicaid

OF Other Federal Program

TV Title V

VA Veteran Administration Plan

WC Workers’ Compensation Health Claim

ZZ Mutually Defined / Unknown

09 Self-pay

10 Central Certification

11 Other Non-Federal Programs

12 Preferred Provider Organization (PPO)

13 Point of Service (POS)

14 Exclusive Provider Organization (EPO)

15 Indemnity Insurance

16 Health Maintenance Organization (HMO) Medicare Risk

AM Automobile Medical

BL Blue Cross/Blue Shield

PHDSC Payer Type Work Group

current situation
Current Situation
  • This is reportable as the Claim Filing Indicator in SBR09 in the Subscriber and Patient Loops
  • There are major problems with that list
    • Definitional ambiguities
      • What is Central Certification (code 10)?
    • Overlapping issues
      • How do you distinguish a Medicare or Medicaid Managed Care Plan from a private Managed Care Plan?
    • Analysis Problems
      • current categories are not organized in a way to facilitate analysis of payer policies or issues
      • difficult and in some cases impossible with Medicare and Medicaid managed care to analyze payment issues within states or across states

PHDSC Payer Type Work Group

current situation7
Current Situation
  • Maintenance to the ANSI ASC X12 list requires a change to the standard.
    • That adds to the complexity of maintaining a list that meets industry needs in a timely manner.
  • Commonly used data element by states, but improvements would be welcomed.

PHDSC Payer Type Work Group

accomplishments to date
Accomplishments to Date
  • Developed a flexible and expandable Payer typology for reporting and analyzing payer data called “Possible Source of Payment typology”
    • main category with sub-categories containing finer detail, allowing sub-categories to be rolled up if necessary.
  • Refinement of the Payer Typology.
    • Collaboration with The Agency for Healthcare Research and Quality (AHRQ) Hospital Cost and Utilization Project (HCUP)
    • AHRQ/HCUP review of current state Payer reporting practices for 33 states using the Typology as the framework.
    • Modifications made to the PHDSC Payer Typology based on review.

PHDSC Payer Type Work Group

example from the typology
Example from the typology

PHDSC Payer Type Work Group

final thoughts
Final Thoughts
  • Updated Payer Typology available on PHDSC website at:

http://phdatastandards.info/about/committees/payer.htm

  • National Center for Health Statistics will be responsible for maintaining the list.
  • The PHDSC payer work group committee will be developing a guidelines and definition document.
  • Respond to NPRM PlanID when released for comment:
    • incorporate PHDSC’s Typology into mechanics of PlanID system
    • leveraging support from Consortium members in this effort.
  • Continue outreach to the industry on viability of typology. (Note: Georgia is first state planning to pilot this typology)
  • Propose a change to the standards.
    • An external code source for X12 standards to be appended to the SBR segment
    • a Code-Code-Value on the UB-04

PHDSC Payer Type Work Group

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Questions?

PHDSC Payer Type Work Group