PHDSC Payer Type Work Group Joint NUBC / NUCC Meeting Baltimore, Maryland February 1, 2006

PHDSC Payer Type Work Group PHDSC Payer Type Work Group Organized July 20, 2000 Co-Chairs: 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) Judy Parlato, M.B.A., B.S.N., R.N. Clinical Advisor Massachusetts Division of Health Care Finance & Policy

PHDSC Payer Type Work Group Goals of the Committee To create a payer type standard for reporting payer data for health care services. 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 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 type standard will be flexible, expandable and allow for different levels of detail. The payer standard will be one that all providers can use. The payer standard will be one that all providers can use.

PHDSC Payer Type Work Group Need for Payer typology There is currently no national standard for reporting and classifying source of payment data. 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. 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. 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. 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 09Self-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 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

PHDSC Payer Type Work Group Current Situation This is reportable as the Claim Filing Indicator in SBR09 in the Subscriber and Patient Loops This is reportable as the Claim Filing Indicator in SBR09 in the Subscriber and Patient Loops There are major problems with that list There are major problems with that list Definitional ambiguities Definitional ambiguities What is Central Certification (code 10)? What is Central Certification (code 10)? Overlapping issues Overlapping issues How do you distinguish a Medicare or Medicaid Managed Care Plan from a private Managed Care Plan? How do you distinguish a Medicare or Medicaid Managed Care Plan from a private Managed Care Plan? Analysis Problems Analysis Problems current categories are not organized in a way to facilitate analysis of payer policies or issues 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 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 Situation Maintenance to the ANSI ASC X12 list requires a change to the standard. 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. 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. Commonly used data element by states, but improvements would be welcomed.

PHDSC Payer Type Work Group Accomplishments to Date Developed a flexible and expandable Payer typology for reporting and analyzing payer data called “Possible Source of Payment typology” 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. Refinement of the Payer Typology. Collaboration with The Agency for Healthcare Research and Quality (AHRQ) Hospital Cost and Utilization Project (HCUP) 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. 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. Modifications made to the PHDSC Payer Typology based on review.

PHDSC Payer Type Work Group Example from the typology 01 MEDICARE (SBR09 value - MA or MB) 1. Medicare (managed care) 1 Medicare HMO (SBR09 value - 16) 2 Medicare PPO 3 Medicare POS 9 Medicare managed care other 2. Medicare (non-managed care) 1 Medicare FFS 2 Medicare drug benefit 3 Medicare Medical Savings Account (MSA) 4 Medicare drug benefit (Part D) 9 Medicare non-managed care other

PHDSC Payer Type Work Group Final Thoughts  Updated Payer Typology available on PHDSC website at:  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 Questions?