Health Care Quality and Cost Council Communications and Transparency Committee - PowerPoint PPT Presentation

1 / 17
About This Presentation
Title:

Health Care Quality and Cost Council Communications and Transparency Committee

Description:

Implemented Health Safety Net claims processing in house, on time, under short deadline. ... Level 1 contains only utilization information by type of service ... – PowerPoint PPT presentation

Number of Views:22
Avg rating:3.0/5.0
Slides: 18
Provided by: divisionhe8
Category:

less

Transcript and Presenter's Notes

Title: Health Care Quality and Cost Council Communications and Transparency Committee


1
Health Care Quality and Cost Council
Communications and Transparency Committee
  • Proposal for DHCFP Management of
  • QCC Claims Data Intake and Analytic File
    Production
  • March 12, 2009

2
DHCFP Proposal
  • Building on expertise and experience with health
    care claims data, the Division of Health Care
    Finance and Policy would be ready to assume
    responsibility for the intake and storage of QCC
    claims data and production of public use data
    sets beginning July 1st, 2009.

3
Project Management Team
  • David Wessman, CIO, Division of Health Care
    Finance and Policy
  • Will supervise design efforts ensure continuing
    integrity of hardware and software systems and
    implement technical architecture
  • Related experience
  • Implemented Health Safety Net claims processing
    in house, on time, under short deadline.
  • Oversees intake of casemix data as well as
    hospital and community health center financial
    filings
  • Extensive development of analytic tables for use
    in edit and QA of major datasets
  • Dave will oversee Chloen Systems Inc.
  • Chris Campeau, Chloen lead, has extensive
    experience designing claims adjudication systems
  • Will design and test the claims intake functions
    develop, test and implement key reference and
    edit tables and provide overall technical
    management of the process.
  • Projects completed include HSN Claims Data
    Collection (medical, eligibility and pharmacy)
    UCP Pharmacy Claims Data Collection UCP
    Hospital/CHC Claims Data Collection Insurer and
    Third Party Payer Surcharge Collection
  • Linda Green, Director, Health Data Analytics,
    Division of Health Care Finance and Policy
  • Will oversee development of QA metrics, design of
    public use file specifications production of
    related documentation annual dataset updates
    liaison to MHQP data staff and review of public
    use data requests
  • Related experience
  • Liaison to HCQCC staff during 2008 website
    analytics development
  • Supervises analytic staff responsible for
    Division reports, including utilization and
    casemix data verification and public data file
    production

4
Advantages of DHCFP Management of QCC Claims
Intake and Public Use File Production
  • Expertise in MA health data environment
  • Streamlined data intake
  • Enhanced quality assurance
  • Enhanced collaboration with insurers
  • Production of analysis-ready pubic use files
  • Integrated data intake and analysis

4
5
DHCFPs Expertise with Health Data
  • Experience with similar claims data
  • Health Safety Net claims processing
  • Intake, payment and analysis with links to
    eligibility files
  • Retrieval of pharmacy data incorporated into
    payment system
  • Built claims processing model in less than 6
    months
  • Long experience with Hospital Inpatient, ED, and
    Observation Stay datasets
  • Over 20 years of increasing access and
    availability to the public
  • Continuous, reliable data security maintained
    from intake through storage
  • Successful annual creation of six levels of
    regulation-compliant datasets
  • Experience with 2008 HCQCC Data
  • Implemented rigorous data quality tests on MHIC
    data extracts
  • Filled MHIC knowledge gaps about MA hospital
    volume and naming conventions
  • Developed and produced summary analytics for
    comparison and review by HCQCC members and staff

5
6
Data Intake Model
  • Utilize existing secure, streamlined file
    transfer system
  • Data passed into warehouse is fully encrypted and
    edited for accuracy
  • Security conforms to highest standards
  • Advantages
  • Minimal transition for carriers
  • Uninterrupted data submissions
  • Ability to implement automated submission process
    (currently staff at each insurer must manually
    manage the file transfer process)

7
Enhanced Quality Assurance
  • Evaluate data integrity and consistency
  • QA testing for internal logic
  • Review distribution of values across time and
    within particular parameters
  • Compare current month submission to historical
    averages
  • Establish benchmarks for common data quality
    metrics
  • Create documentation of issues to allow analysts
    to account for unanticipated effects
  • Verification checks with carriers
  • Reports developed with input of carriers
  • Advantage
  • Develop and apply testing protocols to ensure
    that QCC claims dataset is reliable for research,
    health care trend monitoring and calculation of
    measures for QCC website
  • Opportunity for carriers to review and validate
    QA reports

7
8
Collaboration with Insurers
  • Convene Technical Advisory Group
  • Venue during transition for reviewing data
    submission issues common to all plans
  • Provides standard point of contact to communicate
    with both in-state and out-of-state insurers
  • Provide input on data verification report design
  • Advantage
  • Discuss submission issues affecting more than one
    insurer

9
Public Use File Creation
  • Regulatory Guidance (129 CMR 4.00)
  • Certain fields are not included at any level
    (name, date of birth, address)
  • Level 1 contains only utilization information by
    type of service
  • Level 2 contains more detailed claims information
  • Level 3 will only be released to state agencies
  • Data Release Review Board to develop regulatory
    clarifications and fee schedule for review by QCC
  • Public Use File specifications and documentation
  • Time periods and how different types of services
    are grouped
  • Member demographic information (as permitted by
    regulation for the specific level) to expedite
    analysis
  • Describe how any summaries or value added fields
    were created
  • Document known issues about the data
  • Advantages
  • Accurate, analyst ready files in accordance with
    existing regulatory guidance
  • Timeline
  • Non-grouped, flat file would be available
    starting summer 2009

10
Integrated Data Intake and Analysis
  • Local data management allows more flexible
    queries and investigation of issues
  • Allows rapid resolution of questions and concerns
  • Access will support testing of MHQP-proposed
    measurements early in the development process

11
Next Steps Expand Dataset to All Payers
  • MassHealth conversations initiated
  • Medicare application process now underway
  • Drafting required supporting documentation
  • Schedule for dental claims in-take to be reviewed
    in conjunction with MHQP recommendations

12
Proposed Timetable
12
13
Cost of Claims Intake, Warehousing and Analytic
Dataset Production
13
14
Additional Information
15
Role of the Maine Health Information Center (MHIC)
  • MHIC became the HCQCC Data Intake Coordinator in
    late 2007
  • Contract covered carrier claims intake process,
    including
  • application of encryption software,
  • running edits,
  • storing the passed submissions, and
  • coordinating with carriers to resolve issues with
    submitted files.
  • Deliverables included statistical plan and data
    dictionaries
  • Based on Maine and New Hampshire documentation.
  • Began data intake in early 2008
  • Contract amendment needed to create analysis
    ready extract for website measure calculation
  • Limited to 8 carriers and one year
  • Extract only included for 19 specified conditions
    or surgeries
  • Outpatient file

16
Dataset Status
  • MHIC warehouse holds billions of paid claims
    lines from 28 carriers
  • Date of service July 2006 forward
  • To date, includes fully insured and some self
    insured
  • Minimal data quality edits are run
  • Passed files are loaded into the data warehouse
  • Failed files are reported to carrier for
    resubmission or edit criteria are overwritten on
    a plan-by-plan, month-by-month basis to allow the
    file to pass
  • Carriers are largely compliant
  • Data is then stored in the MHIC warehouse until
    analytic data is requested via contract amendment
  • One time development of analytic extract dataset
    for website launch occurred in spring 2008 at a
    cost of 40,000

16
17
Recent Experience From Claims Lines to
Inpatient Discharges for the 2008 Cost Measures
  • Carriers submit line by line claims data
  • MHIC holds these claims lines in its warehouse
  • Includes all versions of the claim paid, voided,
    adjusted
  • May include a variety of product lines
    commercial, Medicare
  • Organized by date paid
  • Includes over 30,000 home grown codes that do
    not match standard ICD-9
  • More than 640,000 unique provider names records
    in MA alone
  • Member information is valid within a particular
    carrier but has not been verified across all
    carriers
  • To build an analytic dataset, the data must be
  • Reviewed to determine the final claim status and
    exclude earlier versions
  • Limited to MA providers and given a standardized
    hospital name
  • Edited for non-MA providers and non-MA residents
  • Aggregated into discharges
  • Run through a severity grouper (inpatient claims
    only)
  • Examined for obvious differences in payment rules
    (such as mom/baby rates for obstetrical stays)

17
Write a Comment
User Comments (0)
About PowerShow.com