Source of Payment Typology:

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• Source of Payment Typology
• A New National Standard
• Roxanne Andrews, PhD
• Chair, 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/Outreach
• Maintenance

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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
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
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
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SolutionSource 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
1 2 3 4 5 6 7 8 9 Medicare Medicaid Other 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

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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