Transcript Payer Typology: What You Need To Know

Payer Typology:
What You Need To Know
September 2007
Prepared by
Bob Davis
Representing the Public Health Data Standards
Consortium, Payer Type Workgroup
Topics
• Purpose and potential users of Payer
Typology
• Use of Payer Typology
• Available Documentation
• Status of Pilots
• Relationship to National Standards
• Maintenance Activities
Purpose of Payer Typology
To provide a standardized, flexible, and
complete code set that classifies payer (e.g.,
Medicare, VA, private insurance, charity care)
and when possible, to differentiate
organization of payment (e.g., HMO, PPO,
private insurance)
Purpose of Payer Typology
The Payer Typology incorporates typical state
specific requirements, as well as being flexible
enough to be used as a code set in surveys and
other data collected for research or policy
purposes.
Potential Users of Payer Typology
•Researchers
•Policymakers
•Health services researchers
•Public health departments
•Health administrators
•Health care practitioners
•Others concerned with the relationship between
payer and health care access, quality of care,
utilization patterns, and treatment outcomes
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.
Current Claim Filing Indicator List used in
837 implementation Guides
09
10
11
12
13
14
15
16
AM
BL
Self-pay
Central Certification
Other Non-Federal Programs
Preferred Provider
Organization (PPO)
Point of Service (POS)
Exclusive Provider
Organization (EPO)
Indemnity Insurance
Health Maintenance
Organization (HMO)
Medicare Risk
Automobile Medical
Blue Cross/Blue Shield
CH
CI
DS
HM
LI
LM
MA
MB
MC
OF
TV
VA
WC
ZZ
Champus
Commercial Insurance Co.
Disability
Health Maintenance Organization
Liability
Liability Medical
Medicare Part A
Medicare Part B
Medicaid
Other Federal Program
Title V
Veteran Administration Plan
Workers’ Compensation Health
Claim
Mutually Defined / Unknown
Need for Payer typology
Examples of deficiencies in existing code set:
• “HMO” cannot distinguish among Medicare,
Medicaid or privately financed HMOs
• There is no way to distinguish among different
types of Medicare Advantage Plans
• “Champus” no longer exists
• “Self-pay” cannot distinguish among charity care,
professional courtesy, and bad debt
• Some codes are adminstrative hold-overs (e.g.
“Central Certification”)
Use of Payer Typology
• Hierarchical Value Set
– Enables reporting at lowest level of
granularity available
– Enables use at highest level of
granularity needed
Use of Payer Typology
• Payer Type codes are defined as up to six leftjustified alpha numeric characters.
• Each character from the left to the right
represents a new hierarchical level in the value
set.
• The typology is loosely modeled on the ICD
classification system for disease, which codes to
the most specific disease possible.
Use of Payer Typology
•
•
The first digit of each code is the
organization that provides the funds for
the care;
Additional digits provide more
information about the specifics of the plan
or mechanism through which these funds
are provided.
Major Payor Codes
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
Example of second- and third-digit
codes
1
11
MEDICARE
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
Example of second- and third-digit
codes
8
NOPAYMENT from an Organization/Agency/Program/Private Payor
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
Use of Payer Typology
• Explanation of Example
– Current payer classification value sets typically
have only ONE category for non-payment.
– If a patient’s care is reported as CHARITY, the
researchers could analyze those patients
receiving CHARITY Care, or include those
patients with other patients with NO CHARGE
for care, or include those patients with any
where NOPAYMENT for services to the
provider.
Available Documentation
• The Payer Typology –
– http://www.phdsc.org/about/committees/pmt_typology.htm
– The complete hierarchical list of payer categories
• The Payer Typology User Guide
– http://phdsc.org/standards/payer-typology.asp
– & click on Users Guide for Source of Payment Typology
– Payer Category definitions and relevant standards
information
• Public Health Data Standards Consortium Payer
Work Group
– http://phdsc.org/standards/payer-typology.asp
– Group responsible for development and maintenance of
Payer Typology
Status of Pilots
• State of Georgia
– Implementation of Payer Typology hierarchies
by January 2008 for all Georgia discharges for
calendar year 2007.
– Georgia hospitals will be given an opportunity
to stage the reporting of Payer Typology
categories between now and next year.
– NOTE: Georgia is implementing three (3)
hierarchical levels of full Payer Typology, which
currently provides granularity to five (5)
hierarchical levels.
Status of Pilots
• State of California
– Deficiencies of all current payer type code sets have
been identified.
– Staged migration plane for their inpatient collection
system to use ANSI X12 837 and UB-04.
• Establish an electronic connection between the State
and providers
• Migrate legacy system to use standard data content
• Full migration to national formats
– Anticipated that the Payer Typology will replace their
legacy code system with migration to ANSI 837 and UB04
Status of Pilots
• State of Massachusetts
– The proprietary payer type code list
used by the State of Massachusetts is
problematic.
– The state data agency is planning to
solicit the hospital feedback during
calendar year 2007 on the merits or
deficiencies of the Payer Typology as a
replacement to their current proprietary
payer type classification list.
Relationship to National Standards
• Currently Data Maintenance in progress to reference the
•
•
•
typology in the ANSI X12 standards within the 837
transaction.
It is anticipated that the October 2007 (5050) and
beyond versions of the ANSI X12 standards will provide
support for the reporting of the Payer Typology.
It is anticipated that 5050 and beyond versions of the
Health Care Service Data Reporting Guide will support
the reporting of the Payer Typology.
Current versions of 837 implementation guides could
support reporting of the Payer Typology in the K3
segment with approval of the ANSI X12N Health Claims
Work Group (TG2 WG2)
Maintenance Activities
• The Source of Payment Typology is maintained by
the National Center for Health Statistics / Centers
for Disease Control and Prevention.
• Requests to change typology should be directed
to the Payer Type Subcommittee of the Data
Standards Committee of the Public Health Data
Standards Consortium.
(http://phdsc.org/standards/payer-typology.asp)
Bob Davis
Health Data Standards Consultant
[email protected]
518-456-1735
Maintenance Activities
• Changes to the Source of Payment Typology are
•
made bi-annually in October and April.
Any interested industry representative can make
recommendations for additions or modifications
by sending their comments via email to the
committee co-chairs.
• These recommendations would be voted on by
members of the Payer Type Subcommittee for
possible inclusion in the Source of Payment
Typology.