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What Makes the Cut for Colorado APCD Public Reports?

The Colorado APCD currently contains approximately 86 million medical claims and about 100 million pharmacy claims submitted by commercial health insurance companies and Medicaid. These claims currently reflect health care utilization and spending for the period 2009 through 2012 and represent nearly 3.1 million unique Coloradans. I speak from personal experience when I say that this is a lot of claims data! Despite the vast amount of claims currently in the APCD, the public website www.cohealthdata.org doesn’t reflect all of the claims received or all health care services provided in Colorado.

The consumer-focused information that will launch on the public website July 31, 2014 will show variation in typical or median amounts paid for common medical procedures along with select quality indicators. The purpose of publicly reporting this information is to help consumers more meaningfully shop for health care. Availability of this information will be especially helpful to individuals and families with high deductible health plans and medical savings accounts they must manage largely on their own. Unlike most products purchased on a regular basis, there is currently no comparative price or quality information available that would allow consumers to make more informed, value-based decisions regarding their health care.

In the following sections, I’ll explain what claims are included and which ones do and do not make the cut for inclusion in current and future public reporting.

Claims Data Submitted to the Colorado APCD

As noted in Edie Sonn’s blog this month, the Colorado APCD does not currently contain claims data for Medicare Fee for Service (FFS) or self-funded commercial health plans. The Medicare FFS program is administered by the Centers for Medicare and Medicaid Services (CMS) and self-funded plans are regulated under the federal Employee Retirement Income Security Act (ERISA). As you may recall from a long ago Civics lesson, federal law is the supreme law of the land and states cannot enact legislation that conflicts with or otherwise preempts federal law. As a result, House Bill 10-1330, passed in 2010 to establish the Colorado APCD, could not require self-funded plans or CMS to submit data. Because services provided to the uninsured or self-pay patients do not generate insurance claims, the APCD cannot provide information regarding costs or use of health care services by these groups.

Claims Data is Often Messy

Claims data isn’t included in public reports if it appears inaccurate or otherwise doesn’t make sense. For example, we don’t include claims for services provided in unexpected settings of care. We recently discovered that about 750 babies per year were (according to the claims) being delivered in a hospital psychiatric unit. All potential jokes about the impact of kids on their parents aside, since we do not expect to see babies delivered in a psychiatric unit, our APCD report process eliminates claims for services rendered in unexpected places. We also found an average of 35 babies delivered per year in a cancer treatment center according to the submitted claims. To ensure accurate public reporting that reflects typical patient experience in Colorado, we exclude claims that contain potentially inaccurate or unexpected information.

Missing or Invalid Provider Name or Identifier

Some submitted claims are not reflected in APCD public reports because of missing or invalid information regarding the entity (e.g., hospital, physician, etc.) providing services. This is often due to an unrecognized provider name or location, or missing National Provider Identifier (NPI) number. If it is not possible to accurately associate medical services with a recognized health care provider, information from the claim will not be reflected in public reports.

Patient is from out of State or receives services out of State

Some of the claims submitted to the Colorado APCD are associated with individuals who live in other states. This occurs when people visiting Colorado require medical services that are billed by Colorado providers. Because the goal of the APCD is to provide information that reflects the experience of Colorado residents, claims for individuals that live out of state are not included in public reports. Similarly, claims for medical services provided to Colorado residents outside of the state are not reflected in public reports available on the APCD website.

Patient is 65 or Older

The Colorado APCD does not currently contain claims information for beneficiaries covered by the Medicare Fee for Service (FFS) program administered by CMS. Although CIVHC is working to incorporate Medicare FFS claims data into the APCD, public reports do not currently reflect services provided to Colorado residents aged 65 and older.

Claim Reflects $0 Paid or is for Coordination of Benefits

Occasionally, claims submitted to the Colorado APCD show a $0 paid amount. There may be a variety of reasons for this, but as the old saying goes, “nothing in this life is ever free!” Because health care services provided at $0 cost are unlikely to reflect a typical experience, these claims are not included in the calculations.

In some cases, an individual will have more than one insurance plan or more than one type of health coverage. For these patients, Coordination of Benefits (COB) claims ensure that medical services are paid for by the appropriate insurance plan and help to avoid multiple payments for the same service. Some COB claims show a $0 paid amount but list medical services already reimbursed by primary coverage. To avoid over-counting utilization and under-representing costs, COB claims with $0 paid are not reflected in public reports.

Claim Paid Amount is an Outlier

Some claims submitted to the Colorado APCD reflect unusually low or exceptionally high paid amounts for particular services. In some cases, this is due to mistakes in data entry or processing such as misplaced decimal points or a variety of other potential errors. For instance a claim for $100.00 can appear to be $10,000 if the decimal point was not included or otherwise dropped in data entry or claims processing. In other cases, very ill or badly injured patients may experience much higher than expected costs. These cost “outliers” on both the low and high end are not reflected in median total paid amounts. More specifically, in addition to eliminating claims with $0 paid, the top and bottom two percent of claims (based on total paid amounts) are eliminated before median prices are calculated for purposes of public reporting.

So, what is CIVHC doing about all of this?

To ensure that the APCD is a valuable resource for all residents of Colorado, CIVHC continues to work diligently to improve the accuracy and completeness of claims information submitted.
More specifically, CIVHC:

  • Works constantly with both public payers and private health plans to improve the quality, completeness and accuracy of claims data submissions and to eliminate strange results that don’t appear to make sense.
  • Has worked closely with HCPF to obtain Medicare FFS claims data and information for people aged 65 and older will begin to appear in APCD public reports later this year.
  • Is working closely with various stakeholders to develop a strategy and timeline to obtain claims data for self-funded health insurance plans.
  • Will continue to engage with all interested stakeholder groups to make the APCD a valuable and comprehensive source of information that benefits all Coloradans and helps to realize the goals of better health, better quality and lower cost.

If you have questions related to claims data submitted to the Colorado APCD or what is currently available and what is coming, please contact me at jmathieu@civhc.org.
 

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