Introduction to Medicare Utilization Data Created by Sarah - - PowerPoint PPT Presentation

Introduction to Medicare Utilization Data

Created by Sarah Brunsberg

About ResDAC

• Centers for Medicare and Medicaid (CMS)

contractor

• Offer free assistance to researchers interested in

using Medicare and Medicaid data for research

• Staffed by a team of public health and health

services research specialists

• Provide a range of services related to CMS data

˗ Assistance Desk ˗ Workshops and Outreach

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Overview of Medicare Utilization Data

• Goals for today

˗ Define claims data or utilization data ˗ Define the claims types ˗ Discuss the types of claims files that CMS has available

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What are claims data?

• Claims data is derived from reimbursement or

payment of bills

• Claims are bills for services provided to the

Medicare enrollees

• The information in the claims data that is

necessary to pay the bill will be of higher quality than other information

˗ The enrollment data are the basis for determining whose bills are qualified to be paid ˗ Demographic information is largely reliable and valid because it comes from the SSA and the states

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Claims Data: A rich data source

• It is estimated that 98% of adults age 65 and over

are enrollment in Medicare

• Over 99% of deaths in the US for persons age 65

and older are accounted for in the Medicare program

• Information contained in claims data include

diagnosis information, procedure information, dates of service and payment and reimbursement information

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Information on a Claim

• Basic information regarding the service provided:

dates of service, beneficiary information

• Procedure and diagnosis codes
• Payment amounts
• Provider information
• Fee for service utilization

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Claim Types

• Institutional:

˗ Inpatient ˗ Outpatient ˗ Skilled Nursing Facility ˗ Home Health Agency ˗ Hospice ˗ MedPAR file (combines Inpatient and Skilled Nursing)

• Non-Institutional:

˗ Physician/Supplier (AKA Carrier) ˗ Durable Medical Equipment Suppliers

• Prescription Drug Events:

˗ Part D Event Data

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Claims Forms

• CMS collects data on two different forms:
• Uniform Bill-04 (AKA UB-04 or historically CMS-1450)

˗ Institutional providers provide services covered under Part A

• benefit. But, not necessarily exclusively

» Providers or Part A services only: Skilled nursing facilities and hospices » Providers of Part A and Part B services: Hospitals and home health agencies

• CMS 1500

˗ Only used by non-institutional providers which includes: physicians, nurse practitioners, clinical laboratories, ambulance services, durable medical equipment suppliers, stand-alone ambulatory surgical centers

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Claims Processing

• The claims research files contain more variables

than those found on the claim form

˗ Additional fields are added during claims processing ˗ Likewise, not all fields on the claims form are found in the research files

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Standard Analytical Files (SAFs)

• SAFs contain final action claims
• Each SAF contains claims for services rendered in
• ne calendar year (based on claim-through date)
• Each July, CMS SAFs are created and finalized for

the prior years claims, capturing 98% of that year’s claims

• There is a SAF for each type of service

(institutional and non-institutional): Inpatient, Outpatient, SNF, Home Health, Hospice, Carrier, DME

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Medicare Provider Analysis and Review (MedPAR)

• The MedPAR file was created from the SAF files

and contains information on hospital inpatient stays and skilled nursing facility stays

• Each observation contains aggregated data of all

facility claims related to one episode of care (either a hospital or skilled nursing facility stay)

• The MedPAR is available as a fiscal or calendar

year based on the discharge date for the Inpatient MedPAR or the admission date for the SNF MedPAR

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Part D Event Data

• Part D prescription drug data are considered

different than claims, they are considered “events”

• A Part D Event Data record is not the same as a

pharmacy claim and so it differs from point-of- service

˗ There can be post-transaction adjustments between the plan and pharmacy ˗ There can be plan-to-plan adjustments for misenrollees ˗ There can be plan-to-CMS adjustments for some demonstration projects

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Information on a Part D Event

• Product Service Identifier (NDC)
• Prescription Service Date
• Days supply
• Gross Drug Cost

˗ Note: researchers cannot determine “true” cost to Medicare

• r the plan for prescription drugs, but can determine “point
• f sale” cost to beneficiary
• Benefit Phase
• Low Income Subsidy Amount
• Patient Pay Amount
• Third party payments

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Part D Files

• In addition to the drug event file, researchers can

request characteristics files:

˗ Drug Characteristics ˗ Pharmacy Characteristics ˗ Prescriber Characteristics ˗ Plan Characteristics ˗ Formulary File (only available from 2010 forward)

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RIF versus LDS Data

• Research Identifiable Data (RIF) contain beneficiary

level protected health Information

• Requests for RIF data require a DUA and are reviewed

by the CMS privacy board to ensure that the beneficiary’s privacy is protected and the need for RIF data is justified

• Limited Data Sets (LDS) contain beneficiary level

protected health information; however, selected variables are encrypted, blanked or ranged

• LDS requests require a DUA but do not require a

privacy board review

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Research Identifiable Files Limited Data Sets Requires privacy board review Yes No Requires DUA Yes Yes File includes beneficiary level data Yes Yes Data file can be customized to only include a specific cohort Yes No (only available as 100% or 5% national sample) Data can be linked to non-CMS data using a beneficiary identifier (such as SSN_ Yes No

Variable Differences between RIF and LDS Data

Variable File Research Identifiable File Limited Data Set Beneficiary Identifier Claims & Enrollment Files Encrypted Identifier Encrypted Identifier Health Insurance Claim (HIC) or SSN Claims & Enrollment Files Not included in file Not included in file Dates (MM/DD/YYYY) Claims Files Included Included as of calendar year 2010 Beneficiary Zip Code Enrollment File Included Not included, only county or state Beneficiary Date

• f Birth

Enrollment File Included Not included, either age year or 5-year age range Date of Death Enrollment File Included Included, only for validated dates of death UPIN/NPI of performing provider Claims Files Included Included but encrypted Institutional Provider Number Claims Files Included Included

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RIF versus LDS

• The Standard Analytical Files (SAFs) are available as

an LDS or a RIF

• The MedPAR file is available as an LDS or a RIF

˗ MedPAR LDS is a stand-alone file that cannot be linked to

• ther files, MedPAR RIF can be linked to other files
• The Part D files are only available as a RIF
• Both LDS and RIF files have a Medicare enrollment file

which provides information about a beneficiaries Medicare enrollment and demographics

˗ LDS Denominator ˗ RIF Master Beneficiary Summary file (base/enrollment segment)

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Structure of CMS Medicare Data Files

• Available as annual calendar year files, most files

available back to 1999 (Part D 2006)

• RIF data can be requested as a standard national

sample (5% or sometimes 20%) or a as a customized cohort (based on researcher’s criteria)

• LDS data can be requested as a 5% sample or for

most files as a 100% file

• Organized by beneficiary

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Resources for Help

• ResDAC Assistance Desk

˗ Email: resdac@umn.edu ˗ Phone: 1-888-973-7322 ˗ Web: http://www.resdac.org

• ResDAC Website

˗ CMS Data ˗ ResConnect (Resource Library)

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Webinar Series

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• 02/28 – Introduction to CMS Data
• 03/19 – Non-Identifiable Data
• 04/04 –Cost Reports
• 04/09 - DE-SynPUFs
• 04/10 –Limited Data Sets
• 04/25 –Research Identifiable Data
• 05/02 – Util

tiliza zati tion D Data ta View past webinars and register for upcoming webinars at the ResDAC website (www.resdac.org/training/media/webinars)