The Division has taken the position that any state agency/authority that has regulatory permission for payer data need only to establish an ISA,

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Rosa Campbell
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2 The Division has taken the position that any state agency/authority that has regulatory permission for payer data need only to establish an ISA, those that don t have this authority in their statute need to file a data request application and go through the Data Review Committee for access. 2

those that don t have this authority in their statute need to file a data

3 We collect more information than most states due to the service bureau approach. The Division collects all the data necessary to meet everyone's (other agencies, authorities, and researchers) needs and then provides the data, rather than payers send multiple copies to all the data requestors. Another challenge many APCDs face is linking the data between files. We have indicated in our user guides the fields payers must use to facilitate this ability. It has proven to be very effective.

then provides the data, rather than payers send multiple copies to all the data requestors.

4 APCD Data Collection s foundation is from the QCC Data Collection historically a proven collection with the majority of Massachusetts Risk Holders across lines of business. Then additional files were added to round-out the dataset in anticipation for a more complete picture of the Massachusetts Healthcare overall experience and reporting/research needs. APCD referenced standard billing mappings (both paper and EDI) where applicable so that data submitters could look to their internal systems mapping for the same elements and decrease additional coding needs. Elements that are MA APCD Specific were addressed in many TAG meetings to supply clarification on collection/usage or to obtain industry standard language/usage for these same elements 4

APCD referenced standard billing mappings (both paper and EDI) where applicable so that data submitters could look to their internal systems mapping for the same elements and decrease

5 MA APCD created a 3-tier team approach to insure that submitters had access to support at various levels in the process Liaison/Analyst/Work Group; The Liaison for introduction to systems and reports and aid with submissions and variances on a daily basis, if needed. The Analyst to provide detail feedback on compiled logicmismatches and to verify appropriateness of data along the submission stream, assigned Analyst is teamed with assigned Liaison to insure continuity of direction and to maintain working relationships with submitters. The Work Group for two-way conversations at a higher level to insure overall understanding of the want and need for correct data across submitters and for APCD to obtain industry understanding. 5

The Analyst to provide detail feedback on compiled logicmismatches and to verify appropriateness of data along the submission stream, assigned Analyst is teamed with assigned Liaison

6 The major lines of insurance business were identified by working with the Division of Insurance. This identifier (License Type) is collected on the Product file for each product the submitter has on file with the DOI and is the foundation of the remaining elements collected in both the Product and Eligibility Files. 6

This identifier (License Type) is collected on the Product file for each

7 The License Type provides the first filter in determining the types of Products that have the most activity and is tightly tied to Product Line of Business Model and Market Size values. These refine this high level identifier into various models: i.e., HMO, PPO, POS, Indemnity, Self Insured, etc. into Individual, Small Group or Large Group bandwidths. The size bandwidth with this level of refinement has proven to be one of the most sought after measurements in our health data collection efforts. 7

e., HMO, PPO, POS, Indemnity, Self Insured, etc. into Individual, Small Group or Large Group bandwidths.

8 As stated, since the Eligibility file maintains the detail of the group size at the member level, as the member moves from plan to plan and/or group to group, the APCD is able to collect this changing attribute to better understand member options and selections, both within and across submitting Risk Holders. 8

group, the APCD is able to collect this changing attribute to better

9 We found in the very early stages of discussions that security was one of the first things we were asked about. It didn t matter if it was a payer, service provider, employer or state agency. We documented our internal auditing and submitted to various audits from some of the major carriers. We also contracted with a third party independent auditing firm to perform certified security and privacy audits. As a state agency everyone is very skeptical, but we were very aggressive to validate our measures and seek advice to improve where possible. Taking this off the table removes a major area of distraction and enables you to focus on the core project. 9

We documented our internal auditing and submitted to various audits from some of the major carriers.

10 The SSAE16 used to be known as a SAS70 audit. It is a very comprehensive review of all written policies as well as the ongoing monitoring and enforcement of them. This is a very lengthy process of reviewing documentation, providing artifiacts of training/awareness, logs and supporting information, and response plans for any incidents. The type 2 includes performing various network and application scans to make it a very comprehensive set of measures. Even though we are not a HIPAA covered entity, we felt it was important to also submit to HIPAA audits. This was due to the comfort level and awareness people have of HIPAA. We found it to be well worth the time and effort and helps put people at ease. 10

The type 2 includes performing various network and application scans to make it a very comprehensive set of measures.

11 Because the APCD is still in its initial stages and we were unfamiliar with the 3R modeling requirements, the Connector and the Division jointly determined the swiftest was to know if the APCD could fill the needs was to have the vendor running the modeling do a quick assessment. The vendor came to the Division, met with staff to understand what we had, then proceeded to interrogate the data. This was done by Milliman (Connector s modeling vendor) deploying staff to the Division and running a series of queries against the databases. Because the APCD has such a diverse make-up of claims, this is a challenging job and requires deeper knowledge of the records. Quality aside, I m talking about knowing to filter out vision claims, workmans comp, etc. It takes more ramp up time to understand the data than was originally planned by the vendor and something other states will also encounter. 11

This was done by Milliman (Connector s modeling vendor) deploying staff to the Division and running a series of queries against the databases.

12 Milliman is working for the Connector on their 3R Project (Re-insurance, Risk Adjustment, Risk Corridor) and is using MA APCD data in aggregate to validate base scores for the Risk Model. The data in aggregate was focused on individuals and small groups (<50 employees) with medical and/or pharmacy benefits barring all Self Insured Products/Eligibilities. Their main objective was to QA the APCD data and analyze the results to determine the usability of the APCD for additional components of the 3R Project. This QA involved removing exact duplicate lines of data within a carrier and then linking Products to Eligibilities to determine match rate. 12

The data in aggregate was focused on individuals and small groups (<50 employees) with medical and/or pharmacy benefits barring all Self Insured

13 Milliman is scheduled to take the QA to the next level and validate if the linked Product/Eligibilities can be linked to medical and pharmacy claims lines submitted for members reported within the refined selection. This process also includes a deduplication process but adds in the necessity to identify the final version of all claim lines for a given member. Once completed, Milliman will need to use elements on the Eligibility and Claim Lines to determine what the total Out of Pocket expense was for the member. This will be taken to the next level to identify members with their subscribers to determine family size. 13

This process also includes a deduplication process but adds in the necessity to identify the final version of all claim lines for a given member.

14 The APCD utilizes many avenues to validate data, most of which has occurred on the intake side of the business. Since there are values that are valid but not appropriate for every line of data, the APCD Analyst team reviews for some basic errors not captured by current intake editing: nine or zero fill data, individual providers identified as facility, first and last name both in last name field, misusage of Yes/No flags, etc. Once these have been identified, carriers are contacted with both the Liaison and the Analyst to discuss remediation and resubmission. Files that are resubmitted with corrected data are then re-analyzed for compliance. 14

intake editing: nine or zero fill data, individual providers identified as facility, first and last name both in last name field, misusage of Yes/No flags, etc.

15 The APCD is currently contracted with JEN Associates to provide QA metrics, but is also investigating other methods/applications/vendors to expand on quality efforts to insure that the best possible data will be available for reporting and research. 15

methods/applications/vendors to expand on quality efforts to

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Massachusetts All-Payer Claims Database: Analytic and Technical Workgroups. September 27, 2011

Massachusetts All-Payer Claims Database: Analytic and Technical Workgroups September 27, 2011 Objectives for today s meeting Define an all-payer claims database (APCD) and review recent efforts in Massachusetts