medical data call validation - ncci holdings inc. · baseline period to pre-reform period...

© Copyright 2020 National Council on Compensation Insurance, Inc. All Rights Reserved.

Medical Data Call ValidationPresented by:David Colon and John Foust


NCCI’s 2020 Data Educational Program

Objective

To gain a better understanding of:• NCCI’s need for high-quality medical data to perform legislative pricing

and research studies

• NCCI’s medical data validation test approach, results, andcommunication with data providers

2 2

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Agenda

3

Purpose of theMedical Data Call

Validation Processes

Common Medical Data Quality Topics


Purpose of the Medical Data Call

2



Main Objectives

5

Legislative Pricings

Stakeholder Requests

Research

Informational Resources



Main Purposes of Regulation

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• Ensure adequate access to medical providers

• Contain medical costs

• Provide rules for the price of services provided, thereby reducing disputes regarding medical service reimbursements

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3



Legislative PricingsFee Schedules

• Medicare fee schedules set maximum reimbursements on a fee-for-service basis

• States may set their reimbursement for workers compensation at some percentage of the Medicare rate• Most states have implemented Medicare-based physician fee schedules

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States With Physician Fee Schedules as of Year-End 197912 States Total

No Fee Schedule

Fee Schedule

8

4



States With Physician Fee Schedules as of Year-End 201845 States Total—34 Have a Medicare-Based Schedule

No Fee Schedule

Non-Medicare

Medicare-Based

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A Fee Schedule Excerpt

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5




11

Procedure Code




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Procedure Code

Maximum Allowable Reimbursement (MAR)

6



Physician Example

• State X physician MARs are currently 150% of 2019 Medicare. Their new fee schedule will be 160% of 2020 Medicare.

• There are only three medical services in State X:

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Code Description SY 2018 Paid29405 Apply Short Leg Cast $400,000 29999 Unlisted Complex Arthroscopy $100,000 30400 Simple Nose Reconstruction $500,000

Hypothetical example



Step 1: Determine the % Change in MARs

Code 2019 MAR 2020 MAR % Change in MAR29405 $126 $128 +1.6%29999 N/A N/A -30400 $1,560 $1,680 +7.7%

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Hypothetical exampleCodes without a MAR are assumed to be unaffected by fee schedule updates.

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Step 2: Payment-Weight the % Changes

Code 2018 Payments Weight % Change in MAR29405 $400,000 40% +1.6%29999 $100,000 10% -30400 $500,000 50% +7.7%Total $1,000,000

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Hypothetical examplePayment data is from NCCI’s Medical Data Call for the latest service year.



Step 3: Payment-Weight the % Changes

Code 2018 Payments Weight % Change in MAR29405 $400,000 40% +1.6%29999 $100,000 10% -30400 $500,000 50% +7.7%Total $1,000,000 +4.5%

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Hypothetical examplePayment data is from NCCI’s Medical Data Call for the latest service year.

Code 2018 Payments Weight % Change in MAR29405 $ 400,000 7% +1.6%29999 $ 100,000 2% -30400 $5,000,000 91% +7.7%Total $5,500,000 +7.1%

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Pricing Rx Fee Schedules

FROM TO High No Medium LowHigh -- 0% -1% -9%

No 1% -- -1% -9%

Medium 1% 1% -- -8%

Low 10% 10% 8% --

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> 100% High Fee Schedule

= 100% Medium Fee Schedule

< 100% Low Fee Schedule

None No Fee Schedule

AWP Fee Schedule Type



Regulatory Requests

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DiagnosisAccident DateService Date

National Drug CodeUnits

PaymentsProvider TaxonomyTransaction Counts

PaymentsClaim CountsTransaction Counts

Cost TrendsMedical

Cost Distribution

Claim Information

Drug Information

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Research—Post-Reform Analysis of Closed Drug Formulary Implementations

“N” Drugs—Prior Authorization Required

“Y” Drugs—No Prior Authorization Required

April 1, 2019

NAME STATUS

Gabapentin/Neurontin® Y

Pregabalin/Lyrica®

Alprazolam/Xanax N

Tramadol/Ultram® Y

Y

Y

NN

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Arizona Formulary Implementation Timeline

Baseline Pre-Reform

Post-Reform

October 1, 2014–September 30, 2015



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10



N-Drug Utilization Drops in Arizona

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–12%

–19%

–13% –13%–12%

–14%

Baseline Period to Pre-Reform Period Pre-Reform Period to Post-Reform Period

Perc

enta

ge C

hang

e in

N-D

rug

Utili

zatio

n

Arizona Similar Nonformulary States All Nonformulary States

Source: NCCI’s Medical Data Call



Y-Drug Utilization Decreases More Slowly

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Utilization for N-drugs and Y-drugs are measured by units per active claim.Source: NCCI’s Medical Data Call.

–5%–7%–7% –7%–7%

–5%

Baseline Period to Pre-Reform Period Pre-Reform Period to Post-Reform Period

Perc

enta

ge C

hang

e in

Y-

Drug

Util

izatio

n

Arizona Similar Nonformulary States All Nonformulary States

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Research—Monitoring the Time From Injury to Treatment

Accident Date Service Date

Diagnosis Code Provider Type

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Time Until the First Evaluation & Management Encounter

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3

75th Percentile

Days

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12



Days to Initial Treatment by Type of Injury

Open Wounds Contusions Sprain and Strain

85th Percentile

0 Days

3 Days

5 Days

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Research—The Impact of Fee Schedule Updates on Physician Payments

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Service Date

State of Jurisdiction

Procedure Code

Payment Amount

Unit Count

Network Service Code

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Fee Schedules Have an Effect on Prices Paid

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NCCI analysis based on Medical Data Call, for services provided between 2011 and 2016.



Fitted Univariate Linear Regression Line Change in Price vs. Change in MAR

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= + = 80%

NCCI analysis based on Medical Data Call, for services provided between 2011 and 2016.

Each observation (or dot) relates a change in MAR and a change in price for a procedure code, state, place of service, and year combination.

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NCCI’s 2020 Data Educational Program29



State Medical Data Reports

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NCCI’s State Medical Data Reports provide a data source for regulators and other industry stakeholders.

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State Medical Reports

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Overall Medical Average Cost per Lost-Time Claim (in 000s)

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Average Inpatient Amount Paid per Stay for Hospital Inpatient Services

3232

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New Excel Version of Medical Reports

3333



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Your Data Is Very Valuable

Accurate and timely reporting provides:Best loss costs estimatesReliable industry informationReduced validation costs

3636

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Validation Processes



Aggregate Data Quality

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Process approximately:• 80 million transactions

• 3 million claims

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Data Quality—A Layered Approach

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Submission File Editing

Quarterly Aggregate Reviews

Usage Specific Reviews



Limited Record Rejects—Key Field Errors

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Define Bill Lines

Carrier Code

Policy Number

Policy Effective

DateClaim

Number Bill ID Line ID

Organize Bill Line Transactions

Transaction Date Transaction Code

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Quality Tracking Edits

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Identify records reporting:

• Missing Values

• Invalid Values



Quality Validation Edits

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Reasonability checks:

• Compare fields on the same record

• Compare records to the database

Primary ICD Diagnostic Code Secondary ICD Diagnostic CodeS52.01

Amount Charged by Provider Paid Amount$100 $100

Amount Charged by Provider Paid Amount$100 $120

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Quality Validation Edits

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Reasonability checks:

• Compare fields on the same record

• Compare record to the database

Transaction Code Transaction Date03 10/1/2019

Transaction Code Transaction Date01 10/1/2019

Submitted replacement record Record to be replaced



Validation Tests

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• Percentage of quarterly data meeting test criteria

• Compare group to industry to identify outliers

• Examples of tests• Paid Duplicate Transactions• Jurisdiction State to Provider

State Comparison• Common National Drug Code

(NDC) Units

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Service Year Trending

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Unusual percentage of:

• Duplicate transactions

• Pharmacy, inpatient and outpatient hospital, and physician cost by state of jurisdiction

Industry Averages

Outliers



Communication

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NCCI Medical Data

Validator

Carrier/ Medical Data

Provider Contact(s)

Issue Descriptionand Detail Data

Explanation

Detailed discussion helps NCCI determine how to refine our tests and analyses.

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Common Medical Data Quality Topics



Importance of Claim Key Fields

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Claim ID

Carrier Code

Policy Number

Policy Effective

Date

Claim Number

Claim ID

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Carrier Code: 99990

Policy Number: ABC123

Effective Date: 1/1/2019

Claim Number: WC111________________________

________________________

________________________

________________________

________________________

Medical Data Claims

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Claim ID

Carrier Code: 99990



Claim Number: WC111________________________

________________________

________________________

________________________

________________________

Carrier Code: 99990



Claim Number: WC111________________________

________________________

________________________

________________________

________________________

Key data elements must be consistent on a per-claimant basis from all submitters.

Claim ID: 123 Claim ID: 124Carrier

Medical Data Provider 1

Medical Data Provider 2



Consistency With Unit Statistical Reporting

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Comparing Medical to Unit Stat

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Medical Call Transactions

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01

02

03

Original

Cancellation

Replacement



Medical Call Transactions

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Transaction Date:

• Date the medical transaction was originally processed and paid by the administering entity

• Date the medical transaction was updated in the administering entity’s system

Replacements must report all values cumulatively.

Bill line keys on cancellations and replacements must match previous reported transactions.

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Duplicate Records—Additional Reimbursements

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Amount Paid = $50 Additional Reimbursement = $10

Amount Charged = $75

A claimant is injured and visits a doctor’s office …

1/4/2019 1/26/2019 3/4/2019



Additional Reimbursements

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Reporting Option #1—Submit one Original

Field TitleOriginal Reported As

Claim Number 12345Transaction Date 3/4/2019Transaction Code 01Bill ID 101Line ID 1Paid Procedure Code 99201

Amount Charged by Provider

$75

Paid Amount $60

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Reporting Option #2—Submit a Replacement


Replacement Reported As

Claim Number 12345 12345

Transaction Date 1/26/2019 3/4/2019

Transaction Code 01 03

Bill ID 101 101

Line ID 1 1

Paid Procedure Code

99201 99201


$75 $75

Paid Amount $50 $60




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Reporting Option #3—Submit a Cancellation record and a New Original


Cancellation Reported As

New Original Reported As

Claim Number 12345 12345 12345

Transaction Date 1/26/2019 1/26/2019 3/4/2019

Transaction Code 01 02 01

Bill ID 101 101 102

Line ID 1 1 1

Paid Procedure Code 99201 99201 99201


$75 $75 $75

Paid Amount $50 $50 $60

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Duplicate Billing

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First Notice Bill ID 101

Second NoticePayer’s system assigns

Bill ID 201

1/1/2019 2/1/2019



Duplicate Billing

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Original Reported As

Claim Number 12345 12345

Transaction Date 1/1/2019 2/1/2019

Transaction Code 01 01

Bill ID 101 201

Line ID 1 1

Paid Procedure Code

99201 99201


$75 $75

Paid Amount $75 $75

Common example of how this might be incorrectly reported:

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Duplicate Billing

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To prevent:

Option 1: Do not submit both records to NCCI.

Submit one of the two bills/records; if both bills are created in the same quarter and the first has not been reported, submit the second bill only.

Option 2: Submit a Cancellation record and NewOriginal record.



Duplicate Billing—Cancellation

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Cancellation Reported As

New Original Reported As

Claim Number 12345 12345 12345

Transaction Date 1/1/2019 2/1/2019 2/1/2019

Transaction Code 01 02 01

Bill ID 101 101 201

Line ID 1 1 1

Paid Procedure Code

99201 99201 99201


$75 $75 $75

Paid Amount $60 $60 $60

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Duplicate Validation

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Not properly creating Cancellations/Replacements• Additional Reimbursement

• Duplicate Billings

Bill ID 101Bill ID 201



Duplicate Transactions—Example

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The records below have the same claim keys.

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Duplicate Transactions—Example

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The records below have the same claim keys.



Diagnosis Related Groups (DRGs)

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• Diagnosis driven reimbursement for the entire stay

• CMS and several states use MS-DRGs

When a state changes to DRG reimbursement, reporting systems

may need to be updated.

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DRGs versus Hospital Revenue Codes

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DRG Description DRG Revenue Code Revenue Code DescriptionHeart Transplant or Implant of Heart Assist System With MCC

001 0001 Total Charges

Percutaneous Cardiovascular Procedures Without Coronary Artery Stent With MCC

250 0250 Pharmacy

DRG Revenue Code

Applies to inpatient stays May apply to inpatient stays

Calculated by the payer Billed by the facility

A single DRG summarizes the payment Multiple codes break down the costs

3-byte numeric code 4-byte numeric code

Leading zeroes are important!



Inpatient Hospital Bills

66

A hospital bill may be reported to NCCI in a number of ways, depending on how it is reimbursed:

Bundled

Line IDService

From DateServiceto Date

Paid Procedure

Code

Secondary Procedure

Code

Amount Charged by

Provider Paid Amount

1 1/30/2019 2/2/2019 508 0111 $10,000 $8,000

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Line IDService


Paid Procedure

Code

Secondary Procedure

Code

Amount Charged by


1 1/30/2019 2/2/2019 508 0111 $10,000 $8,000

2 1/30/2019 2/2/2019 508 0250 $2,000 0

3 1/30/2019 2/2/2019 508 0270 $2,000 0

4 1/30/2019 2/2/2019 508 0360 $2,000 0

5 1/30/2019 2/2/2019 508 0370 $2,000 0


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A hospital bill may be reported to NCCI in a number of ways, depending on how it is reimbursed:

Incorrect Reporting Services Audited Separately



or

Report Diagnosis-Related

Group (DRG) payment record with total

charges—Revenue Code transactions reported with no

charges

Report individual charges on Revenue Code transactions

Reporting Services Audited Separately

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Method 1

Report DRG payment record with total charges—Revenue Code transactions reported with no charges

Line IDService


Paid Procedure

Code

Secondary Procedure

Code

Amount Charged by


1 1/30/2019 2/2/2019 508 0111 $10,000 $8,000

2 1/30/2019 2/2/2019 508 0250 $0 $0

3 1/30/2019 2/2/2019 508 0270 $0 $0

4 1/30/2019 2/2/2019 508 0360 $0 $0

5 1/30/2019 2/2/2019 508 0370 $0 $0




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Method 2

Report individual charges on Revenue Code transactions

Line IDService


Paid Procedure

Code

Secondary Procedure

Code

Amount Charged by


1 1/30/2019 2/2/2019 508 0111 $2,000 $8,000

2 1/30/2019 2/2/2019 508 0250 $2,000 0

3 1/30/2019 2/2/2019 508 0270 $2,000 0

4 1/30/2019 2/2/2019 508 0360 $2,000 0

5 1/30/2019 2/2/2019 508 0370 $2,000 0

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Provider Zip Code

71

LA

MS

TN

AL GA

FL

NC

SC

Report Zip Code HierarchyZip Code that impacts reimbursement 1Zip Code where service was performed 2Billing Zip Code, unless billing house or pharmacy benefit manager

3



Jurisdiction to Provider State

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FL

Jurisdiction State Provider State Comparison

FL

SC GA

IAME

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State Comparison—Example

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Quantity/Number of Units per Procedure Code

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From the Medical Data Call Reporting Guidebook:

• Report the number of units of service performed or the quantity of drugs dispensed

• Use the base quantity specified by the applicable procedure code to determine the quantity or number to report

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Units per Procedure Code

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• Supplies• 3 pairs of gloves on a “per pair” code: 3 units

• Physical Therapy• 1 session of 30 minutes on a “per-15 minute”

procedure: 2 units



Units per Anesthesia Code

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• Basis of Reimbursement• Base rate• Modifiers• Time

• Report minutes for anesthesia CPTs that use time units

• Report unit counts for modifying anesthesia codes

38



NDC Units

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NDC defines the measurement:

• Pill counts

• Standard package count

• Quantity (e.g., milliliters)

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