introduction to medicare utilization data -...
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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
one 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 or the plan for prescription drugs, but can determine “point of 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 of 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 17
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
other 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: [email protected] ˗ 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 – Utilization Data View past webinars and register for upcoming webinars at the ResDAC website (www.resdac.org/training/media/webinars)