Lesson - Questions Covering the Underlying Claims Data

What are the different Medicare programs?

  • Medicare Part A Fee-For-Service Hospital Insurance
    • Part A Hospital Insurance is sometimes called “Original Medicare”. Part A insurance is a Fee-For-Service (FFS) reimbursement program that enables enrolled beneficiaries to see institutionally-based enrolled providers they choose. Providers enroll in Medicare programs and accept the fee schedules and act like an unstructured PPO network. Part A covers mainly catastrophic healthcare-related events, including inpatient hospital stays (“IP”), some outpatient services (“OP”) as well as some post-acute care services across a variety of settings, including care in a skilled nursing facility (“SNFs”), some services provided by home health agencies (“HHAs”) and Hospice services.
  • Medicare Part B Fee-For-Service Medical Insurance
    • Part B Medical Insurance is sometimes called “Original Medicare” as well. Part B insurance is an optional “opt-in” Fee-For-Service (FFS) reimbursement program that enables enrolled beneficiaries to see office-based enrolled providers they choose. Part B covers certain doctors’ services, outpatient care, medical supplies, and preventive services. Providers enroll in Medicare programs and accept the fee schedules and act like an unstructured PPO network.
  • Medicare Part C Medical Advantage Insurance
    • Part C plans are offered by private insurance companies approved by Medicare. These so-called “Medicare Advantage” or “MA” plans cover most Medicare services through the plan and those services generally are then not paid for under Original Medicare. MA plan types include “at risk” Health Maintenance Organization (HMO) plans as well as Private Fee-For-Service (PFFS) Preferred Provider Organization (PPO) plans, Special Needs Plans and Medicare Medical Savings Account (MSA) Plans. Most Medicare Advantage Plans offer Part D prescription drug coverage and are sometimes referred to as “MA-PD” plans.
  • Medicare Part D Medical Insurance)
    • Part D plans are offered by private insurance companies approved by Medicare. These Medicare Prescription Drug Plans (“PDPs”) add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans. Part D plans are offered by private insurance companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans.
  • NOTE: The CMS Limited Data Set (LDS) data are made available at the de-identified claim level for 100% of the census of annual Part A Fee-For-Service claims but only 5% samples of annual Part B and Durable Medical Equipment (DME) claims. The CMS LDS Denominator file provides demographics, eligibility, coverage histories and current status for 100% of the aged and disabled beneficiaries.

How do beneficiaries qualify for the different Medicare programs?

  • Medicare programs are often referred to as “entitlement” programs. Once a person has met criteria for a benefit, they become “entitled” to receive it. What are the qualifications for the various Medicare programs? Eligibility criteria can include age, a disability, or End Stage Renal Disease (ESRD).
    • Over age 65 beneficiaries include persons over 65 years of age and are often referred to as “aged beneficiaries”. Aged beneficiaries may apply for Medicare Part A within 6 months of their 65th birthday with coverage starting the month when they turn 65 with retroactive coverage to 6 months from when they enrolled.
    • Under age 65 beneficiaries include “disabled” beneficiaries as well as those suffering from End Stage Renal Disease (ESRD). Qualified persons automatically receive Part A Hospital Insurance and Part B Medical Insurance after they apply for and receive disability benefits from the Social Security Administration (SSA) or have received certain disability benefits. A person who is entitled to monthly Social Security or Railroad Retirement Board (RRB) benefits on the basis of disability is automatically entitled to Part A after receiving disability benefits for 24 months. Disabled Federal, State and local government employees who are not eligible for monthly Social Security or RRB benefits may get deemed entitlement to disability benefits and automatically entitled to Part A after being disabled for 29 months. There is a special rules for other disabled individuals. For example, there is a special rule for People with Amyotrophic Lateral Sclerosis (ALS) (Lou Gehrig’s disease) where those individuals are entitled to Part A the first month they are entitled to Social Security or RRB disability cash benefits absent any waiting period. There is also a special rule for individuals claiming Child Disability Benefits where SSA rules do not allow for child disability benefit to begin earlier than age 18. Therefore, Part A entitlement based on child disability benefit entitlement can never begin before the month the person attains age 20 (or age 18 if the individual’s disability is ALS). Those individuals who are entitled to Part A coverage based on ESRD are eligible for premium-free Part A if they receive regular dialysis treatments or have had a kidney transplant, have filed an application for Medicare, and meet 1 of the following conditions: (i) they have worked the required amount of time under Social Security, the Railroad Retirement Board (RRB), or as a government employee; or (ii) are eligible for or are receiving Social Security or RRB benefits; or (iii) are the spouse or dependent child of a person who has worked the required amount of time under Social Security, the RRB, or as a government employee; or are getting Social Security or RRB benefits. For ESRD eligible beneficiaries, Part A coverage begins: (i) the 3rd month after the month in which a regular course of dialysis begins; or (ii) first month a regular course of dialysis begins if the individual engages in self-dialysis training; or (iii) month of kidney transplant; or (iv) two months prior to the month of transplant if the individual was hospitalized during those months in preparation for the transplant.
  • Medicare Part A (Hospital Insurance)
    • Aged beneficiaries may apply for Medicare Part A within 6 months of their 65th birthday with coverage starting the month when they turn 65 with retroactive coverage to 6 months from when they enrolled.
  • Medicare Part B (Medical Insurance)
    • Beneficiaries may opt not to acquire Medicare Part B coverage right away or ever depending on other coverage conditions including current employer coverage, COBRA benefits, retired employer or union coverage, military, Tricare or veterans’ benefits.
  • Medicare Part C (Medical Insurance)
  • Medicare Part D (Medical Insurance)
  • NOTE: The CMS LDS Denominator file provides demographics, eligibility, coverage histories and current status for 100% of the aged and disabled beneficiaries. For example, CMS obtains eligibility information from the Social Security Administration (SSA) and Railroad Retirement Board (RRB) record systems as well as through their own enrollment systems and codes each beneficiary’s record in the denominator file for both the Original Reason for Entitlement Code (OREC) as well as the Current Reason for Entitlement Code (CREC) as follows: (i) 0 = Old Age and Survivors Insurance (OASI), (ii) 1 = Disability Insurance Benefits (DIB), (iii) 2 = End State Renal Disease (ESRD), or (iv) 3 = Both DIB and ESRD.

How do beneficiaries pay for the different Medicare programs?

Medicare programs are either premium free or require premiums and/or co-pays from the beneficiaries. Subsequently, the various benefits are referred to as “premium-free” Part A and “premium” (fee required) Part A, Part B and Part D where coverage requires payment of monthly premiums. Certain individuals are required to pay higher premiums, including: (i) Individuals with income greater than $85,000 and married couples with income greater than $170,000 must pay a higher premium for Part B and an extra amount for Part D coverage in addition to their Part D plan premium.  This “additional premium” is called the “Income-Related Monthly Adjustment Amount” or “IRMAA” premium. Less than 5 percent of people with Medicare are affected, so most people will not pay a higher premium. (ii) Individuals who enroll late for Part A coverage can be charged a “late enrollment penalty” for premium Part A.  Individuals who did not enroll in Part A when first eligible be required to pay up to a 10% higher late enrollment penalty as part of their monthly premium if they decide to enroll later. This “late enrollment penalty” for premium Part A is charged to the individual for twice the number of years the individual could have enrolled in premium Part A coverage, but did not sign up. (iii) Individuals who enroll late for Part B coverage can be charged an even more significant  “late enrollment penalty” for Part B coverage.  For individuals who did not sign up for Part B when first eligible are charged a 10% higher late enrollment penalty for each full 12-month period that the individual could have had Part B, but did not sign up for it.

  • Medicare Part A (Hospital Insurance)
    • Most beneficiaries receive Part A coverage for free, but some individuals have to pay a premium for Part A coverage. To be eligible for premium-free Part A, an individual must be entitled to receive Medicare based on their own earnings or those of a spouse, parent, or child. To receive premium-free Part A, the worker must have a specified number of quarters of coverage (QCs) and file an application for Social Security or Railroad Retirement Board (RRB) benefits. The exact number of QCs required is dependent on whether the person is filing for Part A on the basis of age, disability, or End Stage Renal Disease (ESRD). QCs are earned through payment of payroll taxes under the Federal Insurance Contributions Act (FICA) during the person’s working years. Most individuals pay the full FICA tax so the QCs they earn can be used to meet the requirements for both monthly Social Security benefits and premium-free Part A coverage. Individuals already receiving Social Security or RRB benefits at least 4 months before being eligible for Medicare and residing in the United States (except residents of Puerto Rico) are automatically enrolled in both premium-free Part A and Part B. Premium Part A and Part B coverage requires payment of monthly premiums.
  • Medicare Part B (Medical Insurance)
    • The eligibility rules for Part B depend on whether an individual is eligible for premium-free Part A or whether the individual has to pay a premium for Part A coverage. Individuals who are eligible for premium-free Part A are also eligible for enroll in Part B once they are entitled to Part A. Enrollment in Part B can only happen at certain times. Individuals who must pay a premium for Part A must meet the following requirements to enroll in Part B as follows: (i) they must be age 65 or older; (ii) they must be both a resident AND a citizen of the United States; or (iii) they may be an alien who has been lawfully admitted for permanent residence and has been residing in the United States for 5 continuous years prior to the month of filing an application for Medicare. Regardless of how individuals become eligible for Part B coverage, for all individuals, Part B is a voluntary program which requires the payment of a monthly premium for all months of coverage.
  • Medicare Part C (Medical Insurance)
  • Medicare Part D (Medical Insurance)
  • NOTE: The CMS LDS Denominator file provides demographics (including Age, Sex and Race/Ethnicity), eligibility (original reason and current reason), coverage histories (Part A, Part B and MA) and current status (including Part A termination of benefits, Part B termination of benefits and death) for 100% of the aged and disabled beneficiaries. For example, CMS obtains eligibility information from the Social Security Administration (SSA) and Railroad Retirement Board (RRB) record systems as well as through their own enrollment systems and codes each beneficiary’s record in the denominator file for both the Original Reason for Entitlement Code (OREC) as well as the Current Reason for Entitlement Code (CREC) as follows: (i) 0 = Old Age and Survivors Insurance (OASI), (ii) 1 = Disability Insurance Benefits (DIB), (iii) 2 = End State Renal Disease (ESRD), or (iv) 3 = Both DIB and ESRD.  In addition, the LDS denominator file provides a duplicate field called Code for Beneficiary Medicare Entitlement (MS_CD) as follows: (i) 10 = Aged Without ESRD, (ii) 11 = Aged With ESRD, (iii) Disabled Without ESRD, (iv) Disabled With ESRD, and (v) ESRD Only.

What are the different Medicare data sets?

  • In general, Medicare provides 3 types of files for research purposes:
    • Research Identifiable Files (RIFs): Research identifiable files (RIFs) contain beneficiary level protected health information (PHI). Requests for RIF data require a Data Use Agreement (DUA) and are reviewed by CMS’s Privacy Board to ensure that the beneficiary’s privacy is protected and only the minimum data necessary are requested and justified. CMS provides criteria for the release of RIF data, which provides researchers permitted uses as well as what the CMS Privacy Board expects as part of the data request.
    • Limited Data Set (LDS) Files: Limited Data Set (LDS) files also contain beneficiary level protected health information similar to the RIF files. In fact, many of the RIFs have an LDS equivalent. LDS files are considered identifiable because of the potential to re-identify a beneficiary.  The difference, however, between RIF and LDS is that selected variables within the LDS files are blanked or ranged. LDS requests require a DUA, but do not go through a Privacy Board review.  LDS files are available as a 100% or 5% random sample file. The DUA-Limited Data Sets (LDS) page on the CMS website describes the ways in which the LDS files may be used. LDS files are defined by HIPAA, under “Permitted Uses and Disclosures” section of the Summary of the HIPAA Privacy Rule, as “…protected health information from which certain specified direct identifiers of individuals and their relatives, household members, and employers have been removed. A limited data set may be used and disclosed for research, health care operations, and public health purposes, provided the recipient enters into a data use agreement promising specified safeguards for the protected health information within the limited data set.”
    • Public Use Files (PUFs): also called “Non-Identifiable Data Files”, have been edited and stripped of all information that could be used to identify individuals. In general, the PUFs contain aggregate-level information. In general, PUFs provide aggregate or summarized information on utilization, payment, and/or charges. Because PUFs do not include protected health information, these files can be requested and used without Data Use Agreements (DUAs).

What are the differences between the Medicare data sets?

  • Differences exist in terms of privacy level and information level:
    • Privacy differences include differences between levels of identification of beneficiary and provider information presented in the data. CMS defines “Identifiable Data Files” as those that contain actual beneficiary-specific and physician-specific information, which are the RIF files. That appears to be a legacy definition that fit before 2014 when CMS began to provide physician-specific information in the LDS files. Access to “Identifiable Data Files” or RIF data requires formal request and approval by CMS. CMS is required by law to make the data its operations generate “available to the public, subject to privacy release approvals and the availability of computing resources”. Differences in privacy information among the various types of files includes:

 

PUFs

(HCP Non-Identifiable/ Beneficiary Non-Identifiable)

LDS

(HCP Identifiable/ Beneficiary Encrypted)

RIF

(HCP HCP Identifiable/ Beneficiary Identifiable)

Requires Privacy Board Review? No No Yes
Requires a Data Use Agreement? No Yes Yes
Files include beneficiary-level data? No Yes Yes
Researchers may request customized cohorts (e.g. Diabetics residing in MN)? No No Yes
Data can be linked at beneficiary level to non-CMS data using a beneficiary identifier? No No Yes
Claim run off period NA Annual files: 6-month run off Annual files: 12-month run off
NA Quarterly files: 3-month run-off Quarterly files: 3-month run-off

 

  • What are the differences between the Medicare data sets?
    • Differences exist in terms of privacy level and information level:
      • Data variable differences are also related to privacy issues. LDS data contains beneficiary level health information, but excludes specific “direct identifiers” as outlined in the Health Insurance Portability and Accountability Act of 1996 (HIPAA). CMS considers LDS files identifiable even without the specific direct identifiers. Since the information is considered identifiable, it also remains subject to the provisions of the Privacy Act of 1974. These data are identifiable because of the potential for identifying a beneficiary due to technology, particularly in linking and re-identifying data files.

 

Variable File LDS RIF
Unique Beneficiary Identifier Claims & Denominator files Included Encrypted identifier Included
Unique Beneficiary Identifier MedPAR files Not Included Included
Health Insurance Claim (HIC) or

Social Security Number (SSN)

Claims & Denominator files Not Included Included
Dates (MM/DD/YYYY) Claims files Included as of CY2010 Included
Dates (MM/DD/YYYY) MedPAR files Quarter and Year only Included
Claim from date Claims files Not Included Included
Claim through date Claims files Included Included
Beneficiary Zip Code Claims files County & State Included
Beneficiary Zip Code MedPAR files State Only
Beneficiary Date of Birth Claims & MedPAR files Not included. Age year or age range Included
Beneficiary Year of Birth Denominator file Included Included
Date of Death Denominator file Included, for validated dates of death only Included
NPI/UPIN HCP providers (AT_NPI, OP_NPI, OT_NPI) for 3 different roles Claims files Included Included
NPI/UPIN HCP providers (AT_NPI, OP_NPI, OT_NPI) for 3 different roles MedPAR files Not Included Not Included
Provider Of Service (POS) number for HCO providers (PROVIDER) Claims & MedPAR files Included Included
NPI number for HCO providers (ORGNPINM) Claims & MedPAR files Included Included

 

  • What are the different Medicare data sets included in the PurpleLab platform?
    • PurpleLab has loaded multiple years of the Standard Analytical Files (SAF) LDS files that contain provider identifiable and beneficiary encrypted claim level data for Fee-For-Service (FFS) enrolled Part A and Part B programs.
      • Part A SAF LDS files include: (i) diagnosis (ICD9/ICD10 diagnosis) codes, (ii) procedure (ICD9/ICD10/CPT/HCPCS procedure) codes, (iii) dates of service, (iv) type of service (Revenue Center Codes), (v) units of service (Revenue Center Units), (vi) reimbursement amounts and (vii) beneficiary demographic information (Age, Sex and Race/Ethnicity). Available years of data include 2010 through 2015 along with quarterly updates for 2016.
        • Inpatient (IP) 100% census files: IP file contains 100% final action, fee-for-service, claims data submitted by IP providers.
        • Outpatient (OP) 100% census files: OP file contains 100% final action, fee-for-service, claims data submitted by OP providers.
        • Nursing Facility (SNF) 100% census files: SNF file contains 100% final action, fee-for-service, claims data submitted by SNF providers.
        • Home Health (HHA) 100% census files: HHA file contains 100% final action, fee-for-service, claims data submitted by HHA providers.
        • Hospice (Hosp) 100% census files: Hosp file contains 100% final action claims data submitted by Hosp providers. The Hospice file contains all final action claims submitted by Hospice providers regardless if the beneficiary is in Medicare fee-for-service or in a Medicare managed care plan.
      • Part B SAF LDS files include: (i) diagnosis (ICD9/ICD10) codes, (ii) procedure (CPT/HCPCS) codes, (iii) dates of service, (iv) reimbursement amount and (v) beneficiary demographic information. Available years of data include 2010 through 2015 along with quarterly updates for 2016.
        • Carrier (Physician/Supplier) 5% sample files: The Carrier file (aka the Physician/Supplier Part B claims file) contains final action fee-for-service claims submitted on a CMS-1500 claim form. Most of the claims are from non-institutional HCP providers (e.g., physicians, podiatrists, dentists, chiropractors, physician assistants, clinical social workers, nurse practitioners, etc.). Claims for other providers, such as free-standing facilities are also found in the Carrier file. Examples include independent clinical laboratories, ambulance providers, and free-standing ambulatory surgical centers (ASCs). Carrier file contains 5% final action, fee-for-service, claims data submitted by Carrier providers.
        • Durable Medical Equipment (DME) 5% sample files: DME file contains 5% final action, fee-for-service, claims data submitted by DME providers.
      • Part B Aggregated PUF files include: (i) (CPT/HCPCS procedure) codes, (iii) dates of service, (iv) reimbursement amount and (v) provider demographic information. This data contains no claim level data including no de-identified beneficiary information.  Also, this data has been subjected to small cell size suppression.  Available years of data include 2012, 2013 and 2014.

 

  • NOTE: PurpleLab has reformatted 100% of the LDS data to enable more efficient querying of the data. This re-formatting does not alter the original claim level information.  Rather the re-formatting homogenizes the various data dictionaries, file layouts and table structures that the data is presented in by CMS into a single unified structure for all Part A claims and a separate.  Absent this effort, the data would be in different data dictionaries for post 2011 data (format version J) versus several different formats for pre 2011 data.  In addition to annual changes to the data dictionaries, each of the five separate Part A settings of IP, OP, SNF, HHA and Hosp all unencrypt into 5 separate tables upon delivery.  Each of those settings has a unique native file layout, field names and definitions.  PurpleLab has undertaken considerable effort to unify and simplify the table structures across settings and years of different presentations of the claim level data without altering the native data in a single claim.
  • What are the Medicare restrictions that the PurpleLab platform is subject to?
    • CMS “small cell size” suppression policy sets minimum thresholds for the display of associated data. The “small cell size” suppression policy stipulates that no cell (e.g. admissions, discharges, patients, services, etc.) containing a value of 1 to 10 can be reported directly. For purposes of clarity, a value of zero does not violate the minimum cell size policy. However, a value between 1 to 10 does. In addition, no cell can be reported that allows a value of 1 to 10 to be derived from other reported cells or information.
    • CMS rational for minimum cell sizes is state t”o protect the confidentiality of beneficiaries by avoiding the release of information that can be used to identify individual beneficiaries”. The CMS “small cell size” policy applies to any output describing any of the following: beneficiaries, procedures, and diagnoses. Any release or dissemination using CMS data must adhere to the CMS “small cell size” suppression policy.
    • There are several options that researchers can employ to comply with the minimum cell size requirements outlined in the CMS cell size suppression policy. Common strategies to avoid displaying a cell of 1 to 10 include collapsing cells, coarsening data, and cell suppression.
    • CMS “small cell size” policy statement presents three common scenarios that would violate the cell size suppression policy and provides examples of strategies that can be undertaken to comply with the CMS cell size suppression policy.
      • Table displays a cell with a value between 1 and 10.
      • Information from multiple tables can be used to derive values between 1 and 10.
      • Table displays a value for excluded patients that is between 1 and 10.
    • Problem Example: Violates CMS “small cell size” suppression rules because it displays a cell value between 1 to 10.
Procedure “XYZ” (N=2,690)
Beneficiary age group N (%)
60-69 years 1,900 (71)
70-74 years 400 (15)
75-79 years 290 (11)
80-84 years 94 (3.5)
85+ years 6 (0.22)

 

  • Answer Example 1: Does not violate CMS “small cell size” suppression rules because it collapses cells to avoid displaying any value between 1 to 10.

 

Procedure “XYZ” (N=2,690)
Beneficiary age group N (%)
60-69 years 1,900 (71)
70-74 years 400 (15)
75-79 years 290 (11)
80+ years 100 (3.7)

 

  • Answer Example 2: Violates CMS “small cell size” suppression rules because although it does not display a cell value between 1 to 10, but simple math enables the cell value to be derived but since the column total is known, the value for the age category 85+ can be derived [e.g., * = 2,690 – (1,900+400+290+94) = “6”].

 

Procedure “XYZ” (N=2,690)
Beneficiary age group N (%)
60-69 years 1,900 (71)
70-74 years 400 (15)
75-79 years 290 (11)
80-84 years 94 (3.5)
85+ years * or <11

 

  • Answer Example 3: Does not violate CMS “small cell size” suppression rules because it suppresses multiple cell values to avoid derivation of the cell value that would enable “small cell size”

 

Procedure “XYZ” (N=2,690)
Beneficiary age group N (%)
60-69 years 1,900 (71)
70-74 years 400 (15)
75-79 years 290 (11)
80-84 years * or <11
85+ years * or <11

 

  • There are several ways in which PurpleLab has designed its reports in order to avoid small cell size issues. For example, PurpleLab’s use of aggregation of individual years into totals aggregates many counts between 1 to 10 into larger totals.  PurpleLab enables users to build larger Clinical Groupers/Code Groups to enable diagnosis or procedure counts to increase.  Nonetheless, small counts do arise and in any of these situations, PurpleLab’s policy for maintaining CMS “small cell size” suppression policy follows Answer Example 3 above. PurpleLab reports will suppress multiple cells (staring with the earliest year of analysis, which enables users of the platform to gain the greatest understanding of more recent trends in the data while PurpleLab still fulfills its obligations with respect to the small cell size suppression rules.

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