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Payer Typology:What You Need To Know
September 2007
Prepared byBob Davis
Representing the Public Health Data Standards Consortium, Payer Type
Workgroup
Topics
•Purpose and potential users of Payer Typology
•Use of Payer Typology
•Available Documentation
•Status of Pilots
•Relationship to National Standards
•Maintenance Activities
Purpose of Payer Typology
To provide a standardized, flexible, and complete code set that classifies payer (e.g., Medicare, VA, private insurance, charity care) and when possible, to differentiate organization of payment (e.g., HMO, PPO, private insurance)
Purpose of Payer Typology
The Payer Typology incorporates typical state specific requirements, as well as being flexible enough to be used as a code set in surveys and other data collected for research or policy purposes.
Potential Users of Payer Typology
•Researchers•Policymakers•Health services researchers•Public health departments•Health administrators•Health care practitioners•Others concerned with the relationship between payer and health care access, quality of care, utilization patterns, and treatment outcomes
Need for Payer typology
• There is currently no national standard for reporting and classifying source of payment data.
• Existing ASC X12N 837 categories in the subscriber section are currently neither mutually exclusive nor comprehensive.
• Ability to compare source of payment data across databases is critical to policymakers and researchers examining effects of payment policy.
• PlanID is not expected to meet the Committee’s goals.
Current Claim Filing Indicator List used in 837 implementation Guides
09 Self-pay10 Central Certification11 Other Non-Federal Programs12 Preferred Provider Organization (PPO)13 Point of Service (POS)14 Exclusive Provider Organization (EPO)15 Indemnity Insurance16 Health Maintenance Organization (HMO) Medicare RiskAM Automobile MedicalBL Blue Cross/Blue Shield
CH Champus CI Commercial Insurance Co.DS DisabilityHM Health Maintenance OrganizationLI LiabilityLM Liability MedicalMA Medicare Part AMB Medicare Part BMC MedicaidOF Other Federal ProgramTV Title VVA Veteran Administration PlanWC Workers’ Compensation Health ClaimZZ Mutually Defined / Unknown
Need for Payer typology
Examples of deficiencies in existing code set:• “HMO” cannot distinguish among Medicare,
Medicaid or privately financed HMOs• There is no way to distinguish among different
types of Medicare Advantage Plans• “Champus” no longer exists• “Self-pay” cannot distinguish among charity care,
professional courtesy, and bad debt• Some codes are adminstrative hold-overs (e.g.
“Central Certification”)
Use of Payer Typology
•Hierarchical Value Set– Enables reporting at lowest level of
granularity available– Enables use at highest level of
granularity needed
Use of Payer Typology
• Payer Type codes are defined as up to six left-justified alpha numeric characters.
• Each character from the left to the right
represents a new hierarchical level in the value set.
• The typology is loosely modeled on the ICD classification system for disease, which codes to the most specific disease possible.
Use of Payer Typology
• The first digit of each code is the organization that provides the funds for the care;
• Additional digits provide more information about the specifics of the plan or mechanism through which these funds are provided.
Major Payor Codes
11
22
33
44
55
66
77
88
99
MedicareMedicare
MedicaidMedicaidOther Government (Other Government (not Medicare, Medicaid or corrections)not Medicare, Medicaid or corrections)
Department of CorrectionsDepartment of Corrections
Private Health InsurancePrivate Health Insurance
Blue Cross/Blue ShieldBlue Cross/Blue Shield
Managed Care, unspecified (*)Managed Care, unspecified (*)
No payment from organizationNo payment from organization
Miscellaneous/otherMiscellaneous/other
Example of second- and third-digit codes
1 MEDICARE
11 Medicare (Managed Care)
111 Medicare HMO
112 Medicare PPO
113 Medicare POS
119 Medicare Managed Care Other
12 Medicare (Non-managed Care)
121 Medicare FFS
122 Medicare Drug Benefit
123 Medicare Medical Savings Account (MSA)
129 Medicare Non-managed Care Other
19 Medicare Other
Example of second- and third-digit codes
8 NOPAYMENT from an Organization/Agency/Program/Private Payor Listed
81 Self-pay
82 No Charge
821 Charity
822 Professional Courtesy
823 Research/Clinical Trial
83 Refusal to Pay/Bad Debt
84 Hill Burton Free Care
85 Research/Donor
89 No Payment, Other
Use of Payer Typology
• Explanation of Example– Current payer classification value sets
typically have only ONE category for non-payment.
– If a patient’s care is reported as CHARITY, the researchers could analyze those patients receiving CHARITY Care, or include those patients with other patients with NO CHARGE for care, or include those patients with any where NOPAYMENT for services to the provider.
Available Documentation
• The Payer Typology –– http://www.phdsc.org/about/committees/pmt_typology.htm– The complete hierarchical list of payer categories
• The Payer Typology User Guide – http://phdsc.org/standards/payer-typology.asp – & click on Users Guide for Source of Payment
Typology– Payer Category definitions and relevant standards
information• Public Health Data Standards Consortium
Payer Work Group– http://phdsc.org/standards/payer-typology.asp – Group responsible for development and
maintenance of Payer Typology
Status of Pilots
•State of Georgia– Implementation of Payer Typology
hierarchies by January 2008 for all Georgia discharges for calendar year 2007.
– Georgia hospitals will be given an opportunity to stage the reporting of Payer Typology categories between now and next year.
– NOTE: Georgia is implementing three (3) hierarchical levels of full Payer Typology, which currently provides granularity to five (5) hierarchical levels.
Status of Pilots
•State of California– Deficiencies of all current payer type code sets have
been identified. – Staged migration plane for their inpatient collection
system to use ANSI X12 837 and UB-04.
• Establish an electronic connection between the State and providers
• Migrate legacy system to use standard data content
• Full migration to national formats– Anticipated that the Payer Typology will replace their
legacy code system with migration to ANSI 837 and UB-04
Status of Pilots
•State of Massachusetts– The proprietary payer type code list
used by the State of Massachusetts is problematic.
– The state data agency is planning to solicit the hospital feedback during calendar year 2007 on the merits or deficiencies of the Payer Typology as a replacement to their current proprietary payer type classification list.
Relationship to National Standards
• Currently Data Maintenance in progress to Currently Data Maintenance in progress to reference the typology in the ANSI X12 standards reference the typology in the ANSI X12 standards within the 837 transaction.within the 837 transaction.
• It is anticipated that the October 2007 (5050) and It is anticipated that the October 2007 (5050) and beyond versions of the ANSI X12 standards will beyond versions of the ANSI X12 standards will provide support for the reporting of the Payer provide support for the reporting of the Payer Typology.Typology.
• It is anticipated that 5050 and beyond versions of It is anticipated that 5050 and beyond versions of the Health Care Service Data Reporting Guide will the Health Care Service Data Reporting Guide will support the reporting of the Payer Typology.support the reporting of the Payer Typology.
• Current versions of 837 implementation guides Current versions of 837 implementation guides could support reporting of the Payer Typology in could support reporting of the Payer Typology in the K3 segment with approval of the ANSI X12N the K3 segment with approval of the ANSI X12N Health Claims Work Group (TG2 WG2)Health Claims Work Group (TG2 WG2)
Maintenance Activities
• The Source of Payment Typology is maintained by the National Center for Health Statistics / Centers for Disease Control and Prevention.
• Requests to change typology should be directed to the Payer Type Subcommittee of the Data Standards Committee of the Public Health Data Standards Consortium. ((http://phdsc.org/standards/payer-typology.asp))
Maintenance Activities
• Changes to the Source of Payment Typology are made bi-annually in October and April.
• Any interested industry representative can make recommendations for additions or modifications by sending their comments via email to the committee co-chairs.
• These recommendations would be voted on
by members of the Payer Type Subcommittee for possible inclusion in the Source of Payment Typology.
