Understanding Purchased Care Data and Contracts in TRICARE System
Explore the relationship between DHA, Managed Care Support Contractors, Civilian Health Care Providers, and Beneficiaries in the context of Purchased Care data. Learn about the various tables, filters, and synonyms associated with Purchased Care. Understand common terms and the role of Managed Care Support Contractors in establishing provider networks under TRICARE contracts.
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Purchased Care Data (TED-I & TED-NI) VERONIKA PAV KENNELL & ASSOCIATES, INC.
Objectives Objectives Understand the relationship between DHA, the Managed Care Support Contractors, Civilian Health Care Providers, and Beneficiaries Describe the characteristics of the Institutional, Non- Institutional, and Provider purchased care data tables Apply appropriate filters to separate out inpatient professional, outpatient professional, pharmacy, Prime and TRICARE For Life 2
Purchased Care Synonyms Purchased Care Synonyms Purchased Care is referred to in a variety of ways: Claims Data Downtown Private Sector or PSC Network Managed Care Leakage TED Data (TED-NI, TED-I, TED-PR) 3
Common Terms Common Terms National Provider ID HIPAA Taxonomy Code ICD Dx Code CPT/HCPCS Code MDC APC Basic Workload Person IDs Bencat & Bencat Common HCDPs, Enrollment Group PCM ID Enrollment MEPRS Code Deployment Information Geography Tmt DMIS ID MEPRS Code ICD Px Code CCS Category MS-DRG Service Dates Weighted Workload Demographics Enrollment Site Eligibility Group Raw vs Total Record ID 4
Purchased Care Contracts Purchased Care Contracts Managed Care Support Contractors (MCSC) Managed Care Support Contractors (MCSC) MCSCs are required to establish networks of providers who have agreed to take TRICARE patients and who are paid under negotiated agreements 5
Purchased Care Contracts Purchased Care Contracts Managed Care Support Contractors (MCSC) Managed Care Support Contractors (MCSC) Region Contractor Name Contractor Number (T17) East Humana 12 West Health Net 13 6
Purchased Care Contracts Purchased Care Contracts Managed Care Support Contractors (MCSC) Managed Care Support Contractors (MCSC) Region Contractor Name Contractor Number (Tnex/T3) West TriWest/United 62/08 South Humana 63/05 North Health Net 64/04 7
Other Purchased Care Contractors Other Purchased Care Contractors Acronym Contract Name TRICARE Overseas Program Contractor Number TOP 15/10 TPharm TRICARE Pharmacy 70/73 TRICARE Dual Eligible Fiscal Intermediary Contract TDEFIC 71/74 8
Claims Payment Process Claim MCSC TED-I TED-NI TED-PR Payment DHA TED database DEERS Eligibility Check Health Care Event 9
Two Different Claim Types & Two Different Claim Types & One Provider Record One Provider Record Institutional (TED-I) Contains claims submitted by institutions Inpatient Care and Inst-based Home Health (Does not contain ER or Hosp Outpat Dept) Non-institutional (TED-NI) Contains all other claims Sometimes called Professional claims Professional Care, Supplies, Services, Outpatient Facilities, Prescriptions Purchased Care Providers Records of providers authorized to bill TRICARE 10
MERHCF Flag MERHCF Flag MERHCF is Medicare Eligible Retiree Health Care Fund Medicare Eligible Flag is T or U TRICARE is second payer, except for care that Medicare does not cover No requirement for matching Provider record T is Medicare Elig 65, U is Medicare Elig < 65 11
MERHCF Flag MERHCF Flag DHP is Defense Health Program Flag is N or A TRICARE is usually first payer T-U-N-A DHP and MERHCF represent funding, they are NOT identifications of programs A is Active Duty and Active Duty Family Members, N is all other <65 care 12
Institutional & Non Institutional & Non- -Institutional at at Record Level Record Level Institutional For Institutional Data, one record for range of dates at one institution for one beneficiary on one bill. Use Record ID for atomic level data For Non-Institutional Data, each record represents one procedure code for one date or a range of dates Multiple procedure codes may be present on one Non-Institutional claim as line items Therefore, Line Item No. must be used in conjunction with the Record ID to capture all records. Use Record ID and line item no. for atomic level data There is a concatenated field called Record ID/Line Item No (TEDNO + LINUM) that does this for you in TED-NI. 13
Record IDs For TEDI: For non-acute care: Ted Number (TEDNO) For acute care: Admitting TEDNO (ADMTEDNO) ** For TED-NI: Record ID +Line Item No (TEDNO || LINUM) 14
Non-Institutional Use Line Item Number Adding Line Item No to this query shows that there are 4 records for this one Non-Institutional claim Note: use Raw values instead of Total values for individual claims and line items 15
Geography Related Data Elements on TEDs Based on where beneficiary lives: Beneficiary Zip Code Catchment Area: 40 mile inpat MTF only MTF Service Area: 40 mile, inpat + amb MTF PRISM Area: 20 mile, inpat + amb MTF Prime Service Area: Y/N flag indicating whether in Prime Service Area or not TPR Flag: Y/N flag indicating whether in TRICARE Prime Remote Area or not Market Area ID: Prime Service Area sub-classifications as defined in MCSC contracts Beneficiary Region and Beneficiary HSSC Region 16
Geography Related Data Elements on TEDs Based on where care is provided: Provider Zip Provider State/Country Code Provider Catchment Area: 40 mile inpat only Provider Market Area ID: Prime Service Area sub-classifications as defined in MCS contracts Provider PRISM Area: 20 mile, inpat + amb Provider Catchment Area MSMA: Multi-Service Market Area (MSM) and Enhanced Multi-Service Market Areas (eMSM) Provider Catchment HSSC Region (Tnex Region) Note: Important for Demand/Supply Questions 17
DEERS Data in TEDs DEERS Data in TEDs When a claim is processed by the MCSC there is a query sent to DEERS to determine the status of the beneficiary. The resulting DEERS fields are added to the TED record When the claim is added to MDR, and then M2, several weeks later, it is matched to the most current DEERS extract file for that date of care The timing difference can lead to differences between what is reported on the TED and DEERS fields added at the time of MDR processing 18
Enrollment Related Data Enrollment Related Data From MCSC Eligibility Check From MDR/M2 Merge with DEERS Extract Ben Cat Common of Record Ben Cat Common Enrollment Site of Record Enrollment Site Enrollment Status ACV, ACV Group 19
Enrollment Status Enrollment Status TEDI and TEDNI FY 2017 FY 2017 - - Number of Records Number of Records TEDI and TEDNI Enrollment Status Description Inst Non-Inst FS TRICARE for Life 475,949 82,417,782 PS TRICARE Senior Pharmacy 43,602,336 V Extra 108,190 42,469,756 U Prime, Civilian PCM 115,736 32,419,213 Z Prime, Military PCM 87,639 25,749,530 T Standard 47,513 12,704,725 All Others 20,500 6,615,588 SR Supplemental 25,319 6,146,185 20
Relative Weighted Data in TEDs Relative Weighted Data in TEDs RVU: Relative Value Unit Measures relative complexity or resources used for a procedure or service TED-NI APC Weights: Ambulatory Payment Classification Represents the relative resource intensity from a facility perspective of the reported procedure. Only applicable to procedures and facility that are paid by APC. TED-NI MS-DRG RWP: Relative Weighted Product Measures relative complexity and resources used for inpatient facilities Based on MS-DRG codes TED-I Acute Care Only 21
Completeness of Data Completeness of Data Completion estimates are made for almost all measures ,Raw means what has been reported to date; the actual data for a record ,Total means what we expect to report when all records have been processed; represents records that haven t been processed recalculated every month 22
TED-I Completion Factor by Month as of 10/25/2017 23
Provider Information on Inst and Non Provider Information on Inst and Non- -Inst Records Inst Records NPI: National Provider Identifier a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS). Provider Specialty, HIPAA 10-byte specialty code If there is no NPI, then use the Purchased Care Provider Table 24
Non Non- -Institutional Data Institutional Data Each record is a billed procedure code (line item) Includes: Professional Services (provider bills), both inpatient and outpatient Pharmacy Durable Medical Equipment Services (like ambulance) ER and other ambulatory, or outpatient, facility bills Laboratory and Radiology (outpatient) 26
Non Non- -Institutional Data Institutional Data Pharmacy Claims Pharmacy Claims Pharmacy claims are in two locations in M2: Purchased Care Non-Institutional PDTS Usually better to use PDTS for analyses of prescription usage Note: foreign Rx in TED-NI only 27
Non Non- -Institutional Data Institutional Data Pharmacy Claims Pharmacy Claims To exclude pharmacy claims from non-institutional analyses use Program Ind Code (PIC) Not Equal to D 28
Non Non- -Institutional Data Institutional Data Service Type Code Service Type Code For inpatient professional care, select Service Type Code I (contains some outpatient with global codes pre-op and post-op) Can also use PLACE OF SERVICE (PLACE) = 21 29
Non Non- -Institutional Data Institutional Data Place of Service Code Place of Service Code Where care was rendered Place of Service (PLACE) Examples: Urgent Care = 20 (does not include all UC) Inpatient Hospital = 21 Outpat Hosp = 22 (and 19 starting 1/1/2016) Emergency Room = 23 Office = 11 MTF = 26 Pharmacy = 01 30
Non Non- -Institutional Data Institutional Data Place of Service Code FY 2016 Place of Service Code FY 2016 Code Place of Service Records % Total 11 Office 86,547,023 34% 01 Pharmacy 79,024,572 31% 22 Hospital Outpatient Department 35,085,791 14% 12 Home 12,296,265 5% 23 Emergency Room 12,247,680 5% 21 Inpatient Hospital 10,751,385 4% 81 Outpatient Lab 9,680,906 4% All Others 8,692,824 3% As of 10/25/2017 31
Non Non- -Institutional Data Institutional Data Service Nature Service Nature Service Nature Indicates the clinical nature of care reported on the claim e.g. medical care (1), radiology (4), lab (5), and mental health (H) Used to distinguish between TRICARE Mail Order Pharmacy (M) and Retail Pharmacy (B) 32
Non Non- -Institutional Data Institutional Data Visits Visits Visits Evaluative Visits Definition Mixed definition - Evaluative, care management and assessments Treatment services Examples: o Physical therapy o Immunizations o Allergen therapy Evaluative, care management and assessments only. Limited to encounters involving history, exam or decision making which is not included in a separately coded procedure. Terminology Visit Evaluative Visit More appropriately reflects the type of care captured and minimizes misuse or confusion. FY2014 Count of Visits 104,889,552 46,129,655 #HCPCS/CPT Included in Algorithm Approximately 900 static list. Approximately 300 updated each year to accommodate code additions and deletions. 33
Non Non- -Institutional Data Institutional Data Building Episodes Building Episodes No good way to discern encounters . Depending on the type of care, can apply logic: Per person per provider per day (e.g. office visits dermatologist, PCM, etc.) Per person per day (e.g. Same day surgeries) 34
Non Non- -Institutional Data Institutional Data Linked Referral and Claims Linked Referral and Claims Referral File Added Network Referral Indicator: 0/1 flag. 1 means that the referral was used in a claims adjudication process (US only). 0 means it was not. 0s could be MTF referrals, unused network referrals or unnecessary referrals. Derived by matching to a claims adjudication file from the MCSCs. This information is not available in CHCS alone. Jan 15+ MHS-wide Referrals for FY2016 FM 1 FM 10 35
Non Non- -Institutional Data Institutional Data Linked Referral and Claims Linked Referral and Claims Referral objects Referring Provider ID/EDIPN/NPI MTF-MCSC Referral Flag Referring MTF and Hierarchy Referring MTF MEPRS Code UIN Referral Begin Date MTF Referral Access to Care Category Referral End Date Referral FY/FM Initial MTF Referred Visit Flag 36
Non Non- -Institutional Data Institutional Data Linked Referral and Claims Linked Referral and Claims Note the matching UINs. This referral generated 5 office visit anesthesiologist encounters, for $547. Referred from Family Practice Medical Home. MEPRS Code FCC = CHAMPUS Beneficiary Support (caution, not always used with network referrals) Note: United (MCSC) only links the earliest line item associated with a referral with the UIN. Using rules coordinated with the Referral Management Workgroup, the MDR linking logic incorporates additional line items. Access to Care Category = Specialty. Access Standard (<28 days) was met. 37
Non Non- -Institutional Data Institutional Data Key Fields Key Fields Demographic Patient Information Patient Enrollment Information (PCM, Enrollment Site, etc.) MDC 1 Procedure (CPT) + 2 Modifiers + Units of Service (SVCS) 5 Diagnoses Facility Claims/Charges Provider Specialty = 99 Provider Information (NPI, Specialty, location) 38
Institutional Claims Institutional Claims Includes institutional bills for Inpatient Care Acute Care: Hospitals Non-Acute: SNF, RTC, Rehab, Hospice Home Health Care Outpatient Hospice Some records represent parts of a stay Called Interim Bills Allows providers to get paid for care, prior to patient discharge Can adjust initial TED or be separate TED record (sequential dates and same Person ID) Admitting TED Number available in M2/MDR, for Acute Care only 40
Additional Records for a Claim Additional Records for a Claim Institutional Claims in sequence for same patient for same hospital stay Payments occur over many month New record created each month Discharge status = 30, Still a Patient Admitting TED Number will be the same but TED Number (TEDNO) will be different Admission Date Begin Date Of Care End Date Of Care Discharge Status Record ID Person ID 111111111 AAA 10/31/2016 10/31/2016 11/30/2016 30 222222222 AAA 10/31/2016 12/1/2016 12/31/2016 30 333333333 AAA 10/31/2017 1/1/2017 1/31/2017 30 41
Institutional Claims Institutional Claims Acute Care Hospital Indicator Acute Care Hospital Indicator Indicates whether care is delivered in an acute care facility 1 = Acute Care, 0 = Not Acute Care All Direct Care MTFs are Acute Care Non Acute Care cannot be done by the MTF Not recapturable 42
Admitting TED Number (ADMTEDNO) Admitting TED Number (ADMTEDNO) Used to group Inst and Non-Inst records into episodes of care Only available for acute care claims Added to both Inst and Non-Inst records during MDR/M2 processing Collects all records associated with an acute care institutional stay 43
Example of Inpatient Episode From TED-I. Note admitting TED Number Data Element Person ID Value ------849 MS-DRG (Description) Admission Date Begin Date End Date Record ID Admitting TED Number Amount Paid Bed Days C / Section w no complications 2/27/2016 2/27/2016 3/1/2016 2016072CA 96736 1905065 2016072CA 96736 1905065 4,546.96 3 44
Example of Inpatient Episode Use Admitting TED Number to get matching records from TED-N Data Element Claim 1 Claim 2 Claim 3 Person ID ------849 ------849 ------849 Begin Date Of Care 2/28/2016 2/28/2016 2/28/2016 End Date Of Care 2/28/2016 2/28/2016 2/28/2016 Place Of Service 21 - Inpatient 21 - Inpatient 21 - Inpatient Provider Specialty Code 05 16 22 Anesthesiology Obstetrics Pathology Amount Paid, Raw $255.36 $1,123.20 $38.37 Overall RVU, Raw 0 21.27 1.01 Procedure Code 01961 59514 88305 45
Institutional Claims Institutional Claims Institution Type for FY 2015 Institution Type for FY 2015 Acute Care Inst Type Description FY 2015 % Total 1 10 General medical and surgical 586,665 67% 0 76 Skilled Nursing Facility 126,669 14% Sole community/Critical Access 1 91 53,490 6% 0 22 Psychiatric hospital 42,433 5% Home Health Care Agency or unit 0 70 20,540 2% All Others 51,191 6% 46
Institutional Claims Institutional Claims Discharge Status Discharge Status Indicates how patient left the institution Values for routine discharge, death, transfer, etc Value of still a patient (30) indicates more bills are to follow to cover remainder of stay 10.0% of records overall 0.15% for acute care* Remove still a patient when doing average LOS, average cost, case mix * Many of these are low birth weight newborns 47
Institutional Claims Institutional Claims Key Fields Key Fields Patient Demographic Information Patient Enrollment Information Referral Information (if the stay was a result of a referral from the MTF) MDC MS-DRG 12 Diagnoses 6 Procedures Admission Source / Discharge Status ICU flag Indicates if patient stayed in an ICU for at least some of the stay OR Flag Indicates if patient used the operating room during the stay 48
Institutional Claims Institutional Claims Measures Measures Number of Claims Set to 1 for all records Number of Admissions Admission credit only given to admitting record, in case of interim claims Bed Days / Authorized Days Number of days in hospital / Number of days for which TRICARE will pay Note that Home Health Agencies (Inst Type 70) are reporting bed days, so take care to remove them Relative Weighted Product (MS-DRG RWP) Only for acute care hospitals 49
