An Introduction to CMS
data
CMS SAS Users Group Conference
Learn more about THE POWER TO KNOW®
October 17, 2011
Claims data
Who provides service?
• Providers – Institutional providers who are
‘certified’ based upon conditions of
participation such as Hospitals, Skilled Nursing
Homes
• Physicians
• Suppliers/Others – Includes non-physician
practitioners, group practices, labs,
ambulance, DME suppliers
• Approximately 1.2 million providers,
physicians, suppliers & others serve Medicare
2
Claims data
The Medicare claims process
• Using information returned from Common Working File (CWF),
FI/Carrier process claim for payment or denial.
• FI/Carrier now referred to as Medicare Administrative
Contractors
• CWF host sites transmit claims data to CMS daily.
• CWF is the initial point where claims are submitted from the
providers
• CMS processes the transmitted claims through the CWF Medicare
Quality Assurance System (MQAS) prior to loading data into the
National Claims History (NCH) Repository
• NCH is where claims are housed after some initial processing is
performed on the CWF
3
Claims data
General claim layout info
• Fixed portion
–
–
–
–
Common to all files
Many fields exist across all files
Demographics
Claim total dollars
• Trailers
–
–
–
–
–
Vary in length, content
Count in fixed portion
Loop processes each segment
Specific to claim type
Revenue centers / Line items
4
NCH / NMUD
• Derived from CWF
• Original repository for all claims
• All iterations of single claim
5
Claims data
• National Claims History (NCH)
– Source for all claims
– Fed by Common Working File (CWF)
– CWF is raw claims submitted by providers
– Some processing is done as claim moves to NCH
– Not final action processed
– Final action is the process of synthesizing a claim to
the final outcome after all adjustments have been
made
6
Claims data
•
•
•
•
•
Standard Analytical Files (SAFs)
Extracted from NCH and split by type
• Inpatient
• Outpatient
• Skilled Nursing Facilities (SNF)
• Home Health Agencies (HHA)
• Hospice
• Durable Medical Equipment (DME)
Final action processed applied
Place of service determines file
Integrated Data Repository (IDR) houses the Parts A and B claims
7
Claims data
• Physician/Supplier
– One for each state
– Too voluminous to fit in a single file
8
Other claims files
• MEDPAR - Medicare Provider Analysis and Review
– Extended hospital/SNF stay synthesized to a single
record
– Gives full view of a bene’s experience in single
record
• 5% Sample
– Exists for all claim types (inlcuding
Physcian/Supplier)
– Based on bene’s HIC (SSN)
– Proven reliability at high level
9
Enrollment data
• Enrollment database (EDB) and Medicare
Database (MDB)
– Consolidated and attempted to be reconciled in the
Common Medicare Environment (CME)
– All enrollees over time
– Derived from information from SSA
– MDB is updated to reflect corrected information,
but the EDB is not updated from the MDB
– Multiple segments must be consolidated to
determine a bene’s status
10
Denominator
• Derived from Enrollment Database (EDB)
• Created each year at the end of March
• Summary information on all benes who
received service during previous year
–
–
–
–
–
Basic demographic info (including DOD)
Entitlement
ESRD
Buy-in
HMO
11
Drug data
• Housed in Integrated Data repository (IDR)
only
• IDR is source for all claims and enrollment
data
• Built on Teradata platform
12
Cost Reports
 Annual reports
 Detailed utilization, revenue and expense data
 By individual health care providers
• The following provider types are required to submit MCRs
annually on a fiscal or calendar year basis:
– Hospitals (acute-care and specialty)
– Skilled Nursing Facilities (SNFs)
– Home Health Agencies (HHAs)
– End Stage Renal Disease Facilities (ESRDs)
– Hospice Facilities
13
Cost Reports
• Timing
– Annual files are updated quarterly
– MCR data files are nearly complete for
1996-2009 (90+ % response)
– 2010 file is 50% complete as of Q2 2011
• General Uses
– Cost-reimbursement
– Downstream Payment Updates
• Medicare Payment Adequacy Analysis
• Market Basket Updates
• Refinement of DRG Relative Weight Calculation
– Other Cost, Payment, and Utilization Analyses
14
Cost Reports
Accessing the reports
• http://www.cms.gov/CostReports
– Hospital Cost Report Dataset Supplemental Files
• Readme; Data Dictionary; Worksheet Codes;
Data Model; and Cost Center Codes
• Hospital Cost Report Data Set File Size
• Provider Control Type, Type of Hospital, etc.
• Facility Numbering, State Codes, Table
Descriptions & SQL
• HCRIS File Data Elements
15
Other data sources
• Hospital Outpatient Prospective Payment System
(OPPS)
• Name/address/vital status file
• Renal management Information System (REMIS)
• Medicaid Analytical Extract (MAX) – formerly SMRF
• Long Term Care Minimum dataset (MDS)
• Health Outcomes Survey (HOS)
• Health Care Information system (HCIS)
• Part B Analytics Reports (PBAR)
16
Claims data
Data dictionary
•
•
•
•
•
•
•
•
Basic information on all fields in a claim record
General description of field
Location, length, format
Description
Alias
Source code tables
Mainframe CLIST: [email protected](RIF)
http://www.cms.hhs.gov/IdentifiableDataFiles/02_StandardAnaly
ticalFiles.asp
17
SAS claims input statements
•
•
•
•
Input statements exist for all claim types
Also exist for each version
See B1G4.DESY.CNTL for all types
Contact [email protected]
for access
18
Oh No!!! Don’t make me use the
mainframe!
The mainframe is probably the most feared technology
at CMS
It’s nothing more than a server on steroids.
It has it’s quirks, but doesn’t everything?
It’s as easy to use as the PC once you get used to it.
19
Getting to the mainframe
• Host on Demand (HOD) URL
https://158.73.207.36/cms/tn3270.html.ascii
20
HOD
21
CMS Data Center
22
Application selection screen
23
Main menu
24
Dataset list utility
25
Dataset list utility
26
Dataset list utility
27
Dataset list utility
28
PF Keys
29
PF Keys
30
Split screen mode
31
Use PF 9 to swap
32
Use PF 9 to swap
33
Edit panel
34
Member selection list
35
Edit member
36
IOF
37
IOF
38
Questions???
• Contact information:
Joe Brenner
Office of the Actuary
[email protected]
410-786-6262
39