Code of Massachusetts Regulations › 957 CMR - CENTER FOR HEALTH INFORMATION AND ANALYSIS › Title 957 CMR 2.00 - Payer Data Reporting › Section 2.05 - Reporting Relative Prices

Current through Register 1525, July 5, 2024
(1)
Relative Prices for
			 Hospitals
.
(a) Payers
			 must report Relative Price data separately by Medicare, Medicaid,
			 commercial (fully-insured and self-insured), and any other insurance
			 categories as specified by the
Data Specification
			 Manual
.
(b)
			 Payers shall report hospital categories separately for inpatient and
			 outpatient.
(c) Payers
			 must report Relative Price data separately by hospital category for
			 acute hospitals, chronic hospitals, rehabilitation hospitals, and
			 psychiatric hospitals.
(d) Notwithstanding 957 CMR
			 2.05(1)(c), Payers shall report additional behavioral health-only
			 Relative Price data for acute hospitals with psychiatric or substance
			 abuse units with the psychiatric hospital file. Payers must develop a
			 standard definition of behavioral health services to be used for all
			 acute hospitals impacted by 957 CMR 2.05(1)(d).
(e)
Required Data
			 Elements - Hospital Inpatient
.
1. CHIA Organization ID;
2. Hospital Type;
3. Insurance Category;
4. Product Type;
5.
Hospital-specific
			 Base Rate
: the negotiated rate per discharge, excluding
			 any adjustments for case mix or severity of illness. Payers must note
			 when Hospital-specific Base Rates are derived from payment data.
a. For acute hospitals that are not
			 paid on DRG model, the Payer must calculate a Hospital-specific Base
			 Rate equivalent. Payers who are able to demonstrate significant
			 hardship in developing acute hospital DRG base rates and obtaining
			 DRG software may apply to the Center for a waiver to use a standard
			 per unit rate.
b. For
			 chronic, rehabilitation, or psychiatric hospitals, Payers may use a
			 per unit rate as long as a uniform unit is applied within each
			 hospital category.
6.
Network Average Base
			 Rate
: the simple average of the Hospital-specific Base
			 Rate for all Hospitals within a Payer's network.
7.
Total Non-claims
			 Payments
: the sum of all Non-claims Related Payments.
			 The allocation method for Non-claims Related Payments is outlined in
			 the
Data Specifications Manual
.
8.
Total Claims-based
			 Payments
: the sum of all medical claims
			 payments.
9.
Total Payments
: the sum of total
			 claims-based and Non-claims Related Payments.
10.
Case
			 Mix
: the Payer's case mix index for the Provider
			 including all cases.
11.
Number of Discharges
: the total number of
			 discharges associated with a Provider.
12.
Hospital-specific
			 Product Mix
: the proportion of the Hospital's inpatient
			 payments for HMO and POS, PPO, Indemnity, and any other Massachusetts
			 Provider network products.
13.
Network-wide
			 Product Mix
: the proportion of the Payer's payments for
			 HMO and POS, PPO, Indemnity, and any other Massachusetts Provider
			 network products.
14. DRG
			 version and group number used in calculation.
15. The Center will delineate any
			 other required data elements in the
Data Specification
			 Manual
.
(f)
Calculation of
			 Relative Prices - Hospital Inpatient
. Based upon the
			 data specified in 957 CMR 2.05(1)(e), the Center shall calculate
			 Hospital Inpatient Relative Prices by dividing Total Claims-based and
			 Non-claims Related Payments by the product of Case Mix and Number of
			 Discharges to derive an Adjusted Base Rate. The sum of the products
			 of the Adjusted Base Rate by the Network-wide Product Mix will
			 produce the Hospital Product Adjusted Base Rate. The Hospital's
			 Product Adjusted Base Rate divided by Payer's Network Average Product
			 Adjusted Base Rate shall result in the Hospital's Inpatient Relative
			 Price. Payers will be provided a copy of the calculation.
(g)
Required Data
			 Elements - Hospital Outpatient
.
1. CHIA Organization ID;
2. Hospital Type;
3. Insurance Category;
4. Product Type;
5.
Hospital-specific
			 Service Multipliers
: the negotiated fee schedule
			 multipliers for each Hospital, for each fee schedule category as
			 determined by the Payer, for each product. For Hospitals paid on a
			 non-fee schedule basis, multipliers shall be derived by dividing
			 payments for a service category by the amount that would have been
			 paid if the Hospital was paid at a standard fee schedule or base rate
			 for that service category. Payers must note when Hospital-specific
			 Service Multipliers are derived from payment data;
6.
Total Claims-based
			 Payments
: the sum of all medical claims
			 payments;
7.
Total Non-claims Payments
: the sum of all
			 Non-claims Related Payments. The allocation method for Non-claims
			 Related Payments is outlined in the
Data Specification
			 Manual
;
8.
Hospital-specific Service Mix
: the
			 proportion of the Hospital's revenue for outpatient categories
			 established by the Payer in 957 CMR 2.05(1)(g)5.;
9.
Network-wide Service
			 Mix
: the proportion of the Payer's payments for
			 outpatient categories established by the Payer in 957 CMR
			 2.05(1)(g)5.;
10.
Hospital-specific Product Mix
: the
			 proportion of the Hospital's outpatient payments for HMO and POS,
			 PPO, Indemnity, and other Massachusetts Provider network
			 products;
11.
Network-wide Product Mix
: the proportion of
			 the Payer's payments for HMO and POS, PPO, Indemnity, and other
			 Massachusetts Provider network products; and
12. The Center will delineate any
			 other required data elements in the
Data Specification
			 Manual
.
(h)
Calculation of
			 Relative Prices - Hospital Outpatient
. Hospital
			 Outpatient Relative Prices shall be calculated by the Center by
			 summing the products of the Hospital-specific Service Multiplier for
			 each product type by the Network-wide Service Mix for that product
			 type to derive a Base Service Weighted Multiplier. The sum of the
			 products of the Base Service Weighted Multiplier for each product
			 type and the Network-wide Product Mix shall produce the Base Service
			 and Product Adjusted Multiplier. The Center shall derive a Non-claims
			 Multiplier of each product for each Hospital by dividing Total
			 Non-claims Payments by Total Claims-based Payments and multiplying
			 the result by the Base Service Weighted Multiplier. The sum of the
			 products of the Non-claims Multiplier and the Network Average Product
			 Mix shall produce the Product-adjusted Non-claims Multiplier. The sum
			 of the Product-adjusted Non-claims Multiplier and the Base Service
			 and Product Adjusted Multiplier divided by the Network Average
			 Hospital Outpatient Multiplier shall result in the Hospital's
			 Outpatient Relative Price. Payers will be provided a copy of the
			 results.