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
Universal Citation: 957 MA Code of Regs 957.2
Current through Register 1531, September 27, 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.
(2) Physician Groups.
(a) Payers must separately identify
and report Relative Price data for the top 30 Physician Groups within
a Payer's network, determined by revenue from the Payer.
(b) Payers shall report aggregate
Relative Price data for all remaining Physician Groups outside of the
top 30 in the relevant reporting period. The Center may request
additional information on such Providers.
(c)
Required Data
Elements.
1. CHIA
Organization ID or Payer's Internal Provider Number;
2. Name of Physician Group
Practice;
3. Name of
Physician Local Practice Group;
4. Pediatric Indicator;
5. Insurance Category;
6. Product Type;
7.
Physician
Group-specific Service Multipliers: the negotiated fee
schedule multipliers for each Physician Group, for each fee schedule
category as determined by the Payer, for each product. For Physician
Groups 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 Physician Group was paid at a standard fee
schedule or base rate for that service category. Payers must note
when Physician Group-specific Service Multipliers are derived from
payment data;
8.
Physician Group-specific Service Mix: the
proportion of the Physician Group's revenue for service categories
established by the Payer in 957 CMR 2.05(2)(c)7.;
9.
Network-wide Service
Mix: the proportion of the Payer's payments to Physician
Groups for service categories established by the Payer in 957 CMR
2.05(2)(c)7.;
10.
Physician Group-specific Product Mix: the
proportion of the Physician Group's 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;
12.
Total Claims-based
Payments: the sum of all medical claims
payments;
13.
Total Non-claims Payments: the sum of all
Non-claims Related Payments. The allocation method for Total
Non-claims Payments is outlined in the Data Specification
Manual; and
14.
The Center will delineate any other required data elements in the
Data Specification Manual.
(d)
Calculation of
Relative Prices - Physician Groups. Physician Group
Relative Prices shall be calculated by the Center by summing the
products of the Physician Group-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
for each Physician Group 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 Physician
Group Multiplier shall result in the Physician Group's Relative
Price. Payers will be provided a copy of the results.
(3) Other Providers.
(a) Payers
must report the Relative Price data separately for the following
Provider categories:
1. Ambulatory
Surgical Centers;
2.
Community health centers;
3. Community mental health
centers;
4. Freestanding
clinical labs;
5.
Freestanding diagnostic imaging centers;
6. Home health agencies;
7. Skilled nursing facilities;
and
8. The Center may
specify additional Provider categories for which Payers must submit
Relative Prices by Administrative Bulletin.
(b) Payers must separately identify
and report Relative Prices for Providers who received 3% or more of
payments in a given Provider category as identified in 957 CMR
2.05(3)(a) for the relevant reporting period.
(c) Payers shall report aggregate
Relative Price data for all Providers who received less than 3% of
payments in the relevant reporting period for a given Provider
category, but were not paid on the Payer's standard fee schedule. The
Center may request additional information on such
Providers.
(d) Payers
shall report aggregate Relative Price data for all Providers who
received less than 3% of payments in the relevant reporting period
for a given Provider category and were paid on the Payer's standard
fee schedule. The Center may request additional information on such
Providers.
(e)
Required Data Elements.
1. CHIA Organization ID or Payer's
Internal Provider Number;
2. Pediatric Indicator;
3. Insurance Category;
4. Product Type;
5.
Provider-specific
Service Multipliers: the negotiated fee schedule
multipliers for each Provider, for each fee schedule category as
determined by the Payer, for each product. For Providers 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 Provider was paid at a standard fee schedule or base
rate. Payers must note when Provider-specific Service Multipliers are
derived from payment data;
6.
Provider-specific
Service Mix: the proportion of the Provider's revenue
for service categories established by the Payer in 957 CMR
2.05(3)(e)5.;
7.
Network-wide Service Mix: the proportion of
the Payer's payments for service categories established by the Payer
in 957 CMR 2.05(3)(e)5.;
8.
Provider-specific
Product Mix: the proportion of the Provider's payments
for HMO and POS, PPO, Indemnity, and other Massachusetts Provider
network products;
9.
Network-wide Product Mix: the proportion of
the Payer's payments for HMO and POS, PPO, Indemnity, and other
Massachusetts Provider network products;
10.
Total Claims-based
Payments: the sum of all medical claims
payments;
11.
Total Non-claims Payments: the sum of all
Non-claims Related Payments. The allocation method for Total
Non-claims Payments is outlined in the Data Specification
Manual; and
12.
The Center will delineate any other required data elements in the
Data Specification Manual.
(f)
Calculation of
Relative Prices - Other Providers. Other Provider
Relative Prices shall be calculated by the Center by summing the
products of the Provider-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
for each Provider 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 Provider
Multiplier shall result in the Provider's Relative Price. Payers will
be provided a copy of the results.
(4) Network Average Relative Price Amount. Payers must report the dollar value associated with the network average Relative Prices that are used in the Relative Price calculations for each product type of each insurance category if applicable for Hospitals, Physician Groups, and Other Providers. Data submissions must conform to specifications as set forth in the Data Specification Manual.
(5) Due Dates: Annual Reports.
(a)
Hospitals. Payers must submit required
Relative Price data reports for Hospitals each year for the Calendar
Year prior to the deadline as specified in the Data
Specification Manual.
(b)
Physician
Groups. Payers must submit Relative Price data reports
for Physician Groups each year for the Calendar Year ending 18 months
prior by the deadline as specified in the Data Specification
Manual.
(c)
Other Providers. Payers must submit required
Relative Price data reports for Ambulatory Surgical Centers,
community health centers, community mental health centers,
Freestanding clinical laboratories, Freestanding diagnostic imaging
centers, home health agencies, and skilled nursing facilities by the
deadline as specified in the Data Specification
Manual each year for the prior Calendar Year.
(d)
Network Average
Relative Price Amount. Payers must submit required
dollar value information by the deadline as specified in the
Data Specification Manual each year for the prior
Calendar Year.
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