With a resource the size of the Colorado All Payer Claims Database (CO APCD), it is easy to presume that the possibilities for exploration are endless. In some senses, it is true, that comprehending the potential combinations of data elements from over 870 million claims is nearly impossible. However, the scale of the database doesn’t translate into unlimited capabilities. Some limitations exist because of the nature of claims data itself, and others are created due to information not being submitted to the CO APCD, elements not being collected by payers or regulations around certain types of data.

Claims Data Limitations

Claims data is administrative data and meant to transmit reimbursement information between provider and health plan. Given this most basic function, it does not include clinical information such as test results or patient health histories. It also, by necessity, is retroactive as it takes time for the claim to move through the system of processing and payment before it reaches the CO APCD. Finally, because the database only contains information that comes in from paid health insurance claims, any service paid for out-of-pocket, or that does not have a claim attached, is not included. This means that the CO APCD does not capture the uninsured population in Colorado or services where a fee is not charged.

Information Not Submitted to the CO APCD

Despite its name, the CO APCD does not include all payers in Colorado. Some, such as self-funded employer plans subject to the Employee Retirement Income Security Act (ERISA) or Worker’s Compensation insurers do not submit claims because they are not required by law like other payers. Similarly, data from TriCare, the Veterans Administration, Indian Health Service, Federal Employee Health Benefits (FEHB), or other Federally sponsored programs is not part of the database.

The Data Submission Guide (DSG) provides the payers with the data elements that should be submitted each month, and not all of the potential information on a claim is included. Currently, CIVHC does not collect premium or health plan design information or data about capitated fees or provider incentive payments. These items could be collected in the future via a Rule Change with the Colorado Department of Health Care Policy and Financing (HCPF).

Elements Not Collected by Payers

In some cases, data cannot be included in the CO APCD because it is not collected by the submitters. For example, free-standing emergency rooms (FSED) are frequently billed by the hospital with which they are affiliated rather than as a stand-alone facility. Lumping the two types of facilities under one billing entity makes it difficult to determine where a service actually took place. Another example is demographic and socioeconomic information about patients, which has become increasingly vital in identifying and eliminating health disparities during COVID. Fields in the claims designed to capture race and ethnicity in particular are frequently indicated as “Unknown” for most commercial payers. This is because the majority of commercial payers do not ask for this information at the time of enrollment, and if they do, it is not a required field and may be left intentionally blank by the enrollee. In both of the examples above, there are efforts underway to overcome these types of challenges.

Data Not Submitted Due to Regulations

Federal and state regulations also play a role in determining what data is included in the CO APCD. The two types of information currently most impacted by regulation are claims from self-funded ERISA employers and substance use disorder (SUD) claims.

Self-funded ERISA Claims

Due to a 2016 ruling by the United States Supreme Court, states cannot mandate submission of claims data from self-insured Employee Retirement Income Security Act (ERISA) plans to APCDs. The ruling did not impact collection of data from non-ERISA self-insured employers or those ERISA-based employers who choose to voluntarily submit claims to APCDs. CIVHC continues to collect non-ERISA self-insured employer claims and conducts robust outreach to encourage voluntary submission from the ERISA employers. Self-insured claims are estimated to represent half of the total commercially insured lives in Colorado and CIVHC estimates that the CO APCD currently contains approximately a quarter of those lives.

Substance Use Disorder Claims

Part two of item 42 in the Code of Federal Regulations (CFR) details the rules surrounding the confidentiality of information related to SUDs. Similar to the Health Information Portability and Accountability Act (HIPAA), which addresses the release and use of personal health information and allows for use of this data in specific instances, 42 CFR (Part 2) has criteria for the release of SUD information. Compared to HIPAA, however, the circumstances that allow for sharing SUD data are very narrow and submitting claims to the CO APCD does not meet the criteria for release. As a result, CIVHC does not request payers to submit data that is subject to Part 2. However, the criteria for submitting substance use data was updated with the passing of the CARES Act in early 2020. As of this post, CIVHC is still learning how this will impact the claims collection process, and has not yet provided guidance to payers regarding submitting claims based on the changes in the CARES Act. As more information becomes available about the new regulations, it will be shared with the payers and the process to collect SUD data will begin.

These are a handful of the limitations that can arise when working with claims data and the CO APCD. Others may stem from external factors like incompatible computer systems or data files – like those between claims and clinical data. There is also no consistent format for payers to house their claims information with each devising their own systems and ability to produce analytics (a problem common to many other types of health care data as well). Therefore, some payers are unable to produce all of the data elements according to the DSG and in some cases have to apply for a submission waiver until they can figure out a solution.