Methodology for Hospital Price Report

Colorado All-Payers Claims Database (APCD) 2018 Table - from the Center for Improving Value in Health Care (CIVHC).

 

General
Data in this analysis represents 2012-2017 health insurance claims submitted by Medicaid, Medicare and over 33 commercial payers (including Medicare Advantage claims) to the Colorado All Payer Claims Database (CO APCD). In addition to adjudicated claims, Medicaid supplemental payments, submitted by the Department of Health Care Policy and Financing (HCPF), were included in paid amounts to account for additional payments made outside the claim process. For more information on member counts by payer submitting to the CO APCD, please visit civhc.org/get-data/co-apcd-overview/data-submission/.

Average allowed amounts in this analysis represent the average value of the total amounts paid to facilities by Medicaid, Medicare Advantage, and commercial health insurance companies and patients (through copays, coinsurance and deductibles). Inpatient (hospital stay) claim amounts for Diagnosis Related Groups (DRGs) and Outpatient (no hospital stay) CPT amounts represent ONLY the allowed amounts paid to facilities (facility fee) and do not include physician or other ancillary payments.

Average charges reflect the average value of the total charges submitted by Medicaid, Medicare Advantage, and commercial health insurance companies and do not include any patient or member liability amounts.

Average percent of Medicare rates reflect the average percentage commercial payment differ from Medicare. For comparisons to Medicare payments, the following two sources of information were used:

  • The public CY2012-CY2017 Medicare Physician Fee Schedule (MPFS) for Colorado for comparisons of Outpatient services; the MPFS Facility Price was used to compare against payments for outpatient services.
  • The statewide average Medicare Fee-for-Service Inpatient payment using claims collected in the CO APCD, for comparisons of Inpatient DRGs, with one exception: data for DRG 795, Newborn (normal), are not available among Medicare Fee-For-Service claims.

Exclusions
Inpatient (hospital stay) claims with payments below $1,500 and outpatient (no hospital stay) claims with payments of $1 or lower are excluded from analysis. After calculating average allowed amount values and average charges, the resulting average amounts were rounded to the nearest multiple of $10.

Implementation of this rule this caused the exclusion of roughly 6.6% and 6.6%, respectively, of Medicaid outpatient claims.

Regional Comparisons
The Colorado Division of Insurance (DOI) geographical rate setting areas, used to assign commercial premiums, were used as a method to evaluate regional variation in prices. The assigned region is based on the billing provider’s location of service. Claim from providers with an address outside of the state of Colorado are excluded from analysis.

Data Suppression
Following privacy protection standards used by the Centers for Medicare & Medicaid Services (CMS), data are suppressed for values based on fewer than 11 procedures. Throughout the report, a blank dashboard element (map, bar chart or trend chart), or a blank map region or missing year in the trend chart indicates that data has been suppressed due to low volume.

Data Limitations
Data presented in this report are the result of a process that strives to ensure a high quality, reliable, and accurate final product. Through an in-depth Quality Control process, potential areas of concern are investigated and addressed accordingly, on a regular basis, and while every effort is made to address all known areas of concern for this report, some may remain.

Definitions

  • Allowed Amount: This is the maximum amount a plan/payer will pay for a covered health care service.
  • Charged Amount: This the amount that a health care provider bills a plan/payer for a service that was performed.

Data Vintage
Information regarding the payers and covered lives represented in this public report is available in the Member by Payer reference guide, available at: civhc.org/get-data/data-submission.

Terms & Conditions of Use
This report and any such data made available on or obtained through the CIVHC website is subject to the current Terms of Use and Privacy Policy available at civhc.org.

Further Information 

 

Contact Information
Division of Insurance, Colorado Department of Regulatory Agencies
1560 Broadway, Suite 850
Denver, CO 80202