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1. HIPAA transaction code sets mandates the proper use and definition of data that is collected on a claim https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/Code-Sets   Authoritative – the standardized definitions support the notion that the collected information is consistent therefore reliable.
2. The boss of the actual claim form is https://www.nubc.org/topics/national-uniform-billing-committee-nubcub-04 all professional and facilities collect the data on their bills as defined by these two forms. Authoritative – the standardized definitions support the notion that the collected information is consistent therefore reliable. The dental form is ADA- DME is a CMS form but not same teeth and RX also has variability but the content is standardized.  Although in litigation you do not get this form of the bill – if you understand the bill and the medical record you can back into key data elements.  As a habit I would recommend always asking for bills in the claim format. Providers who submit any bill electronically MUST have the ability to generate an 837i or 837p claim.
3. Providers submit the forms electronically through a clearing house - https://coa.org/docs/WhitePapers/Clearinghouses.pdf https://clearinghouses.org/   They have scrubbing activity and often reject claims that have issues.  The scrubbing data enhances the processing of "clean" claims to their final destination – thus increasing the reliability and use of the data that it generates.
4. After the clearing house the data gets to payers (examples include Medicare Fiscal Intermediaries contracted by CMS; Various state Medicaid processors; private payers; etc….. the original charges are captured in the technical term 837' and 837p.  the response or paid data is routed back through an 835 file.  (same technical rules too much for this email)
5. Major market players like optum capture the 837 data and repurpose into data repositories.  Some of those data repositories are known to us such as Fairhealth – the PMIC is not totally clear of all of their suppliers but it is still capturing the end product of the 837 files.  VA also uses the same data and suppliers.  Most people that I see on this list serve appear to be referencing the 837p file which are professional claims.  This data often does come in percentiles. (very different route for facilities). The percentile concept is not appropriate for facilities claims because the data is NOT collected in a manner that is produced in percentile format– too much precedent on this subject will confuse the legal community. The concept of percentiles is ONLY relevant to professional claims.  Please note, that data repositories that pull up facility data by zip code are applying a factor that is not associated with the original source -837i 
6. Unless you can dig deeply into public use files the data repository such as fair health DOES not include the license of the rendering provider. Actually most suppliers of charge capture data do not.  Why is this important – now I will piggy back off of percentile standardization discussions – when you look at percentiles it is diluted by MD (pediatric infectious disease doctor at the lower end of compensation to Neurosurgeons upper end of compensation); Nurse Practitioners, some DDS when they are providing medical services; PA's, PT's etc….)
7. Thus as with any LCP – the expert needs to gather their data – decide what needs to be considered – including professional charge capture data and analyze what price would reflect the condition of that individual and the services they are to receive.  Thus why I shy away from  a one size fits all approach for professional services.    I really like our practice standards which supports collecting relevant data within a defined methodology – analyze and conclude……. By having a defined percent percentile as a standard it appears to skip the step of analyzing your data within your defined methodology and the data collected for that individualized LCP. 

Data can be so much fun…… I really look forward to the various committees working on this subject; these brain storming conversations; and all the perspectives I find them very helpful .

Respectfully

Becky

1. HIPAA transaction code sets mandates the proper use and definition of data that is collected on a claim https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/Code-Sets   Authoritative – the standardized definitions support the notion that the collected information is consistent therefore reliable.
2. The boss of the actual claim form is https://www.nubc.org/topics/national-uniform-billing-committee-nubcub-04 all professional and facilities collect the data on their bills as defined by these two forms. Authoritative – the standardized definitions support the notion that the collected information is consistent therefore reliable. The dental form is ADA- DME is a CMS form but not same teeth and RX also has variability but the content is standardized.  Although in litigation you do not get this form of the bill – if you understand the bill and the medical record you can back into key data elements.  As a habit I would recommend always asking for bills in the claim format. Providers who submit any bill electronically MUST have the ability to generate an 837i or 837p claim.
3. Providers submit the forms electronically through a clearing house - https://coa.org/docs/WhitePapers/Clearinghouses.pdf https://clearinghouses.org/   They have scrubbing activity and often reject claims that have issues.  The scrubbing data enhances the processing of "clean" claims to their final destination – thus increasing the reliability and use of the data that it generates.
4. After the clearing house the data gets to payers (examples include Medicare Fiscal Intermediaries contracted by CMS; Various state Medicaid processors; private payers; etc….. the original charges are captured in the technical term 837' and 837p.  the response or paid data is routed back through an 835 file.  (same technical rules too much for this email)
5. Major market players like optum capture the 837 data and repurpose into data repositories.  Some of those data repositories are known to us such as Fairhealth – the PMIC is not totally clear of all of their suppliers but it is still capturing the end product of the 837 files.  VA also uses the same data and suppliers.  Most people that I see on this list serve appear to be referencing the 837p file which are professional claims.  This data often does come in percentiles. (very different route for facilities). The percentile concept is not appropriate for facilities claims because the data is NOT collected in a manner that is produced in percentile format– too much precedent on this subject will confuse the legal community. The concept of percentiles is ONLY relevant to professional claims.  Please note, that data repositories that pull up facility data by zip code are applying a factor that is not associated with the original source -837i 
6. Unless you can dig deeply into public use files the data repository such as fair health DOES not include the license of the rendering provider. Actually most suppliers of charge capture data do not.  Why is this important – now I will piggy back off of percentile standardization discussions – when you look at percentiles it is diluted by MD (pediatric infectious disease doctor at the lower end of compensation to Neurosurgeons upper end of compensation); Nurse Practitioners, some DDS when they are providing medical services; PA's, PT's etc….)
7. Thus as with any LCP – the expert needs to gather their data – decide what needs to be considered – including professional charge capture data and analyze what price would reflect the condition of that individual and the services they are to receive.  Thus why I shy away from  a one size fits all approach for professional services.    I really like our practice standards which supports collecting relevant data within a defined methodology – analyze and conclude……. By having a defined percent percentile as a standard it appears to skip the step of analyzing your data within your defined methodology and the data collected for that individualized LCP. 

Data can be so much fun…… I really look forward to the various committees working on this subject; these brain storming conversations; and all the perspectives I find them very helpful .

Respectfully

Becky

1. HIPAA transaction code sets mandates the proper use and definition of data that is collected on a claim https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/Code-Sets   Authoritative – the standardized definitions support the notion that the collected information is consistent therefore reliable.
2. The boss of the actual claim form is https://www.nubc.org/topics/national-uniform-billing-committee-nubcub-04 all professional and facilities collect the data on their bills as defined by these two forms. Authoritative – the standardized definitions support the notion that the collected information is consistent therefore reliable. The dental form is ADA- DME is a CMS form but not same teeth and RX also has variability but the content is standardized.  Although in litigation you do not get this form of the bill – if you understand the bill and the medical record you can back into key data elements.  As a habit I would recommend always asking for bills in the claim format. Providers who submit any bill electronically MUST have the ability to generate an 837i or 837p claim.
3. Providers submit the forms electronically through a clearing house - https://coa.org/docs/WhitePapers/Clearinghouses.pdf https://clearinghouses.org/   They have scrubbing activity and often reject claims that have issues.  The scrubbing data enhances the processing of "clean" claims to their final destination – thus increasing the reliability and use of the data that it generates.
4. After the clearing house the data gets to payers (examples include Medicare Fiscal Intermediaries contracted by CMS; Various state Medicaid processors; private payers; etc….. the original charges are captured in the technical term 837' and 837p.  the response or paid data is routed back through an 835 file.  (same technical rules too much for this email)
5. Major market players like optum capture the 837 data and repurpose into data repositories.  Some of those data repositories are known to us such as Fairhealth – the PMIC is not totally clear of all of their suppliers but it is still capturing the end product of the 837 files.  VA also uses the same data and suppliers.  Most people that I see on this list serve appear to be referencing the 837p file which are professional claims.  This data often does come in percentiles. (very different route for facilities). The percentile concept is not appropriate for facilities claims because the data is NOT collected in a manner that is produced in percentile format– too much precedent on this subject will confuse the legal community. The concept of percentiles is ONLY relevant to professional claims.  Please note, that data repositories that pull up facility data by zip code are applying a factor that is not associated with the original source -837i 
6. Unless you can dig deeply into public use files the data repository such as fair health DOES not include the license of the rendering provider. Actually most suppliers of charge capture data do not.  Why is this important – now I will piggy back off of percentile standardization discussions – when you look at percentiles it is diluted by MD (pediatric infectious disease doctor at the lower end of compensation to Neurosurgeons upper end of compensation); Nurse Practitioners, some DDS when they are providing medical services; PA's, PT's etc….)
7. Thus as with any LCP – the expert needs to gather their data – decide what needs to be considered – including professional charge capture data and analyze what price would reflect the condition of that individual and the services they are to receive.  Thus why I shy away from  a one size fits all approach for professional services.    I really like our practice standards which supports collecting relevant data within a defined methodology – analyze and conclude……. By having a defined percent percentile as a standard it appears to skip the step of analyzing your data within your defined methodology and the data collected for that individualized LCP. 

Data can be so much fun…… I really look forward to the various committees working on this subject; these brain storming conversations; and all the perspectives I find them very helpful .

Respectfully

Becky

1. HIPAA transaction code sets mandates the proper use and definition of data that is collected on a claim https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/Code-Sets   Authoritative – the standardized definitions support the notion that the collected information is consistent therefore reliable.
2. The boss of the actual claim form is https://www.nubc.org/topics/national-uniform-billing-committee-nubcub-04 all professional and facilities collect the data on their bills as defined by these two forms. Authoritative – the standardized definitions support the notion that the collected information is consistent therefore reliable. The dental form is ADA- DME is a CMS form but not same teeth and RX also has variability but the content is standardized.  Although in litigation you do not get this form of the bill – if you understand the bill and the medical record you can back into key data elements.  As a habit I would recommend always asking for bills in the claim format. Providers who submit any bill electronically MUST have the ability to generate an 837i or 837p claim.
3. Providers submit the forms electronically through a clearing house - https://coa.org/docs/WhitePapers/Clearinghouses.pdf https://clearinghouses.org/   They have scrubbing activity and often reject claims that have issues.  The scrubbing data enhances the processing of "clean" claims to their final destination – thus increasing the reliability and use of the data that it generates.
4. After the clearing house the data gets to payers (examples include Medicare Fiscal Intermediaries contracted by CMS; Various state Medicaid processors; private payers; etc….. the original charges are captured in the technical term 837' and 837p.  the response or paid data is routed back through an 835 file.  (same technical rules too much for this email)
5. Major market players like optum capture the 837 data and repurpose into data repositories.  Some of those data repositories are known to us such as Fairhealth – the PMIC is not totally clear of all of their suppliers but it is still capturing the end product of the 837 files.  VA also uses the same data and suppliers.  Most people that I see on this list serve appear to be referencing the 837p file which are professional claims.  This data often does come in percentiles. (very different route for facilities). The percentile concept is not appropriate for facilities claims because the data is NOT collected in a manner that is produced in percentile format– too much precedent on this subject will confuse the legal community. The concept of percentiles is ONLY relevant to professional claims.  Please note, that data repositories that pull up facility data by zip code are applying a factor that is not associated with the original source -837i 
6. Unless you can dig deeply into public use files the data repository such as fair health DOES not include the license of the rendering provider. Actually most suppliers of charge capture data do not.  Why is this important – now I will piggy back off of percentile standardization discussions – when you look at percentiles it is diluted by MD (pediatric infectious disease doctor at the lower end of compensation to Neurosurgeons upper end of compensation); Nurse Practitioners, some DDS when they are providing medical services; PA's, PT's etc….)
7. Thus as with any LCP – the expert needs to gather their data – decide what needs to be considered – including professional charge capture data and analyze what price would reflect the condition of that individual and the services they are to receive.  Thus why I shy away from  a one size fits all approach for professional services.    I really like our practice standards which supports collecting relevant data within a defined methodology – analyze and conclude……. By having a defined percent percentile as a standard it appears to skip the step of analyzing your data within your defined methodology and the data collected for that individualized LCP. 

Data can be so much fun…… I really look forward to the various committees working on this subject; these brain storming conversations; and all the perspectives I find them very helpful .

Respectfully

Becky

1. HIPAA transaction code sets mandates the proper use and definition of data that is collected on a claim https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/Code-Sets   Authoritative – the standardized definitions support the notion that the collected information is consistent therefore reliable.
2. The boss of the actual claim form is https://www.nubc.org/topics/national-uniform-billing-committee-nubcub-04 all professional and facilities collect the data on their bills as defined by these two forms. Authoritative – the standardized definitions support the notion that the collected information is consistent therefore reliable. The dental form is ADA- DME is a CMS form but not same teeth and RX also has variability but the content is standardized.  Although in litigation you do not get this form of the bill – if you understand the bill and the medical record you can back into key data elements.  As a habit I would recommend always asking for bills in the claim format. Providers who submit any bill electronically MUST have the ability to generate an 837i or 837p claim.
3. Providers submit the forms electronically through a clearing house - https://coa.org/docs/WhitePapers/Clearinghouses.pdf https://clearinghouses.org/   They have scrubbing activity and often reject claims that have issues.  The scrubbing data enhances the processing of "clean" claims to their final destination – thus increasing the reliability and use of the data that it generates.
4. After the clearing house the data gets to payers (examples include Medicare Fiscal Intermediaries contracted by CMS; Various state Medicaid processors; private payers; etc….. the original charges are captured in the technical term 837' and 837p.  the response or paid data is routed back through an 835 file.  (same technical rules too much for this email)
5. Major market players like optum capture the 837 data and repurpose into data repositories.  Some of those data repositories are known to us such as Fairhealth – the PMIC is not totally clear of all of their suppliers but it is still capturing the end product of the 837 files.  VA also uses the same data and suppliers.  Most people that I see on this list serve appear to be referencing the 837p file which are professional claims.  This data often does come in percentiles. (very different route for facilities). The percentile concept is not appropriate for facilities claims because the data is NOT collected in a manner that is produced in percentile format– too much precedent on this subject will confuse the legal community. The concept of percentiles is ONLY relevant to professional claims.  Please note, that data repositories that pull up facility data by zip code are applying a factor that is not associated with the original source -837i 
6. Unless you can dig deeply into public use files the data repository such as fair health DOES not include the license of the rendering provider. Actually most suppliers of charge capture data do not.  Why is this important – now I will piggy back off of percentile standardization discussions – when you look at percentiles it is diluted by MD (pediatric infectious disease doctor at the lower end of compensation to Neurosurgeons upper end of compensation); Nurse Practitioners, some DDS when they are providing medical services; PA's, PT's etc….)
7. Thus as with any LCP – the expert needs to gather their data – decide what needs to be considered – including professional charge capture data and analyze what price would reflect the condition of that individual and the services they are to receive.  Thus why I shy away from  a one size fits all approach for professional services.    I really like our practice standards which supports collecting relevant data within a defined methodology – analyze and conclude……. By having a defined percent percentile as a standard it appears to skip the step of analyzing your data within your defined methodology and the data collected for that individualized LCP. 

Data can be so much fun…… I really look forward to the various committees working on this subject; these brain storming conversations; and all the perspectives I find them very helpful .

Respectfully

Becky