APCD Proposed Rule

TOA kept you updated throughout the 2021 Texas Legislature on a legislative proposal that would have created an all-payor claims database (APCD) in the state of Texas. The concept was pushed by the Texas Academy of Family Physicians (TAFP) as a proposal to help private practices. The APCD concept is part of the TAFP’s “Primary Care Marshall Plan” to save primary care. After negotiations with physician groups that expressed concern regarding exclusive contract negotiations with health plans, the Legislature passed the proposal into law through HB 2090.

The Texas Department of Insurance (TDI) proposed a rule on April 7 to implement the new law, and more of that can be found below.

What the Law Requires
The law specifically states that the following items must be collected by the APCD through payor claims.

(c) In determining the information a payor is required to submit to the center under this subchapter, the center must consider requiring inclusion of information useful to health policy makers, employers, and consumers for purposes of improving health care quality and outcomes, improving population health, and controlling health care costs.

The required information at a minimum must include the following information as it relates to all health care services, supplies, and devices paid or otherwise adjudicated by the payor:

(1) the name and National Provider Identifier, as described in 45 C.F.R. Section 162.410, of each health care provider paid by the payor;

(2) the claim line detail that documents the health care services, supplies, or devices provided by the health care provider;

(3) the amount of charges billed by the health care provider and the payor’s: (A) allowed amount or contracted rate for the health care services, supplies, or devices; and (B) adjudicated claim amount for the health care services, supplies, or devices;

(4) the name of the payor, the name of the health benefit plan, and the type of health benefit plan, including whether health care services, supplies, or devices were provided to an individual through:

(A) a Medicaid or Medicare program; 6 21.139.486 House Bill 2090 Senate Amendments Section-by-Section Analysis HOUSE VERSION SENATE VERSION (CS) CONFERENCE

(B) workers’ compensation insurance;

(C) a health maintenance organization operating under Chapter 843;

(D) a preferred provider benefit plan offered by an insurer under Chapter 1301;

(E) a basic coverage plan under Chapter 1551;

(F) a basic plan under Chapter 1575;

(G) a primary care coverage plan under Chapter 1579;

or (H) a health benefit plan that is subject to the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.); and (5) claim level information that allows the center to identify the geozip where the health care services, supplies, or devices were provided.

ASC vs. Hopsital Cost Comparison?
The APCD will be housed at the Center for Healthcare Data at the University of Texas Health Science Center at Houston “to collect, aggregate, and analyze health care claims and encounters for state regulated commercial health insurers and self-insured employee benefit plans that choose to opt in to the program.”

Other states have had their own APCDs for several years. As for tangible evidence regarding the effect of an APCD on a state, the state of Massachusetts did prevent a hospital merger after looking at APCD data.

As the Texas Medical Association pointed out in an article, the APCD could be used by consumers to compare prices in ASCs vs. hospitals.

TDI’s Proposed Rule
The Texas Department of Insurance (TDI) proposed a rule on April 7 to implement the law.

What Payers Must Submit
Payers would be required to register on an annual basis and submit:

 (1) enrollment and eligibility data files; 

 (2) medical claims data files; 

 (3) pharmacy claims data files; 

 (4) dental claims data files; and 

 (5) provider files.  

2023 Start Date
The data on claims must be submitted beginning on January 1, 2023, at the earliest and within five months of the claims finally being adjudicated or reviewed.

Co-insurance and co-payment data must be included in two separate fields.

Other required information would include clearly identifiable claims where multiple parties have financial responsibility by including a coordination of benefits notation. In addition, denied claims and identify a denied claim either by a denied notation or assigning eligible, allowed, and payment amounts of zero.