1.1.................... moves to amend H.F. No. 2412 as follows:
1.2Page 3, line 12, after the period, insert:"The managed care plans and county-based
1.3purchasing plans shall provide the encounter data and claims payment data as specified
1.4in paragraph (m)."
1.5Page 3, after line 32, insert:
1.6"(m) (1) Beginning July 1, 2013, every day, all managed care plans and county-based
1.7purchasing plans and providers shall submit electronic encounter data, as HIPAA
1.8Compliant EDI Health Care Claim (837) when available, and claims payment information,
1.9as HIPAA Compliant HealthCare Payment Advice (835), to a private entity designated by
1.10the commissioner of health for all services provided by managed care and county-based
1.11purchasing plans to medical assistance enrollees as they receive or send them to each
1.12other. The private entity designated by the commissioner shall maintain and operate
1.13an encounter data and payment tracking system to collect, process, store, and report
1.14on services provided by managed care and county-based purchasing plans to medical
1.15assistance enrollees. The system must be implemented by July 1, 2013, to collect, process,
1.16store, and report on covered services provided to all enrollees and payments to providers
1.17for services provided to those enrollees.
1.18The commissioner or the designated entity, in developing the system, shall establish
1.19methods and protocols for ongoing analysis of the encounter and payment data provided
1.20under this paragraph, that adjust for differences in characteristics of plan enrollees to
1.21allow comparison of service utilization and costs among plans and against expected
1.22levels of use. The commissioner shall use this patient level encounter data and plan and
1.23provider payment data to analyze on an ongoing basis the cost, quality, and efficiency
1.24of services provided by managed care and county-based purchasing plans to medical
1.25assistance enrollees.
2.1The agency and any other authorized state and federal agencies shall utilize this
2.2patient level encounter data and plan/provider payment data for any audit or reconciliation
2.3related to managed care plans.
2.4The analysis must identify possible cases of systemic underutilization or denials
2.5of claims, inappropriate service utilization such as higher-than-expected emergency
2.6department encounters, determine administration costs, gain insight into patient treatment
2.7outcomes, determine speed of claims payment, and track and evaluate the efficiency and
2.8quality of service delivery by managed care and county-based purchasing plans.
2.9(2) The claims information submitted shall be the original source files as submitted
2.10by the provider to the managed care or county-based purchasing organization. The
2.11remittance information shall be the original source files as submitted by the managed care
2.12or county based purchasing organization to the providers. The data must include all of
2.13the information that is in the health care claim or equivalent and health care payment
2.14information transaction to ensure transparency of information. The commissioner or the
2.15commissioner's designee shall use the data submitted under paragraph (1) only for the
2.16purpose of carrying out its responsibilities in this paragraph and must maintain the data
2.17that it receives according to the provisions of this subdivision.
2.18(3) Data on providers collected under this paragraph are private data on individuals
2.19or nonpublic data, as defined in section 13.02. Notwithstanding the definition of summary
2.20data in section 13.02, subdivision 19, summary data prepared under this paragraph may
2.21be derived from nonpublic data. The commissioner or the commissioner's designee
2.22shall establish procedures and safeguards to protect the integrity and confidentiality of
2.23any data that it maintains.
2.24(4) The commissioner or the commissioner's designee shall not publish analyses or
2.25reports that identify, or could potentially identify, individual patients.
2.26The commissioner shall provide periodic feedback to the plans and require plans
2.27to take corrective action when necessary.
2.28(5) For purposes of this subdivision, the following definitions apply:
2.29(i) "administrative costs" means expenditures on loss-adjustment activities, prior
2.30authorizations, utilization reviews, underwriting activities, negotiating networks and
2.31contracts with providers, approvals and denials of claims, research activities, reserves,
2.32and capital expenses; and
2.33(ii) "medical costs" means the payments to licensed health care professionals and
2.34health care entities for delivering to specific patients drugs, devices, supplies, and services,
2.35including educational services, or assisting them in accessing medical care. Medical costs
2.36may also include expenses that are designed to improve health care quality and increase
3.1the likelihood of desired health outcomes in ways that are capable of being objectively
3.2measured and of producing verifiable results and achievements. These quality expenses
3.3should be grounded in evidence-based medicine, widely accepted best clinical practice
3.4or criteria issued by recognized professional medical societies, accreditation bodies,
3.5government agencies, or other nationally recognized health care quality organizations.
3.6They must be primarily designed to achieve the following goals:
3.7(A) improve health outcomes;
3.8(B) prevent hospital readmissions;
3.9(C) improve patient safety and reduce medical errors, lower infection and mortality
3.10rates;
3.11(D) increase wellness and promote health activities; or
3.12(E) enhance the use of health care data to improve quality, transparency, and
3.13outcomes.
3.14(6) To eliminate the possibility of a conflict of interest, the vendor for this solution
3.15or any of its subsidiaries or affiliated firms shall not be a vendor for any state funded
3.16health care program."