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HOFS and ASCPS studies data request – Insurers and self-insurers

Why these studies are being conducted?

The HOFS and ASCPS studies are legislatively mandated by Minnesota Statutes 176.1363 and 176.1364. DLI is collecting data from insurers (including self-insurers), hospitals and ASCs to analyze timeliness and accuracy of payments under HOFS and ASCPS.

A 2018 Minnesota law changed the way workers' compensation pays for a portion of its medical care for injured workers. The law, effective Oct. 1, 2018, establishes the Hospital Outpatient Fee Schedule (HOFS) to reimburse non-critical-access hospitals for outpatient facility services and the Ambulatory Surgical Center Payment System (ASCPS) to reimburse ambulatory surgical centers (ASCs) for ASC facility services. The law includes the following mandates for two evaluation studies.

  • HOFS study:  "The commissioner (of Labor and Industry) shall conduct a study analyzing the percentage of claims with a service in the HOFS that were paid timely and the percentage of claims paid accurately."

  • ASCPS study:  "The commissioner shall conduct a study analyzing the impact of the reforms, including timeliness and accuracy of payment under this section, and recommend further changes if needed."

The results of both studies are to be reported by Jan. 15, 2021, to the Workers' Compensation Advisory Council and relevant legislative leaders.

Data request

Who is requested to submit data?

The Department of Labor and Industry (DLI) is requesting data from these Minnesota workers' compensation stakeholder groups:

  • payers, including insurers and self-insurers, that have workers' compensation hospital outpatient cases and/or ambulatory surgical center cases in Minnesota;

  • providers, including non-critical-access hospitals, that have workers' compensation hospital outpatient cases in Minnesota; and

  • ambulatory surgical centers that have workers' compensation ambulatory surgical center cases in Minnesota.

What data is requested?

The essential data elements for the HOFS and ASPCS studies include service date, service code, units of service, amounts charged and paid, bill date, and payment or denial date, and other data. Specific instructions, reporting templates, instructional videos and a link to the online submission portal for each stakeholder group are located below on this webpage.

When is this data request due?

Data is due to DLI via our online submission portal by July 31, 2020.

Is there a help desk for additional questions?

If you have questions, contact David Berry at david.berry@state.mn.us or 651-284-5208 or contact Brian Zaidman at brian.zaidman@state.mn.us or 651-284-5568.

Reporting instructions and materials for insurers and self-insurers

DLI requests two data files from Minnesota workers' compensation insurers and self-insurers.

  • One data file is for billing and payment data about workers' compensation hospital outpatient cases. This request asks for a sample of your workers' compensation hospital outpatient cases with service dates from Nov. 4 to Dec. 18, 2019.

  • A second data file is for billing and payment data about workers' compensation ambulatory surgical center cases with service dates from April 1 to Dec. 15, 2019.

Note:  The instructions and materials are designed to be viewed in sequential order. Please follow each step in the order in which it is presented. Skipping a step will cause confusion.

Step 1:  Review the request letter from DLI Commissioner Nancy Leppink for insurers and self-insurersThis letter explains the statute background, why the DLI is making this request and why it is important for you to complete this data request.

Step 2:  Compile the data file for your non-critical-access hospital outpatient cases (HOFS).

  • Step 2a:  Download HOFS step-by-step instructions for insurers and self-insurers (PDF) as of April 30. These written instructions are for your reference as you complete this data request. Please have them open for your reference at all times.

  • Step 2b:  Watch a 7-minute video to get an overview of this data request for insurers and self-insurers. This video contains important parameters, tips, advice and instructions.

  • Step 2c:  Download and review the reporting template (Excel) as of April 30. Review each tab in order from left to right. Start by reading the Background tab. Make sure to read the "Data Request Overview" section located in the Background tab to gain an understanding of the parameters of this request – what data elements it includes and excludes. This information is also explained in the instructional video 1 for insurers and self-insurers.

    The Instructions tab and the Non-critical-access Hospitals tab are for reference, so you can go back to it as needed.

    It is important you complete the Payer Data tab first, then complete the BP Data with PPO Adjustments tab second, then lastly complete the BP Data without PPO Adjustment tab. Skipping out of order will cause confusion.

  • Step 2d:  Complete the Payer Data tab in the Excel reporting template. This is a necessary step to help you identify which cases to report. Refer to the PDF instructions you downloaded in Step 2a and watch HOFS Insurers instructional video Part 2 for an illustration of how to complete this tab.

  • Step 2e:  Complete the Billing and Payment Data with PPO Adjustments tab in the Excel reporting template. This is where you report detailed data for PPO cases identified in Step 2d. Refer to the PDF instructions you downloaded and watch HOFS Insurers instructional video Part 3 for an illustration of how to complete this tab.

  • Step 2f:  Complete the Billing and Payment Data without PPO Adjustments tab in the Excel reporting template. This is where you report detail data for non-PPO cases identified in Step 2d. Refer to the PDF instructions you downloaded and watch HOFS Insurers instructional video Part 4 for an illustration of how to complete this tab.

  • Step 2g:  Submit the completed data file via the online portal.

Step 3:  Compile the data file for your ambulatory surgical center cases (ASCPS).

  • Step 3a:  Download the ASCPS step-by-step instructions for insurers and self-insurers (PDF) as of April 30. These written instructions are for your reference as you complete this data request. Please have them open for your reference at all times.

  • Step 3b:  Watch a 7-minute video to get an overview of this data request for insurers and self-insurers. This video contains important parameters, tips, advice and instructions.

  • Step 3c:  Download and review the reporting template (Excel) as of April 30. Please review each tab in order from left to right. Start by reading the Background tab. Please make sure to read the "Data Request Overview" section located in the Background tab to gain an understanding of the parameters of this request – what data elements it includes and excludes. This information is also explained in the instructional video 1 for insurers and self-insurers.

    The Instructions tab is for your reference, so you can go back to it as needed.

    It is important you complete the Payer Data tab first, then complete the BP Data with PPO Adjustments tab second, then lastly complete the BP Data without PPO Adjustment tab. Skipping out of order will cause confusion.

  • Step 3d:  Complete the Payer Data tab in the Excel reporting template. This is a necessary step to help you identify which cases to report. Refer to the PDF instructions you downloaded in Step 3a and watch ASCPS Insurers instructional video Part 2 for an illustration of how to complete this tab. 

  • Step 3e:  Complete the Billing and Payment Data with PPO Adjustment tab in the Excel reporting template. This is where you report detailed data for PPO cases identified in Step 3d. Refer to the PDF instructions you downloaded and watch ASCPS Insurers instructional video Part 3 for an illustration of how to complete this tab.

  • Step 3f:  Complete the Billing and Payment Data without PPO Adjustment tab in the Excel reporting template. This is where you report detailed data for non-PPO cases identified in Step 3d. Refer to the PDF instructions you downloaded and watch ASCPS Insurers instructional video Part 4 for an illustration of how to complete this tab.

  • Step 3g:  Submit the completed data file via the online portal.

Important links and files

For request one (hospital outpatient cases)

For request two (ASCPS cases)

For both requests, upload your completed data files.

Frequently asked questions

General questions

Q:  What about data confidentiality? Is my organization able to share the requested data with DLI?

A:  This data request involves only de-identified payment and billing data. DLI will only use this information to assess the timeliness and accuracy of the HOFS and ASCPS systems. Only aggregated, de-identified results will be published. The report generated from this information will only include summary data – that is, statistical records and reports derived from data about individuals but in which individuals are not identified and from which neither their identities nor any other characteristic that could uniquely identify an individual are included. See Minnesota Statutes sections 13.02, subd. 19, and 13.05, subd. 7. The published reports will also not identify specific payers.

Q:  Is this work required?

A:  The Minnesota Department of Labor and Industry (DLI) is required to conduct this study under Minnesota Statutes 176.1363 and 176.1364. The Legislature mandated that DLI collect data from insurers, self-insurers, ambulatory surgical centers and hospitals about timeliness and accuracy of payments under the Hospital Outpatient Fee Schedule (HOFS) and the Ambulatory Surgical Center Payment System (ASCPS).

Q:  What is the reporting period?

A:  This data request concerns patient encounters paid under HOFS with service dates from Nov. 4 to Dec. 18, 2019, and patient encounters paid under ASCPS with service dates from April 1 to Dec. 15, 2019.

Q:  When is this data request due?

A:  This data request is due July 31, 2020.

Q:  What if my organization doesn't have any reportable cases or encounters that fit the criteria of this data request?

A:  If you don't have any reportable encounters, you only need to fill in the Payer Data tab and submit the Excel file online. This helps DLI track which organizations completed the data request and have no reportable encounters. Please read the Background tab and Instructions tab (also available in PDF) and watch instructional video 3 for guidance about how to complete the Payer Data tab.

Q:  I'm dealing with missing and/or erroneous data and cannot fill in every detail for each encounter and/or service. What should I do?

A:  If you are dealing with missing and/or erroneous data, leave the data item blank.

Payer data tab questions

Q:  Is it up to the payer to decide if they want to report all patient encounters or only a sample?

A:  Yes, the choice of whether to report all population encounters or just a sample is specific to the payer.

Q:  How do I know what number of population encounters to put in columns M through N?

A:  By pulling data from the payer's database using the criteria for "countable encounters" provided in the instructions, you will know what number of population encounters to use.

In summary, the criteria for a countable encounter for the HOFS data request are:  (1) the encounter is covered by the Minnesota workers' compensation Hospital Outpatient Fee Schedule (HOFS); (2) the encounter is at least partially paid (not fully denied); (3) the amount paid for the encounter is not affected by a settlement; and (4) the encounter has a service date between Nov. 4 through Dec. 18, 2019. When you pull data, please separate encounters with PPO adjustments from those without PPO adjustments.

The criteria for a countable encounter for the ASCPS data request are:  (1) the encounter is covered by the Minnesota workers' compensation Ambulatory Surgical Center System (ASCPS); (2) the encounter is at least partially paid (not fully denied); (3) the amount paid for the encounter is not affected by a settlement; and (4) the encounter has a service date from April 1 to Dec. 15, 2019.

Q:  What should I do about PPO cases versus non-PPO cases?

A:  You will report encounters with PPO adjustments separately from encounters without PPO adjustments. This is explained in the Instructions Tab in the Excel reporting template as well as in Instructional Video 1, for insurers and self-insurers.

Q:  What is PPO? How do I know if an encounter has any PPO adjustment?

A:  PPO stands for preferred provider organization. Some insurers have an agreement with a PPO that dictates payment differently than the HOFS or ASCPS. To identify an encounter with PPO adjustment, look on the 835 remittance advice. A PPO adjustment is indicated by:  a CARC value of P24 for segment CAS02, CAS05, CAS08, CAS11, CAS14 or CAS17 within loop 2110 or 2100; or a CARC value of 96 for one of these same segments along with a remittance advice remark code (RARC) value of N381 for segment LQ02 within loop 2110 where segment LQ01 is HE.

Q:  How do I know what number of sample encounters to put in columns X through Y?

A: After you have chosen whether to report about all population encounters or a sample for each payer (as you indicate in column P or Q), each payer will be assigned a sample date window in columns R through W. For each payer, use their sample date window to refine your query and pull case counts from the payer's database that fit within their assigned sample window. Make sure you separate encounters with PPO adjustment from encounters without PPO adjustment. After you have numbers to put into columns X and Y, these selected encounters are what you will report in detail on the next two tabs.

BP data with PPO adjustment tab questions

Q:  What should I do if a payer has zero encounters with PPO adjustment?

A:  If a payer has zero encounters with PPO adjustment, fill in nothing for that payer in this tab. If all payers for whom you are reporting have zero encounters with PPO adjustment, leave this tab blank and move on.

Q:  Do I report details of encounters with PPO adjustment for all payers on the same tab?

A:  Yes, for each encounter you report, you will report the Payer Name to identify the payer.

BP data without PPO adjustment tab questions

Q:  The instruction says "Report one line for each service for each sample encounter without a PPO adjustment." That sounds like a lot of detailed data. Do I have to report one line for each service for each encounter?

A:  Yes, you have to report one line for each service for each encounter. However, for the HOFS request, for encounters that have at least one non-denied service with a J1 status indicator, you only need to report those services with a J1 or H status indicator.

Q:  Where can I find a service's status indicator under HOFS?

A:  Under HOFS, the J1, J2 and H status indicators are the only ones that matter for payment. These can be found at www.dli.mn.gov/business/workers-compensation/work-comp-medical-fee-schedules-hofs.

Submitting data file online questions

Q:  What is the link to get to the online submission portal?

A:  The online submission portal is at https://secure.doli.state.mn.us/dlidata20/.

Q:  In what scenario would someone have multiple files to submit?

A:  If you are an insurer or self-insurer, you would have one file for HOFS and one file for ASCPS. Or, if you are a third-party administrator submitting data files for your clients, you may have multiple data files, depending on how you decide to report the data. You can upload all files at the same time.

Q:  How do I know the files are received? Do I get a confirmation?

A:  You will see a confirmation message when your completed files have been successfully uploaded to DLI.

Questions?

If you have questions, contact David Berry at david.berry@state.mn.us or 651-284-5208 or contact Brian Zaidman at brian.zaidman@state.mn.us or 651-284-5568.