Bill Text: VA HB2798 | 2019 | Regular Session | Chaptered
Bill Title: All-Payer Claims Database; penalty.
Spectrum: Partisan Bill (Republican 1-0)
Status: (Passed) 2019-03-21 - Governor: Acts of Assembly Chapter text (CHAP0673) [HB2798 Detail]
Download: Virginia-2019-HB2798-Chaptered.html
Be it enacted by the General Assembly of Virginia:
1. That §§32.1-276.3 and 32.1-276.7:1 of the Code of Virginia are amended and reenacted as follows:
§32.1-276.3. Definitions.
As used in this chapter:
"Actual reimbursement amount" means reimbursement information included in the claims data submitted by data suppliers to the Virginia All-Payer Claims Database, whether such information is referred to in the claims data as "paid amounts," "allowed amounts," or another term having the same or similar meaning and whether in reference to the payer who paid the actual reimbursement amount or the provider who received the actual reimbursement amount.
"Board" means the Board of Health.
"Common data layout" means the national data collection standard adopted and maintained by the APCD Council.
"Consumer" means any person (i) whose occupation is other than the administration of health activities or the provision of health services, (ii) who has no fiduciary obligation to a health care institution or other health agency or to any organization, public or private, whose principal activity is an adjunct to the provision of health services, or (iii) who has no material financial interest in the rendering of health services.
"Covered lives" means subscribers, policyholders, members, enrollees, or dependents, as the case may be, under a policy or contract issued or issued for delivery in Virginia by a managed care health insurance plan licensee, insurer, health services plan, or preferred provider organization.
"ERISA plan" means any self-funded employee welfare benefit plan governed by the requirements of the Employee Retirement Income Security Act of 1974, 29 U.S.C. §1002(1).
"Health care provider" means (i) a general hospital, ordinary hospital, outpatient surgical hospital, nursing home or certified nursing facility licensed or certified pursuant to Article 1 (§32.1-123 et seq.) of Chapter 5 of this title; (ii) a mental or psychiatric hospital licensed pursuant to Article 2 (§37.2-403 et seq.) of Chapter 4 of Title 37.2; (iii) a hospital operated by the Department of Behavioral Health and Developmental Services; (iv) a hospital operated by the University of Virginia or the Virginia Commonwealth University Health System Authority; (v) any person licensed to practice medicine or osteopathy in the Commonwealth pursuant to Chapter 29 (§54.1-2900 et seq.) of Title 54.1; (vi) any person licensed to furnish health care policies or plans pursuant to Chapter 34 (§38.2-3400 et seq.), Chapter 42 (§38.2-4200), or Chapter 43 (§38.2-4300) of Title 38.2; or (vii) any person licensed to practice dentistry pursuant to Chapter 27 (§ 54.1-2700 et seq.) of Title 54.1 who is registered with the Board of Dentistry as an oral and maxillofacial surgeon and certified by the Board of Dentistry to perform certain procedures pursuant to §54.1-2709.1. In no event shall such term be construed to include continuing care retirement communities which file annual financial reports with the State Corporation Commission pursuant to Chapter 49 (§38.2-4900 et seq.) of Title 38.2 or any nursing care facility of a religious body which depends upon prayer alone for healing.
"Health maintenance organization" means any person who undertakes to provide or to arrange for one or more health care plans pursuant to Chapter 43 (§38.2-4300 et seq.) of Title 38.2.
"Inpatient hospital" means a hospital providing
inpatient care and licensed pursuant to Article 1 (§32.1-123 et seq.) of
Chapter 5 of this title, a hospital licensed pursuant to Article 2 (§
37.2-403 et seq.) of Chapter 4 of Title 37.2, a hospital operated by the
Department of Behavioral Health and Developmental Services for the care and
treatment of individuals with mental illness, or a hospital operated by the
University of Virginia or the Virginia Commonwealth University Health System
Authority.
"Nonprofit organization" means a nonprofit, tax-exempt health data organization with the characteristics, expertise, and capacity to execute the powers and duties set forth for such entity in this chapter.
"Oral and maxillofacial surgeon" means, for the purposes of this chapter, a person who is licensed to practice dentistry in Virginia, registered with the Board of Dentistry as an oral and maxillofacial surgeon, and certified to perform certain procedures pursuant to §54.1-2709.1.
"Oral and maxillofacial surgeon's office" means a place (i) owned or operated by a licensed and registered oral and maxillofacial surgeon who is certified to perform certain procedures pursuant to § 54.1-2709.1 or by a group of oral and maxillofacial surgeons, at least one of whom is so certified, practicing in any legal form whatsoever or by a corporation, partnership, limited liability company or other entity that employs or engages at least one oral and maxillofacial surgeon who is so certified, and (ii) designed and equipped for the provision of oral and maxillofacial surgery services to ambulatory patients.
"Outpatient surgery" means all surgical procedures performed on an outpatient basis in a general hospital, ordinary hospital, outpatient surgical hospital or other facility licensed or certified pursuant to Article 1 (§32.1-123 et seq.) of Chapter 5 of this title or in a physician's office or oral and maxillofacial surgeon's office, as defined above. Outpatient surgery refers only to those surgical procedure groups on which data are collected by the nonprofit organization as a part of a pilot study.
"Physician" means a person licensed to practice medicine or osteopathy in the Commonwealth pursuant to Chapter 29 (§54.1-2900 et seq.) of Title 54.1.
"Physician's office" means a place (i) owned or
operated by a licensed physician or group of physicians practicing in any legal
form whatsoever or by a corporation, partnership, limited liability company or
other entity that employs or engages physicians, and (ii) designed and
equipped solely for the provision of fundamental medical care, whether
diagnostic, therapeutic, rehabilitative, preventive or palliative, to ambulatory
patients.
"Surgical procedure group" means at least five procedure groups, identified by the nonprofit organization designated pursuant to §32.1-276.4 in compliance with regulations adopted by the Board, based on criteria that include, but are not limited to, the frequency with which the procedure is performed, the clinical severity or intensity, and the perception or probability of risk. The nonprofit organization shall form a technical advisory group consisting of members nominated by its Board of Directors' nominating organizations to assist in selecting surgical procedure groups to recommend to the Board for adoption.
"System" means the Virginia Patient Level Data System.
§32.1-276.7:1. All-Payer Claims Database created; purpose; reporting requirements.
A. The Virginia All-Payer Claims Database is hereby created to facilitate data-driven, evidence-based improvements in access, quality, and cost of health care and to promote and improve the public health through the understanding of health care expenditure patterns and operation and performance of the health care system.
B. The Commissioner shall ensure that the Department meets the requirements to be a health oversight agency as defined in 45 C.F.R. § 164.501.
C. The Commissioner, in cooperation with the Bureau of
Insurance, may shall collect paid claims data for covered
benefits, pursuant to data submission and use agreements as specified in
subsection C, from entities electing to participate as from data
suppliers, which may shall include:
1. Issuers of individual or group accident and sickness insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis; corporations providing individual or group accident and sickness subscription contracts; and health maintenance organizations providing a health care plan for health care services, for at least 1,000 covered lives in the most recent calendar year;
2. Third-party administrators and any other entities that
receive or collect charges, contributions, or premiums for, or adjust or settle
health care claims for, at least 1,000 Virginia residents
covered lives on behalf of group health plans other than ERISA plans;
3. Third-party administrators, and any other entities, that receive or collect charges, contributions, or premiums for, or adjust or settle health care claims for, an employer that maintains an ERISA plan that has opted-in to data submission to the All-Payer Claims Database pursuant to subsection P;
4. The Department of Medical Assistance Services with
respect to services provided under programs administered pursuant to Titles XIX
and XXI of the Social Security Act; and
4. 5. State government health insurance plans;
6. Local government health insurance plans, subject to their ability to provide such data and to the extent permitted by state and federal law; and
7. Federal health insurance plans, if available
to the extent permitted by federal law, including but not limited to
Medicare, TRICARE, and the Federal Employees Health Benefits Plan.
Such collection of paid claims data for covered benefits shall not include data related to Medigap, disability income, workers' compensation claims, standard benefits provided by long-term care insurance, disease specific health insurance, dental or vision claims, or other supplemental health insurance products;
C. D. The Commissioner shall ensure that the
nonprofit organization executes a standard data submission and use agreement
with each entity listed in subsection B that submits paid claims data to the
All-Payer Claims Database and each entity that subscribes to data products and
reports. Such agreements shall include procedures for submission, collection,
aggregation, and distribution of specified data. and shall provide
for, at a minimum: Additionally, the Commissioner shall ensure that the
nonprofit organization:
1. Protection of Protects patient privacy and
data security pursuant to provisions of this chapter and state and federal privacy
laws, including the federal Health Insurance Portability and Accountability Act
(42 U.S.C. §1320d et seq., as amended); Titles XIX and XXI of the Social
Security Act; §32.1-127.1:03; Chapter 6 (§38.2-600 et seq.) of Title 38.2;
and the Health Information Technology for Economic and Clinical Health (HITECH)
Act, as included in the American Recovery and Reinvestment Act (P.L. 111-5, 123
Stat. 115) as if the nonprofit organization were covered by such laws;
2. Identification of Identifies the type of paid
claims to be collected by the All-Payer Claims Database, and the
entities that are subject to the submission of such claims as well as
identification of specific data elements from existing claims systems to be
submitted and collected, including but not limited to patient demographics,
diagnosis and procedure codes, provider information, plan payments, member
payment responsibility, and service dates;
3. Geographic Administers the All-Payer Claims
Database in a manner to allow for geographic, demographic, economic, and
peer group comparisons;
4. Identification and comparison of Develops public
analyses identifying and comparing health plans by public and private
health care purchasers, providers, employers, consumers, health plans, health
insurers, and data analysts, health insurers, and providers with regard to
their provision of safe, cost-effective, and high-quality health care services;
5. Use of existing Uses common data layout or other
national data collection standards and methods, including the electronic
Uniform Medical Claims Payer Reporting Standard, that utilize a standard
set of core data elements for data submissions, as adopted or endorsed
by The Accredited Standards Committee X12 (ASC X12) and the APCD
Council, to establish and maintain the database in a cost-effective manner and
to facilitate uniformity among various all-payer claims databases of other
states and specification of data fields to be included in the submitted claims,
consistent with such national standards, allowing for exemptions when
submitting entities do not collect the specified data or pay on a per-claim
basis, such exemption process to be managed by the advisory committee created
pursuant to subsection D E;
6. Prohibition on disclosure or reporting of Does
not disclose or report provider-specific, facility-specific, or
carrier-specific reimbursement information, and of or information
capable of being reverse-engineered, combined, or otherwise used to calculate
or derive such reimbursement information, from the All-Payer Claims Database;
7. Responsible Promotes the responsible use of
claims data to improve health care value and preserve the integrity and utility
of the All-Payer Claims Database; and
8. Stipulation Requires that all public
reports and analyses comparing providers or health plans using data from
the All-Payer Claims Database use national standards, or, when
such national standards are unavailable, provide full transparency to providers
or health plans of the alternative methodology used.
D. E. The Commissioner shall appoint
establish an advisory committee to assist in the formation and operation of
the All-Payer Claims Database. Such committee shall include a balanced
representation of all the stakeholders serving on the governing board of the
nonprofit organization as well as individuals with expertise in public health
and specific expertise in health care performance measurement and reporting.
Each stakeholder on the board of the nonprofit organization shall nominate a
member and an alternate member to serve on the committee consist of (i)
a representative from each of the following: a statewide hospital association,
a statewide association of health plans, a professional organization
representing physicians, a professional organization representing pharmacists,
an organization that processes insurance claims or certain aspects of employee
benefits plans for a separate entity, a community mental health center who has
experience in behavioral health data collection, a nursing home health care
provider who has experience with medical claims data, a nonprofit health
insurer, and a for-profit health insurer; (ii) up to two representatives with a
demonstrated record of advocating health care issues on behalf of consumers;
(iii) two representatives of hospitals or health systems; (iv) an individual
with academic experience in health care data and cost-efficiency research; (v)
a representative who is not a supplier or broker of health insurance from small
employers that purchase group health insurance for employees; (vi) a
representative who is not a supplier or broker of health insurance from large
employers that purchase health insurance for employees, and (vii) a
representative who is not a supplier or broker of health insurance from
self-insured employers, all of whom shall be appointed by the Commissioner.
The Commissioner, the chairman of the board of directors of the nonprofit
organization, the Commissioner of Insurance, the Director of the Department of
Medical Assistance Services, the Director of the Department of Human Resource
Management, or their designees, shall serve ex officio.
In appointing members to the advisory committee, the Commissioner shall adopt reasonable measures to select representatives in a manner that provides balanced representation within and among the appointments and that any representative appointed is without any actual or apparent conflict of interest, including conflicts of interest created by virtue of the individual's employer's corporate affiliations or ownership interests.
The nonprofit organization shall provide the advisory committee with details at least annually on the use and disclosure of All-Payer Claims Database data, including reports developed by the nonprofit organization; details on methods used to extract, transform, and load data; and efforts to protect patient privacy and data security.
The meetings of the advisory committee shall be open to all
nominating member organizations and to the public.
E. F. The Commissioner shall establish a data
release committee to review and approve requests for access to data. The data
release committee shall consist of the Commissioner or his designee, and upon
recommendation of the advisory committee, the Commissioner shall appoint an
individual with academic experience in health care data and cost-efficiency
research; a representative of a health insurer; a health care practitioner; a
representative from a hospital with a background in administration, analytics,
or research; and a representative with a demonstrated record of advocating health
care issues on behalf of consumers. In making its recommendations, the advisory
committee shall adopt reasonable measures to select representatives in a manner
that provides balanced representation within and among the appointments and
that any representative appointed is without any actual or apparent conflict of
interest, including conflicts of interest created by virtue of the individual's
employer's corporate affiliations or ownership interests. The data release
committee shall ensure that (i) all data approvals are consistent with the
purposes of the All-Payer Claims Database as provided in subsection A; (ii) all
data approvals comply with applicable state and federal privacy laws and state
and federal laws regarding the exchange of price and cost information to
protect the confidentiality of the data and encourage a competitive marketplace
for health care services; and (iii) the level of detail, as provided in
subsection H, is appropriate for each request and is accompanied by a
standardized data use agreement.
G. The nonprofit organization shall implement the All-Payer Claims Database, consistent with the provisions of this chapter, to include:
1. The reporting of data that can be used to improve public health surveillance and population health, including reports on (i) injuries; (ii) chronic diseases, including but not limited to asthma, diabetes, cardiovascular disease, hypertension, arthritis, and cancer; (iii) health conditions of pregnant women, infants, and children; and (iv) geographic and demographic information for use in community health assessment, prevention education, and public health improvement. This data shall be developed in a format that allows comparison of information in the All-Payer Claims Database with other nationwide data programs and that allows employers to compare their employee health plans statewide and between and among regions of the Commonwealth and nationally.
2. The reporting of data that payers, providers, and
health care purchasers, including employers and consumers, may use to compare
quality and efficiency of health care, including development of information on
utilization patterns and information that permits comparison of health plans
and providers statewide between and among regions of the Commonwealth. The
advisory committee created pursuant to subsection D E shall make
recommendations to the nonprofit organization on the appropriate level of
specificity of reported data in order to protect patient privacy and to
accurately attribute services and resource utilization rates to providers.
3. The reporting of data that permits design and evaluation of alternative delivery and payment models.
4. The reporting and release of data consistent with the purposes of the All-Payer Claims Database as set forth in subsection A as determined to be appropriate by the data release committee created pursuant to subsection F.
H. Except as provided in subsection O, the nonprofit organization shall not provide data or access to data without the approval of the data release committee. Upon approval, the nonprofit organization may provide data or access to data at levels of detail that may include (i) aggregate reports, which are defined as data releases with all observation counts greater than 10; (ii) de-identified data sets that meet the standard set forth in 45 C.F.R. §164.514(a); and (iii) limited data sets that comply with the National Institutes of Health guidelines for release of personal health information.
F. I. Reporting of data shall not commence until
such data has been processed and verified at levels of accuracy consistent with
existing nonprofit organization data standards. Prior to public release
of any report specifically naming any provider or payer, or public reports
in which an individual provider or payers represents 60 percent or more of the
data, the nonprofit organization shall provide affected entities with
notice of the pending report and allow for a 60-day 30-day period
of review to ensure accuracy. During this period, affected entities may seek
explanations of results and correction of data that they prove to be
inaccurate. The nonprofit organization shall make these corrections prior to
any public release of the report. At the end of the review period, upon
completion of all necessary corrections, the report may be released. For the
purposes of this subsection, "public release" means the release of
any report to the general public and does not include the preparation of
reports for, or use of the All-Payer Claims Database by, organizations that
have been approved for access by the data release committee and have entered
into written agreements with the nonprofit organization.
G. The Commissioner and the nonprofit organization shall
develop recommendations for elimination of existing state health care data
submission and reporting requirements, including those imposed by this chapter,
that may be replaced by All-Payer Claims Database submissions and reports. In
addition, the J. The Commissioner and the nonprofit organization
shall consider and recommend, as appropriate, integration of new data sources
into the All-Payer Claims Database, based on the findings and recommendations
of the workgroup established pursuant to §32.1-276.9:1 advisory
committee.
H. K. Information acquired pursuant to this
section shall be confidential and shall be exempt from disclosure by the
Virginia Freedom of Information Act (§2.2-3700 et seq.). The reporting and
release of data pursuant to this section shall comply with all state and
federal privacy laws and state and federal laws regarding the exchange of price
and cost information to protect the confidentiality of the data and encourage a
competitive marketplace for health care services.
I. L. No person shall assess costs or charge a
fee to any health care practitioner related to formation or operation of the
All-Payer Claims Database. However, a reasonable fee may be charged to health
care practitioners who voluntarily subscribe to access the database
All-Payer Claims Database for purposes other than data verification.
J. M. As used in this section,
"provider" means a hospital or physician as defined in this chapter
or any other health care practitioner licensed, certified, or authorized under
state law to provide covered services represented in claims reported pursuant
to this section.
K. N. The Commissioner, in consultation with
the board of directors of the nonprofit organization, shall develop
short-term and long-term funding strategies for the creation and operation
of the All-Payer Claims Database that may include public and private grant
funding, subscriptions for access to data reports, and revenue for specific
data projects operation of the All-Payer Claims Database to provide
necessary funding in excess of any budget appropriation by the Commonwealth.
L. The O. The nonprofit organization, the
Department of Health, the Department of Medical Assistance Services, and the
Bureau of Insurance shall have access to data reported by the All-Payer
Claims Database pursuant to this section at no cost for the purposes of public
health improvement research and activities.
P. Each employer that maintains an ERISA plan may opt-in to allow a third-party administer or other entity to submit data to the All-Payer Claims Database. For any such employer that opts-in, the third-party administrator or other entity shall (i) submit data for the next reporting period after the opt-in and all future reporting periods until the employer opts-out and (ii) include data from any such employer as part of its data submission, if any, otherwise required by this section. Such an employer may opt-out at any time but shall provide written notice to the third-party administrator or other entity of its decision at least 30 days prior to the start of the next reporting period. No employer that maintains an ERISA plan shall be required to opt-in to data submission to the All-Payer Claims Database, and no third-party administrator or other entity shall be required to submit claims processed before it was contracted to provide services. Each third-party administrator or other entity providing claim administration services for an employer shall submit annually to the nonprofit organization by January 31 of each year a list of the ERISA plans whose employer has opted-in to data submission to the All-Payer Claims Database and a list identifying all employers that maintain an ERISA plan with Virginia employees for which it provides claim administration services. Such information submitted shall be considered proprietary and shall be exempt from disclosure by the Virginia Freedom of Information Act (§2.2-3700 et seq.).
Q. Any data release shall make use of a masked proxy reimbursement amount, for which the methodology is publicly available and approved by the data release committee except that the Department may request that the nonprofit organization generate the following reports based on actual reimbursement amounts: (i) the total cost burden of a disease, chronic disease, injury, or health condition across the state, health planning region, health planning district, county, or city, provided that the total cost shall be an aggregate amount encompassing costs attributable to all data suppliers and not identifying or attributable to any individual provider, and (ii) any analyses to determine the average reimbursement that is paid for health care services that may include inpatient and outpatient diagnostic services, surgical services or the treatment of certain conditions or diseases. Any additional report of analysis based on actual reimbursement amounts shall require the approval of the data release committee.
R. The nonprofit organization shall ensure the timely reporting of information by private data suppliers to meet the requirements of this section. The nonprofit organization shall notify private data suppliers of any applicable reporting deadlines. The nonprofit shall notify, in writing, a private data supplier of a failure to meet a reporting deadline, and that failure to respond within two weeks following receipt of the written notice may result in a penalty. The Board may assess a civil penalty of up to $1,000 per week per violation, not to exceed a total of $50,000 per violation, against a private data supplier that fails, within its determination, to make a good faith effort to provide the requested information within two weeks following receipt of the written notice required by this subsection. Civil penalties assessed under this subsection shall be maintained by the Department and used for the ongoing improvement of the All-Payer Claims Database.