Max Rady College of Medicine

Concept: Physician / Hospital Claims

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Concept Description

Last Updated: 2012-04-10


    The Medical Services Data in the MCHP Data Repository contains physician service information. Also called Physician claims or hospital claims, this data identifies the provider, type of service provided, when and to whom the service was provided, and the fee or tariff related to the service.

Types of Claims

    The types of claims in this database include ambulatory (out-of-hospital) services, as well as some in-hospital services. Examples of these services include:

    Ambulatory (out-of-hospital) Services

    • Physician visits/calls
    • Special tests
    • Lab/pathology claims
    • X-ray/radiology
    • Minor surgery
    • Outpatient department
    • Emergency Room visits
    • Out-of-province services; and
    • Chiropractic services

    In-hospital Services

    • Physician visits (consultations)
    • limited Lab/pathology claims
    • limited X-ray/radiology
    • surgical services anesthesia
    • post-operative care; and
    • prosthetic devices/services

    The Medical Services data does not contain all provider/physician services. For example, not all physicians in Manitoba are paid on a fee-for-service basis. Some physicians are paid by salary, session rate, or contract. Shadow billing claims are submitted to Manitoba Health by physicians on these alternative payment plans and these claims are for administrative purposes only (i.e., as a record of service provided). In some cases, not all services received by Manitoba residents are reported in the Medical Services data. In some regions there is a higher proportion of physicians providing services on alternative payment plans. As a result, physician services in these regions may be underreported compared to other regions.

Physician Claims - Special Cases

    There are two special cases related to Physician Claims that require specific attention. These are

    • physician "Dummy" claims for time on-call; and
    • physician claims related to pregnancy and birth.

Physician "Dummy" Claims for Time On-Call

    The Physicians Claims data allows billing that compensates physicians for the time that they are on-call. Most of these on-call cases are for anaesthetists.

    Starting in 1998/99, the Medical Services / Physician Claims data contains two "dummy" values combining scrambled PHIN, Registration Number (REGNO) / (REGNO_CODE), SEX, and BIRTHDATE. These two "cases" are used by physicians to bill on-call time that is not directly related to any specific patient. The associated costs cannot be attributed to actual patients, but are of interest when reviewing physician costs and utilization.

    These two scrambled PHINS must be explicitly dropped from studies that define a cohort or population directly from physician services claims. For more information see:

    Thanks to Deborah Malazdrewicz at Manitoba Health for this information.

Physician Claims Related to Pregnancy and Births

    Physician claims related to pregnancy and birth are referred to as prenatal care visits. For more information on how MCHP has investigated physician claims relating to prenatal care visits, please see the Prenatal Care Visits (PCV) concept.

    For historical information on how prenatal and postnatal care are handled within the MCHP Data Repository, please see the Prenatal and Postnatal Care section of the Ambulatory Visits - Physician concept.

Hospital Claims

    Episodes versus Separations

    It is important to distinguish clearly between episodes and separations. Each time a new hospital claim is generated, it should be counted as a separation. An episode is a contact with the system resulting in one or more separations. Further, someone admitted to a hospital and transferred several times before being discharged may generate multiple claims, but this would be counted as one episode. Discharge and readmission on the same day (or within a short interval) count as the same episode.

    Our episode macro (in the MCHP SAS Macros concept) allows a one day difference between discharge and subsequent admission for stays in the same episode. It does not take diagnosis, or reason for the admission, into account, but more sophisticated episode algorithms certainly could.

    Duplicate Hospital Claims

    When combining multiple years of hospital data, a check for duplicate claims should be done. Some claims in the files are actually corrections to claims in previous years, meant to supersede the original claims. They do not represent new admissions and should not be counted as such.

    These can be identified and eliminated by setting together all the extracted records from the hospital files, and sorting by PHIN, HOSP, DATEADM, DATESEP, and HRN with the NODUPKEY option. For even greater control over which record is selected, sort also by CLAIMYR and keep the record from the most recent file.

    Incomplete Claims at the End of Fiscal Year

    Hospital claims data from Manitoba Health are compiled as patients are discharged from hospital. This means that each annual hospital claims file contains information only on patients who were discharged from a Manitoba hospital during that year, regardless of when a patient was admitted to hospital.

    As a result, research analyses that look at admissions or inpatient hospital census (i.e. the number of hospital beds occupied on any given night) are subject to incomplete data for the days/weeks near the end of a fiscal year.

    Example: the data for a patient admitted to a Manitoba hospital in the last week of fiscal year 97/98 and discharged during the second week of fiscal year 98/99 will appear on the 98/99 hospital claims file.

    If only the 97/98 hospital claims file is used for analyses of admissions or patient census in 1997/98, the results for the latter weeks of this fiscal year will be inaccurate. This problem can be all but eliminated by using both the 97/98 and 98/99 hospital claims files for the analyses of 97/98 hospital data.
    MCHP also has available first quarter of the fiscal year hospital claims files. These files can be used to reduce the aforementioned end-of-the-fiscal-year inaccuracies. However, research at MCHP has shown that for certain types of admissions (notably psychiatry and emergent/urgent surgical) the first quarter hospital claims files still do not provide complete admission and inpatient census data for the end of the previous fiscal year.

    The table Average Daily CENSUS per Week BY Type of Admission in Wpg. Hospitals - 97/98 gives daily average inpatient census counts and number of admissions by type of admission for the Winnipeg acute care hospitals each week during 1997/98. These data were computed first, by using the entire 97/98 hospital claims file plus the first quarter 98/99 hospital file and then secondly, by using the 97/98 claims plus the entire 98/99 hospital dataset. The resulting differences are documented.

    Significant differences were found among psychiatry and emergent/urgent surgical patients for up to 15 weeks prior to the end of the fiscal year. There were also notable differences for the last 4 to 5 weeks of the year for emergent/urgent medical and scheduled medical admissions. There were essentially no differences among newborns and obstetrical cases.
    PHIN and Hospital Claims

    1. Adult and child claims: These are passed against the registration file and if the demographic information agrees, the PHIN from the registration file is added to the hospital claim for the patient, which is then put on the hospital statistics file.

    If the demographic information does not agree, the hospital claim is automatically put on a listing. The non-match is manually investigated until the problem is resolved. The PHIN number is then added to the hospital claim which is then put to the hospital statistics file.

    2. Newborn claims: These are also passed against the registration file and if the mother's demographic information corresponds with the registration information, a PHIN is assigned to the newborn and added to the claim.

    If the demographic information does not match, the claim is put in a listing and a manual investigation occurs until the problem is resolved and a PHIN is assigned and added to the newborn claim, which is then put on the hospital statistics file.
    Note: ** All hospital claims records should therefore contain a PHIN. **

    Thanks to Fred Toll for this information.

Costs / Fee Information

    Each record in the Medical Services data contains information on the physician, patient, service provided and the fee that is paid to the physician for the service. The cost of the service is equal to the professional fee, or tariff, paid to a physician. The fees are negotiated by Manitoba Health and Doctors Manitoba or other bodies representing physicians, and these fees change over time. The current fees, with corresponding codes and descriptions, are available in the Physician Manual on the Manitoba Health web site located at:
    Net Fees

    Based on the nature of the payment system, it is sometimes necessary to adjust the fees paid to a physician due to an accounting adjustment, late entry or a retroactive change in the negotiated fee schedule. In these situations, the real value of the claim must be calculated, based on the original claim plus the adjustment, which can be a positive or negative value. When an adjustment to the original claim is required, a subsequent entry is added to the database, matching on the PHIN, service date, physician ID, and tariff information. This adjustment process is called "netting". For more information, see the section titled Net Value Factors in the Discrepancies Between MCHP and Manitoba Health Published Reports concept.

    Geographic Fee Differentials

    A fee differential may be added to the tariff depending on the geographic location where the service is provided. In the 2010 Physician Manual (as of January 4th, 2011), this fee differential is:

    • 25% for northern Manitoba;
    • 5% for rural Manitoba and Brandon; and
    • 0% for the city of Winnipeg and outside Manitoba.

      NOTE: This geographic differential only applies to fee-for-service physicians. This is an important point for investigators comparing costs between regions; higher costs could be attributed to the differential or higher utilization. The FEECODE variable in the data set identifies whether or not a claim includes a geographical differential.

Other Physician Costs

    In estimating hospital costs, physician services are usually excluded since the methods of physician payment vary across hospitals and by type of physician. If an investigator chooses to include physician costs associated with hospital stay they must calculate the physician visits to patient, consultations taking place in hospital, and if surgery takes place, the surgical fee, fee of the surgical assistant and the anesthetist's fee.

    Similarly, costs for services provided by physicians to PCH residents are not included in the funded services provided by the PCH. All of these services are usually billed separately. They are recoverable from administrative data and fees are found in the Manitoba Health Services Insurance Plan Physician Manual.

    NOTE: For an overview of general costing methods (sources of data, types of costs, and approaches) and the methods of costing specific health services (hospitals, physicians, home care, personal care homes and pharmaceutical/prescription drugs) that have been used in MCHP research over time, please see the Costing Methods: An Overview of Costing Health Services in Manitoba concept.

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Manitoba Centre for Health Policy
Community Health Sciences, Max Rady College of Medicine,
Rady Faculty of Health Sciences,
Room 408-727 McDermot Ave.
University of Manitoba
Winnipeg, MB R3E 3P5 Canada