Payment Systems

For each of the CMS claim file types, the variables used in calculating costs for CMS covered services is reviewed. Calculations are defined by 1) what Medicare reimbursed; 2) the beneficiary's responsibility; 3) other primary payers, and then 4) total due to the provider. The presentation also includes issues to be considered when calculating costs.

Understanding of the CMS payment systems will assist the researcher in knowing how services are reiumbursed and what to expect in the data when costing services. This presentation will provide a historical review of CMS payment systems for all the claims data files, discuss details of calculating acute hospital MS-DRG payments, and review resources for determining 'cost' of services.

This video is one segment in a series of videos from ResDAC’s Introduction to the Use of Medicare Part D Data for Research.

This presentation reviews the "cost" variables found in the Part D Event data. Researchers can determine the "point of sale" cost to the beneficiary. Other variables reviewed in this presentation include the gross drug cost, the patient pay amount, the low income subsidy amount, the other true out-of-pocket amount, patient liability reduction amount, and the covered and non-covered plan paid amounts.

This video is one segment in a series of videos from ResDAC’s Introduction to the Use of Medicare Part D Data for Research.

This presentation begins with a discussion of the difference between a claim and a Part D "event" record. This presentation further reviews how the Part D data are processed, what systems CMS maintains for the event data, the Part D data sources, and a brief review of the Part D Event data file variables that are available to researchers.

This presentation will review the source of the data that is used to build the CMS Medicaid Analytic Extract files (MAX), which are the files released when CMS approves a research project requiring Medicaid data. The sources include state Medicaid Management Information System (MMIS) data and Medicaid Statistical Information System (MSIS) data. By understanding the data source files, researchers can understand some of the limitations and correct implementation of MAX data for research.