Obscure health insurance question
April 18, 2014 10:47 AM   Subscribe

I am doing some rather obscure research on the health insurance industry. I'm having some trouble finding the information I'm looking for. Hopefully someone here can help!

In the parlance of the health insurance industry, there are providers and subscribers. Providers are your doctors, for example. You, the patient, are the subscriber.

Medical service providers account for the majority of medical claims. Generally, subscribers only submit claims when they go to out of network providers.

I'm trying to find the data on subscriber claims--dollar amount and percentage of the overall total (provider + subscriber).

I tried emailing one health insurer and was told that this was something that they didn't actively track. I've tried searching through Google and haven't had any luck.

Anyone have any idea how to dig into this further?

P.S. It is also worth noting that I expect there to be significant geographic variations in how large subscriber claims are. For example, in NYC, mental health services are almost entirely provided on an out of network basis. This is not the case in other parts of the country. This makes it more difficult to extrapolate one insurer's experiences to the entire country. (Notwithstanding the fact that insurers have differing levels of exposure to different types of the market.)

To the extent that I can find more granular data the better. However, I'm thinking that I'm going to have to take whatever I can get.
posted by prunes to Grab Bag (3 answers total) 1 user marked this as a favorite
I would bet that Kaiser Permanente would have this information available, at least internally. Whether they would share it with an outsider is a different matter.

The Kaiser Foundation has and publishes extensive information about the economics of health care.
posted by megatherium at 11:08 AM on April 18, 2014 [1 favorite]

A terms clarification that might help. Subscriber is an insurance company specific term and not universally used by the industry industry. Subscriber is usually used to indicate the policy holder. Member or patient is the person who receives care, e.g. a parent may be the subscriber of insurance and covers the members/patients spouse and dependents.

A more standard nomenclature is:
Provider - Physicians and allied care providers.
Purchaser - Group (usually employer) or individual purchaser
Insurer - Health plan provider who collects premiums and pays claims
Patient - Consumer of services. (Ignores the policy holder vs dependent thing.)

The question you are asking might be better phased as" What percentage of all health insurance claims are submitted by the patient?"

Most claims come through the clearing houses which standardize submissions from providers to insurers. Direct from patient claims would likely not hit the clearinghouse but be sent directly to the insurer. You could get a very, very loose estimate by asking what percentage of claims route through the clearinghouses. It would be imperfect because different companies use clearinghouses differently. Some companies may well pay to claims entered manually and then route to the CH. If you were just looking for something directional, that path of research might yield something usable.

The other thing is that trying to use dollars is going to be problematic. Entity to entity submissions will use/reimburse based on the “Usual, Customary and Reasonable” database. Individual submitters are going to use doctor fees which often exceed the UCR rate. If your looking at mental health specifically, then the direct to patient cost is very frequently higher the UCR.
posted by 26.2 at 11:17 AM on April 18, 2014

I work for a healthcare data analytics firm, but not on the data side of things. So I have some potential leads, but not a lot of firm guidance.

There's a potential that you might be able to dig this data out of a All Payer Claims Database (APCD). Unfortunately I can't confirm that you'd be able to see the distinction between in network and out of network claims or filter easily to just subscriber claims, but this search term might help you in locating available claims data.

These databases includes claims for all Payers (hence the name) usually by state. Payers meaning private insurers, Medicaid, self-insured employers, Medicare and potentially others. The data includes claim level detail, often for medical, pharmacy and dental. The claim details that I've seen from these databases includes both the Submitted/Charged amount (the full cost of the bill) and the Allowed Amount (what the insurer/Payer is covering).

This APCD Council data request page has some options to request data from the states that currently make their data available. I imagine there is some cost involved and likely a wait.

Alternatively, are you by any chance associated with large research university? Many of these will have access to similar claims databases and you might be able to get some assistance with pulling this data.

The database I'm most familiar with is called MarketScan.* It's too pricy for individual purchase, but several universities do purchase access, so that could be an option.

*In the interest of transparency, this database is developed and maintained by my employer.
posted by thatquietgirl at 2:51 PM on April 18, 2014

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