Hospital Casemix Protocol--Medibank Private perspective.
Abstract: Hospital Casemix Protocol data provide a brief summary outlining morbidity data and costs associated with an episode of care. Federal government legislation requires that hospitals report this information to private health insurers who, in turn, merge these data with benefit outlays and report their findings to the Department of Health and Ageing (DoHA). This article gives a brief outline of the collection, cleansing and processing of these data and subsequent reporting to DoHA by Medibank Private, which accounts for approximately 30% of collected data.

Keywords (MeSH): Australia; Private Hospitals; Funding; Data Collection; Data Management Systems
Article Type: Clinical report
Subject: Health insurance industry (Services)
Hospitals (Australia)
Hospitals (Information management)
Information management (Methods)
Medical informatics (Management)
Author: Szakiel, John
Pub Date: 06/01/2010
Publication: Name: Health Information Management Journal Publisher: Health Information Management Association of Australia Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 Health Information Management Association of Australia Ltd. ISSN: 1833-3583
Issue: Date: June, 2010 Source Volume: 39 Source Issue: 2
Topic: Event Code: 360 Services information; 260 General services; 200 Management dynamics Computer Subject: Information accessibility; Company systems management; Company business management
Product: Product Code: 8060000 Hospitals NAICS Code: 622 Hospitals SIC Code: 6321 Accident and health insurance; 8062 General medical & surgical hospitals; 8063 Psychiatric hospitals; 8069 Specialty hospitals exc. psychiatric
Geographic: Geographic Scope: Australia Geographic Code: 8AUST Australia
Accession Number: 231089015
Full Text: Legislation

The Commonwealth Department of Health and Ageing (DoHA) legislation stipulates that each private hospital and day-care facility in Australia (of which there are over 400) submits Hospital Casemix Protocol (HCP) data (a summary of a patient's admission) for privately insured patients to the appropriate health fund within six weeks from the end of the month of separation. The HCP file is comprised of a header line that includes hospital and fund IDs, the period of reporting, number of records, HCP version and ICD10-AM coding version. Further, each line of data in the HCP file represents an episode of stay for a patient and contains the patient's details such as name, date of birth, postcode and fund membership ID, which are used by the fund to match the record to data in the fund's claims database. Other information included are various charge items, morbidity details and other administrative data relating to the patient's episode of care.

Also required from hospitals with a registered rehabilitation program is Australian National Sub-Acute and Non-Acute Patient (AN-SNAP) data, which summarise the rehabilitation admission. These data are similar in structure and include functional impairment scores. The specifications for the format of these files can be found at HCPspecHtoFund0910.

Hospital submission

Data for both Medibank Private Limited (MPL) and Australian Health Management (AHM) arrive via one of three channels: secure web portal, email or diskette. The secure web portal is an MPL innovation, which allows hospitals to submit their data with full 128-bit encryption to ensure the privacy of patients and their details. For this reason, it is MPL's preferred approach and somewhere between 80% and 90% of data arrive via this channel. Most of the balance comes via email, some of it zipped and password protected, with only a handful of facilities still using diskettes and the postal service.

Initial processing at MPL

When a file is received via the web portal, the system scans the file and does a preliminary check to see if the file is basically formatted correctly and the fund ID is MBP (1) or AHM (the defined fund IDs as per DoHA specification). The details of the header line from the file are then broken out into their component fields, labelled and then emailed back to the registered email address. The transaction is also logged for an audit trail.

Data that arrive via email or diskette are treated in the same way. Any files that do not pass initial scrutiny are rejected and deleted and an email is automatically sent to the facility with header details and a reason for the failure in the same way the web portal does. The arrival of all files and their mode of transport are logged at this point as well.


Once a day, the files uploaded to the web page are downloaded to MPL for processing and edit checks. All files collected for the day are then run through the 3M grouper and grouped to versions 4.2, 5.0 and 5.1. The files are then uploaded into a Microsoft SQL Server database for edit checks and further processing. MPL performs all edit checks listed in the specification, plus a few additional checks that include an algorithmic check on the membership ID and a match of the DRG supplied in the file to the appropriate DRG obtained by the 3M grouper mentioned earlier. This means that if the hospital 'groups' in DRG Version 4.2, then their result is compared with Version 4.2 results obtained at MPL (2).

Any data anomalies are assigned an error code and logged. Data that are anomalous, but do not have an impact upon the quality of the HCP submission according to the specifications are assigned a W type error code or WARNING ONLY. Fatal errors are assigned an E type code. Any record that attracts an E type error code is deleted for privacy and security reasons. DoHA has deemed that any submission (month) with more than a 5% error rate shall fail and the month considered as not having been submitted. Only fatal errors count to this error rate.

A summary of errors is logged in the database and an error report emailed to each facility. If there are no errors to report, then the facility is emailed with this result also. A follow-up flag is placed against each month of data for each hospital where there are errors that need correction. If the data are not submitted within four weeks of the error report being sent, a reminder email is sent. A further reminder is sent two weeks later if there has still been no re-submission.

At around the 14th day of each month, a report is generated for each facility listing all months in the previous 12-month period where data have not been received or the error rate remains above the 5% threshold. This report is automatically emailed to each facility in default of the rules. Two weeks after this report has been sent, a similar report is generated for those facilities where action has not been taken. This report is then sent to DoHA as required.

All data that pass edit checks are stored on a secure, restricted access SQL server. Any duplicate records from re-submissions are updated to the newest submission and the old record deleted to prevent duplication.

HCP and billing claims

Once a month, the HCP data are matched up with data in the claims database to connect benefits paid with the charges. These data are de-identified and forwarded on to DoHA as stipulated in legislation. Amendments are submitted to DoHA for six months to include any late data.

Data analysis

HCP data also has its uses at MPL internally. Two major areas of use at MPL are in 'Better Health Management Programs' and Hospital Modelling. All analysis in these areas is done on de-identified views of the hospital data. The Benefit Analytics Department at MPL uses the HCP data to analyse overall hospital benefit outlays using casemix techniques, looking for growth in clinical areas and variations in clinical service delivery by geographic area.

MPL also models individual hospital activity in terms of changing length of stay and readmissions. This information is used by the hospital contract managers in their negotiations with hospitals. MPL use an episodic payment system, Price Weight of One (PWO), with our contracted private hospitals. In this system we pay an agreed fee for hospital separations as per the allocated ARDRG. MPL uses the National Hospital Cost Data Collection (Department of Health, Canberra) to weight the complexity or resource usage of the separations with the ARDRG to determine a price. This is then included under our contract with the hospital as a payment schedule.

MPL aims to provide its members with more than just health insurance. The Health Management team, which includes a doctor, nurses, HIM and other medical specialist professionals, focuses on helping members achieve better health and wellbeing. This is achieved by developing programs for members to support them in losing weight, making healthy food choices and management of chronic health conditions. Trends analysis of HCP data assists in the development of these programs.

(1) While MPL has been used to denote Medibank Private Limited throughout most of the document, the current HCP specification has the fund ID for Medibank as MBP. This will change to MPL on 1 July 2010, to bring the HCP specification into line with Eclipse. For the moment it remains as MBP

(2) When 'grouping' a record to a DRG there are several versions that a hospital can group to. Many still group in Version 4.2 while others group to Versions 5.0 or 5.1 with Version 6.0 about to become another option.

John Szakiel DipSci(AppliedChemistry), PostGradDip(ComputerScience)

HCP Data Manager

Medibank Private

Collins Street

Docklands VIC 3008


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