The No Surprises Act is a federal law for protecting patients from surprise bills and excessive cost sharing. Besides requiring healthcare providers to issue good faith estimates (GFEs) for self-paying and uninsured individuals, it encourages states to create and maintain all-payer claims databases (APCDs), which are large state databases that include pharmacy claims, medical claims, provider files, dental claims, and eligibility collected from public and private payers.
Read on to learn more about APCDs and why they encourage price transparency in healthcare. We will also cover which states have started taking steps toward APCD implementation and how the No Surprises Act helps APCDs.
What Is an All-Payer Claims Database?
An all-payer claims database or APCD is a state system that collects healthcare claims and related data from entities that pay for healthcare services, such as public and private health plans. Insurers and plans directly report APCD data to states, typically as part of a state mandate.
Why APCDs Encourage Price Transparency in Healthcare
APCDs encourage price transparency in healthcare by providing the following information publicly:
- Data on private insurance: Most datasets do not include this information.
- Data from all or most insurance companies operating in any state. Most proprietary datasets do not contain this information.
- Information on patient care across care sites. In contrast, most states only record emergency department visits and hospitalizations. APCD data also include geographic representation, large sample sizes, and longitudinal information on a broad range of individual patients.
Policymakers can use APCD data to provide better healthcare and reduce healthcare disparities and costs. Healthcare consumers can also use the data to develop innovative services, approaches, and programs that may have the potential to deliver cost-effective and responsive healthcare.
Examples of Claims Data
To give you a better understanding of how APCDs work, here's what a medical claim that gets submitted to an APCD would contain:
- Important information about the patient, including the name, address, sex, and birth date of the patient.
- Who helped the patient, and who should get paid? This section lists the name and National Provider Identifier (NPI) of the Servicing Provider and the name, NPI, and address of the Billing Provider.
- What happened during the visit? If the patient was admitted to a hospital, the claim would address the type of visit (emergency, elective, etc.), who referred the patient, and their diagnosis on arrival. For hospital visits and all other types of visits, the claim would also detail the date and primary reason for the patient's visit, additional reasons that may have led to their condition, and the patient's external cause of injury.
- How did the visit go, and what did they do? This section lists out the primary and secondary procedures and services and when they were performed. It also lists out the service units used, when the patient left, and where they went after leaving.
- Codes that determine the cost: This section contains the following codes:
- Condition codes: These codes provide data that might affect the processing of a claim. Examples include change in dates or corrections.
- Revenue codes: These codes show what happened and what dollar amounts were associated with the services the patient received.
- Description codes: These codes describe the patient's visit. They include ICD-10 codes (patient's diagnosis), CPT codes (procedures received), HCPC codes (outpatient services), and NDC codes (drugs the patient may have received).
- Who gets the bill? This section establishes whether the patient is insured and what their unique insurance identifier is. It also shows the employer, group, and health insurance name and ID.
- How much did it cost, and how much gets paid? This section lists the total charges, what health insurance paid, how much the patient owes, additional payments, and non-covered charges.
Research on the Impact of APCDs
APCD implementation has had a large impact on medical costs. According to a University of Michigan reference study that analyzed the effects of New Hampshire’s APCD on medical imaging costs, the cost of medical imaging decreased by 5% for patients and 4% for insurance companies. Patients saved about $7.9 million and insurance companies saved $36 million on medical imaging scans over the five-year period of the study.
Unsurprisingly, an increasing number of states have taken an interest in implementing and maintaining APCDs.
All-Payer Claims Database States
As of January 2023, there are currently:
- 18 states with existing APCDs
- 8 states that are implementing APCDs
- 7 states with a strong interest in APCDs
- 5 states with existing voluntary effort
Here's an overview of some of the states with existing APCDs. We will also cover several states that want to implement APCDs.
Arkansas All-Payer Claims Database (APCD)
Arkansas has an existing APCD called the Arkansas All-Payer Claims Database. Arkansans can use the APCD website as follows:
- Resources: Visitors can use this tab to locate additional information on Arkansas' healthcare transparency efforts.
- Reports and Maps: Visitors can use this tab to view reports about the utilization and price of select procedures.
- About the APCD: Visitors can use this tab to learn more about the Arkansas APCD project, including frequently asked questions, contact information, and a list of data sources.
Arkansans can only request datasets from the APCD through the Arkansas HTI Data Request Process. Analytics, reports, counts, and data output that require custom data aggregation are not currently available.
California’s Health Care Payments Data (HPD)
California is currently implementing an APCD called the Health Care Payments Data (HPD) System.
The HPD Program is implemented by the Department of Health Care Access and Information (HCAI), which is statutorily required to create and administer the HPD to collect healthcare data from health insurers, health care plans, government agencies, and other entities. It will collect a broad range of information, including:
- Encounters and claims generated by transactions among providers and payers on behalf of insured individuals
- Information about non-claims payments, including alternative payment and capitation models
- Information about pharmacy, medical, and dental services
The HPD Program will use the APCD Common Data Layout (APCD-CDL), a national standard for Medi-Cal encounter and claim data and commercial submitters. A standardized format will minimize burdens for data submitters, particularly insurers and health plans that submit data to multiple state APCDs.
Colorado All Payer Claims Database (CO APCD)
The CO APCD has many public data focus areas, including:
- Affordability Dashboard: Coloradans can use this to locate information on health cost opportunities and drivers.
- COVID-19: This provides resources for helping Colorado prevent, plan for, and understand the impact of COVID-19 on Colorado.
- Shop for Care: Coloradans can use this feature to search quality and prices at different facilities for common imaging tests and procedures.
Georgia All Payer Claims Database (GA APCD)
Georgia is implementing an APCD called Georgia All-Payer Claims Database (GA APCD).
Like other APCDs, the GA APCD will allow private and public healthcare consumers to identify and compare health insurers, health plans, health care practitioners, and healthcare facilities that provide value-based, safe, cost-efficient, and high-quality healthcare services. It will also promote quality and cost transparency, track healthcare spending trends and drivers, evaluate geographic variations in utilization and price, and promote public health.
HealthFacts RI Database
Rhode Island currently has an APCD called the HealthFacts RI Database, which includes information on over one million people, most of whom are insured Rhode Island residents. Specifically, it contains data on health status and demographics, emergency room visits, medical services, healthcare providers, pharmacy services, and member enrollment. However, the HealthFacts RI Database does not include the following:
- Information on people who do not have health insurance
- Free healthcare
- Healthcare services paid directly by an individual
- Dental services
- Members who have insurance through a self-funded employer
- Claims by insurance companies with under 3,000 members
All of the information was gathered from health insurance payment systems. The data in the HealthFacts RI Database does not have any addresses, names, or other personally identifying data. Rhode Island residents who do not want their information in this database can opt out at any time.
Maryland Medical Care Database (MCDB)
Maryland has an existing APCD called the Maryland Medical Care Database (MCDB). Like the other APCDs on this list, the MCDB supports estimates of utilization and cost, evaluations of demonstration programs, and policy analyses. State partners like the Health Services Cost Review Commission and the Maryland Insurance Administration also use the MCDB to support their decisions.
Only private claims are available for approved data release. Approved private claims exclude self-insured ERISA health plans starting in 2015 because of the ruling in Gobeille v. Liberty Mutual Insurance Company.
Massachusetts All Payer Claims Database (MA APCD)
Massachusetts' APCD is the Massachusetts All Payer Claims Database (MA APCD). As the most comprehensive source of private and public health claims data in Massachusetts, the MA APCD covers a broad range of services, including dental, vision, medical, pharmacy, specialty, and behavioral health services. Researchers, health plans, and others often use the MA APCD to assess and report on quality outcomes, population health management, and pricing and cost variations.
The MA APCD site contains links and detailed instructions for requesting MA APCD data. Non-government agencies must follow these steps to submit an MA APCD request:
- Review documents associated with data release, formulate the data request, and review the data use agreement template.
- Submit a data request, data management plan, fee waiver or fee remittance form.
- Consult with technical specialists when needed during review of data management plan or data request.
- Committee review
- Execute a data use agreement.
- The MA APCD will process and ship the data to the requestor.
MHDO All Payer Claims Database (Maine APCD)
Maine's APCD system is called the Maine Health Data Organization (MHDO). The MHDO currently holds claims from third-party administrators (TPAs), insurance carriers, dental benefit administrators, pharmacy benefit managers (PBMs), CMS (Medicare), and MaineCare (Maine Medicaid).
Healthcare claims processors must submit a completed healthcare claims dataset for all members who reside in Maine periodically (usually monthly) to the MHDO. The submissions include files with medical claims, member eligibility, dental claims, and pharmacy claims information.
Minnesota All Payer Claims Database (MN APCD)
Minnesota's APCD, the Minnesota All Payer Claims Database (MN APCD), is meant to address key questions about the healthcare delivery system. It features a diverse range of public use files (PUF), including:
- Health care services (2013-2019): Users can use this file to analyze the distribution of healthcare procedural information and services for Minnesota residents.
- Primary diagnoses (2013-2019): This file is for analyzing the distribution of diagnostic data recorded in healthcare use for Minnesota residents.
- Prescription drug (2012-2014, 2016-2018): There are two versions of this data type: The Summary prescription drug PUF, which contains retail pharmacy claims that have been sorted by nonproprietary drug name, and the Detail prescription drug PUF, which contains retail pharmacy claims data that has been grouped by the first two segments of the National Drug Code.
Oregon All Payer All Claims Reporting Program (APAC)
Oregon's APCD, the Oregon All Payer All Claims Reporting Program (APAC), contains data representing over 90% of Oregon residents. Those who are not in APAC are uninsured, covered by self-insured plans not reporting to APAC, or covered by Federal Programs like Veterans Affairs. In 2018, APAC contained:
- 100% of fully-insured
- 36% to 61% of self-insured
- 96% of Medicaid FFS and OHP/CCO
- 100% of Medicare
New York All Payer Database (NY APCD)
In 2011, New York State passed legislation to create the New York All Payer Database (NY APCD). In 2016, the New York State Department of Health secured an analytics and warehousing vendor, issued proposed regulations, and started implementing the NY APCD.
Currently, the NY APCD consists of three main parts:
- Data intake and acquisition, including information about providers, FFS claims, encounters, member coverage, non-claims-based data, and reference files
- Warehousing, including the Master Patient Index and the Master Provider Index
- Analytics and release, including public user files, data enrichments, and limited identifiable information
Texas All-Payor Claims Database (TX APCD)
Texas is currently implementing the Texas All-Payor Claims Database (TX APCD).
It will be administered by UTHealth Houston, a comprehensive academic health university in Texas. UTHealth will collect, process, analyze, and store data about medical, pharmaceutical, dental, and other relevant healthcare encounters and claims, benefit, and enrollment information for the purposes of increasing healthcare transparency costs, improving the affordability and quality of healthcare, reporting access and utilization, and improving population health.
Virginia All-Payer Claims Database (VA APCD)
Virginia has an existing APCD, the Virginia All-Payer Claims Database (VA APCD). The VA APCD is a program under authority of the Virginia Department of Health that aggregates paid pharmacy and medical claims for over four million Virginia residents with Medicare, Medicaid, and commercial coverage across all types of healthcare services.
Washington State All Payer Claims Database (WA-APCD)
Washington's existing APCD, the Washington State All Payer Claims Database (WA-APCD), collects healthcare claims data for analytics and helps the public make better healthcare decisions. The Center for Health Systems Effectiveness at Oregon Health & Science University is responsible for implementing and operating the WA-APCD.
How the No Surprises Act Helps APCDs
APCDs are complex and expensive databases to implement. Fortunately, the No Surprises Act helps states to implement and develop APCDs in several ways:
Grants to establish or enhance all payer claims databases
The No Surprises Act establishes a grant program to create or improve state APCDs. Eligibility is based on an application that specifies the following at a minimum:
- How the state will ensure uniform data collection
- The privacy and security of such data
Grants last for three years, with $1 million being allocated in the first two years, followed by $0.5 million in the third year.
Requires funded APCDs to share data
The No Surprises Act also requires grant-funded APCDs to share aggregate data publicly free of charge. Employers can also request customized reports at a cost.
Federal government will introduce and maintain a standardized format
Finally, the No Surprises Act requires the Secretary of Labor to establish and regularly update a standardized reporting format for group health plans' voluntary reporting of data to state APCDs.
This standardized format requires the Secretary of Labor to create an Advisory Committee of 15 members to advise the Secretary about how to collect data in the standardized format. These members must have distinguished themselves in the fields of health economics, health services research, data privacy and security, health informatics, or the governance of state APCDs. Once chosen, such members will serve three-year terms on a staggered basis.
The Advisory Committee will include the following roles:
- The Assistant Secretary of Employee Benefits and Security Administration of the Department of Labor
- The Assistant Secretary for Planning and Evaluation of the Department of Health and Human Services
- Members appointed by the Secretary, including:
- One member to serve as the chair of the Committee
- One representative of the Centers for Medicare & Medicaid Services
- One representative for the Agency for Health Research and Quality
- One representative of the Office for Civil Rights of the Department of Health and Human Services, one representative of the National Center for Health Statistics
- One representative of the Office of the National Coordinator for Health Information Technology, and one representative of a state APCD
- Members appointed by the Comptroller General of the United States, including:
- One representative of an employer which sponsors a group health plan
- One representative of an employee organization which sponsors a group health plan
- One academic researcher with expertise in health services research or health economics
- One consumer advocate
- Two additional members
The Increasing Importance of APCDs
APCDs are large state databases that include medical claims, pharmacy claims, and other healthcare insurance information from public and private payers. Policymakers can use APCD data to improve healthcare and minimize healthcare disparities and costs. Consumers such as healthcare providers can also use APCD data to create programs, approaches, and services for delivering responsive and cost-effective healthcare.
Only 18 states have existing APCDs as of January 2023. However, an increasing number of states are implementing or interested in implementing APCDs due to the No Surprises Act, which provides grants for creating and enhancing APCDs, requires funded APCDs to share data, and introduces and maintains a standardized format for the APCD data reporting process. APCDs are also expected to become more widespread because research has shown that APCD decreases medical costs for healthcare providers.