Health Care Facility Fees

MHDO’s Annual Report on Health Care Facility Fees
- new January 16, 2025

Public Law 2023, Chapter 410 (LD1795), An Act to Create Greater Transparency for Facility Fees Charged by Health Care Providers and to Establish the Task Force to Evaluate the Impact of Facility Fees on Patients, requires the Maine Health Data Organization (MHDO) to submit an annual report on payments for facility fees made by payers, to the extent that payment information is already reported to the MHDO, to the Office of Affordable Health Care and the Joint Standing Committee on Health Coverage, Insurance and Financial Services.

The Detailed Data Set for MHDO’s second annual report on health care facility fees was produced after discussions with the Office of Affordable Health Care. There are several new data points in MHDO’s second annual report that enhance the content and context of the data set, including the total number of episodes, sum of total payments, and a split billing tab.

The source of data for this report is the claims data submitted to the MHDO under rule 90-590 Chapter 243, Uniform Reporting System for Health Care Claims Data Sets, for the time-period July 1, 2023-June 30, 2024. The data elements required in Chapter 243 align with the information that is populated in the standardized claims forms (UB-04 and the CMS-1500) used by hospitals and other health care providers.

MHDO’s All-Payer Claims Data (APCD) represents approximately 73% of commercially insured individuals which is the claims data that was used in the Detailed Data Set (Data for MaineCare and Medicare are not included in the Detailed Data Set). Highlights from the Detailed Data Set are listed below.

The Detailed Data Set includes:

  • Medical claims data submitted to the MHDO by 16 commercial payors.
  • Breakouts of the top 5 commercial payors represent approximately 91% of the claims data used in this analysis.
  • 197 identified Health Care Settings broken out into 3 categories: Hospital - CA (Critical Access), Hospital (not CA) and Non-hospital (all other health care setting types including clinics, physician practices, behavioral health treatment centers, imaging and radiology centers, etc.)
  • 109 Current Procedural Terminology (CPT®) codes which are included in the Detailed Data Set refer to outpatient encounters only.
  • 4 tabs for different CPT Code Categories including: Office Visits, Behavioral Health Care, Radiology & Imaging, and Other Outpatient Services.
  • A tab labeled Split Billing which identifies the office visit CPT code and the number of episodes where both a UB-04 and CMS-1500 were submitted for payment for the same service.

The Complete Detailed Data Set is available.

The Detailed Data Set Report Methodology is available.

The 1st annual Facility Fee Report, published in 2024 can be found on this page of our website.