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Turquoise has just been certified as a Qualified Entity (QE) under the Centers for Medicare & Medicaid Services' Qualified Entity Certification Program.

It's not every day the federal government certifies we know how to handle America's most sensitive healthcare data. For those who don’t know, that means CMS reviewed how we ingest, secure, manage, and report on protected health information and claims data, and decided we're trustworthy enough to work with Medicare's data. Earned only by proving your data pipeline unimpeachable and your data practices of the highest order, the QE designation is an honor, and we're even more excited to dig into the new data now available to us as a QE.

Medicare claims data under Parts A, B, and D is heading to Turquoise soon

As a QE, in the coming months, we'll be able to access and report on Medicare claims data under Parts A, B, and D. 

That means we’ll soon have:

• Actual utilization and payment data
• Care settings price transparency data doesn’t currently touch (like skilled nursing facilities, home health, hospice, DME, and physician office claims) 
• Part D prescription drug event data (pharmacy benefit, fill-level detail)
• Diagnoses and clinical context
• Longitudinal patient journeys
• Payment adjudication detail

How is this different from the commercial claims data we already coupled with price transparency data? Well, commercial claims data is licensed from an aggregator, originally submitted by entities that choose to share it. That data is good but not reliably robust (hence why it acts as a great accompaniment to price transparency data!). Since almost every provider in the country submits claims to Medicare, Medicare data doesn’t suffer from the same gaps as commercial claims. Even a sample of Medicare data is universal in a way commercial claims isn't—there's no market segment Medicare misses, because there's no provider it doesn't touch. Alongside the commercial payer focus of MRF payer rates, this data set is focused on a different population (since Medicare data skews older and sometimes sicker than a commercially insured population) and a different level of granularity.

Basically, as a QE, we can now work directly with charge, payment, and utilization data alongside negotiated rate data. In addition to this new data, as a QE, we’re now required to report on CMS-approved provider performance measures. More on that soon!

It’s not just more data, it’s another piece of the complexity puzzle

This new data sharpens the resolution of Clear Rates—the foundational model of the rates, rules, and relationships underlying how U.S. healthcare gets paid and the foundation of the Turquoise platform. That directly strengthens our ability to simplify the financial complexity of healthcare. Once the data is in hand, we’ll be able to continue to evolve the PATIENT Framework’s Standard Service Packages (SSPs), our open-source, patient-first grouping methodology that collapses the revenue cycle to a single encounter-level price, reducing administrative overhead and enabling guaranteed upfront costs for patients. 

Take a knee replacement, for example. Does that SSP look identical for a commercially insured patient and a Medicare patient, or does it diverge in ways the aggregated data can't show? Right now that's a real question we’re unable to answer. With claims-level Medicare data, it's one we can actually go answer and use to confirm existing SSPs or build new ones specific to that population. 

More to come soon

Once the claims data starts flowing, it's a field day for us healthcare data enthusiasts. Look out for future reporting on the scintillating insights we find.