Approach B. Billing for IIS Data

Module 1	Introduction	Unit 1 IIS Sustainability Toolkit Introduction
Module 2	Getting Started	Unit 1 How to Use this Toolkit
Module 3	Defining IIS Sustainability	Unit 1 What is IIS Sustainability and Why Does it Matter?
Module 4	Strategy 1: Diversifying Funding	Unit 1 Diversifying Funding Introduction	Unit 2 Approach A. Leveraging Medicaid Match	Unit 3 Approach B. Billing for IIS Data
Module 5	Strategy 2: Optimizing IIS Efficiency	Unit 1 Optimizing IIS Efficiency Introduction	Unit 2 Approach A. Increasing the Use of Shared Services	Unit 3 Approach B: Leveraging Shared Infrastructure	Unit 4 Approach C: Using Open Source Software	Unit 5 Approach D. Implementing Process Automation	Unit 6 Approach E: Modernizing IIS
Module 6	Success Stories from the Field	Unit 1 Success Stories Introduction	Unit 2 Using Medicaid Match to Diversify IIS Funding	Unit 3 Diversifying IIS Funding Through Health Plan Billing	Unit 4 Slowing the Curve to Manage Rising IIS Costs
Module 7	Additional Considerations	Unit 1 Additional Considerations
Module 8	Additional Resources Related to Sustainability	Unit 1 Additional Resources
Module 9	References	Unit 1 References
Module 10	Abbreviations and Acronyms	Unit 1 Abbreviations and Acronyms

What do we mean by billing for IIS data?

Billing for IIS data means asking an IIS partner to pay for IIS data. Most often, this takes the form of jurisdictions billing health plans for the IIS records of their enrolled members (see Success Stories from the Field: Diversifying IIS Funding Through Health Plan Billing). To successfully introduce an effort to bill for IIS data, IIS should develop a plan to obtain leadership approval by demonstrating the costs of producing the data and the benefits to the health plans. Further, IIS programs and/or IIS managers will need to work with the appropriate internal agency leadership and fiscal staff to set up a mechanism for depositing the funds generated into an account that can be accessed by the IIS. Funds deposited in a general health department account will likely be unavailable to the IIS. Other health department fee-for-service programs, such as vital records or professional licensing, may provide models for how to bill external parties for services. Your budget office can assist with setting up accounts to ensure that IIS receive the funds dedicated to flow to it.

Health plans use IIS data to help them conduct outreach to enrollees, assess immunization coverage rates, and report on HEDIS (Healthcare Effectiveness Data and Information Set) performance measures for immunization. Although the Centers for Medicare & Medicaid Services (CMS) no longer requires immunization coverage as a performance measurement, health plans may want to continue using this metric to market their success in meeting best practices in immunization, to drive performance-based payment for providers, or for other purposes.

In addition to health plans and payers, jurisdictions may explore partnerships with universities, foundations, and other organizations that seek IIS data for research, evaluation, or grant-funded projects. In some cases, data-sharing agreements may include provisions for recovering costs associated with data extraction, analysis, reporting, or staff support needed to fulfill the request, helping offset IIS operational expenses.⁴

When states bill health plans for IIS data, they describe the payment request as a charge or contribution for cost recovery—essentially covering the IIS cost to complete the request for data. Payment amounts can be based on a cost per record or a sliding scale according to the number of records requested. Jurisdictions may choose to bill only commercial health plans.

Producing IIS data for a health plan or other entity seeking IIS data requires completing a request form and submission of a file that includes patient identifiers via secure transport in the IIS-required format. The file contains identifying information, such as medical record number, name (first, middle, last), address, date of birth, and gender, for matching in the IIS. The IIS typically runs the file against the IIS database and generates an output file including the immunizations documented for each member found in the IIS. The IIS makes the file available to the health plan and generates a bill, prompting the health plan to send payment to a designated office within the health department for deposit into an account designated for access by the IIS.

States that currently bill health plans for IIS data:

Are legally allowed to share data with health plans, or other entities requesting data, based on authorizing legislation and/or a Data Use Agreement;
Previously went through an internal process to justify the practice to leadership by demonstrating how much it costs the IIS to produce the data and the benefits to the health plans or other entity;
Have a system for tracking data requests through to completion;
Have a mechanism to receive reimbursement for completed requests so that funding is used specifically for IIS activities;
May model their billing processes after fee-for-service programs within the health department (e.g., licensing, vital records).

See a description and examples of the above in Success Stories from the Field: Diversifying IIS Funding Through Health Plan Billing.

Wondering if you’re ready to begin billing for IIS data?

Jurisdictions that successfully bill health plans for IIS data have established legal authority, operational processes, financial mechanisms, and partner relationships to support the effort. Use this checklist to evaluate your jurisdiction’s readiness and identify areas that may require additional planning. These same proactive steps are necessary when planning to bill for IIS data requests from other partners.

How could billing for IIS data be used to diversify IIS funding?

Billing for IIS data can be a substantial source of recurring funding for the IIS. Health plans may have a large number of members, often in the tens or hundreds of thousands. For example, the Louisiana Department of Health reported that midway through the current fiscal year, they had generated approximately $690,000 in revenue by billing commercial health plans for IIS data at a cost of $0.50 per record. A different state, with a smaller population, reported receiving about $300,000 per year by billing health plans according to a sliding scale based on the number of records requested.

Once charges are introduced for IIS data, health plans may question why reimbursement is needed and may lower the number of records requested. This may lead to uncertainty in projecting income generated from billing for IIS data. Jurisdictions need to provide an explanation of the value of the IIS to the health plans, costs borne by the IIS to produce the data, and the billing structure. Having a clear rationale for the need for reimbursement, while emphasizing the value of the data and service, will help alleviate concerns from health plans.

How can billing for IIS data promote IIS sustainability?

Billing for IIS data can promote IIS sustainability by generating a recurring revenue stream that helps offset the costs of system operations, infrastructure, and staffing. By charging partners, such as health plans, payers, or other organizations that benefit from IIS data, jurisdictions can better align funding with the value the system provides. This approach can reduce reliance on a single funding source, improve financial stability, and support ongoing system maintenance and modernization. In addition, revenue generated through billing can be reinvested in activities such as data quality improvement and system enhancements, or even used as a nonfederal match to Medicaid funding, further strengthening the long-term sustainability and performance of the IIS.

Additional resources related to billing for IIS data

4. Model data use agreements: a practical guide. https://admindatahandbook.mit.edu/book/v1.0-rc4/dua.html”>↩