CAQH Universal Provider DataSource
NYSAMSS
April 25, 2014
Administrative Complexity in Healthcare
• According to the Center for Health Transformation, in 2009
total healthcare spending in the U.S. is estimated at $2.3
trillion per year.
• A Healthcare Administrative Simplification Coalition (HASC)
Report notes that approximately 25% of U.S. healthcare
spending is attributed to administrative functions.
• The U.S. Healthcare Efficiency Index estimated healthcare
business efficiency is only operating at 43% (current vs.
potential electronic transactions).
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CAQH – Catalyst for Industry Collaboration
•
CAQH, a nonprofit alliance of health plans and trade associations, is a catalyst for
industry collaboration on initiatives that simplify healthcare administration for
health plans and providers, resulting in a better care experience for patients and
caregivers.
•
CAQH initiatives are national in scope and produce measurable results.
– Help promote quality interactions between plans, providers and other stakeholders.
– Reduce costs and frustrations associated with healthcare administration.
– Facilitate administrative healthcare information exchange.
– Encourage administrative and clinical data integration.
•
3
CAQH Vision: A healthcare system in which administrative processes are
efficient, predictable, and easily understood by patients, caregivers and providers.
CAQH Success Factors
•
Focus on Critical Challenges.
– CAQH initiatives are targeting several priority issues for the industry.
– Identify areas of differentiation which have no competitive advantage.
•
Inclusive Approach.
–
•
Cross-industry and public-private collaboration.
Create Meaningful Impact.
– CAQH initiatives are concrete, national, well-vetted solutions that are working
in the marketplace today.
– Action can be taken immediately.
– Impact can be tracked across a wide group of entities.
•
Support from Providers and Other Stakeholders.
– CAQH has built the trust of the provider community around administrative
simplification.
– States, government groups, and others also engaged.
•
4
Experience.
– Lessons learned though development and implementation.
CAQH Members
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Current Initiatives
Industry-wide, multi-stakeholder collaboration to facilitate development
and adoption of national operating rules for administrative transactions.
Service that replaces multiple paper processes for collecting provider
data with a single, electronic, uniform data-collection system (e.g.,
credentialing).
Service that enables providers to enroll in electronic payments with
multiple payers and manage their electronic payment information in one
location, automatically sharing updates with selected payer partners.
Objective industry collaboration tracking progress and savings
associated with adopting electronic solutions for administrative
transactions across the industry.
COORDINATION OF BENEFITS
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Collaboration designing a registry of coverage status information that
will help health plans and providers correctly identify which claims
require coordination of benefits in order to be processed correctly the
first time.
MGMA Survey
•
Simplifying health care administration could reduce annual health care costs
by almost $300 billion over ten years*
•
MGMA Group Practice Research Network asked practices to identify
administrative burdens
– Calls to verify insurance up to 25 times per day
– Up to 50 incoming pharmacy calls per day
– Up to three hours per day on each credentialing application
– Total for a 10 practitioner practice: $250,000 annually
*From Health Affairs Web Exclusive, Feb 7, 2003
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MGMA Survey
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•
Medical groups may have 100 or more payer contracts
•
Every health plan, hospital, ambulatory surgery facility or other organizations
in which a physician participates verify that physician’s credentials every two
or three years
•
Compounding the redundancy, each health plan and other organization
independently contacts primary sources such as state licensing agencies and
hospitals
•
Completing application for each payer can be a manual process, with
followup via mail, fax, phone and sometimes in person
•
Requires long lead time, and begins 4-6 months prior to due date
•
Primary Source Verification is performed in conjunction with accreditation
standards
•
Time sensitive information may need to be re-verified prior to presentation to
committee
Credentialing: Data Collection Is the Most Inefficient Step
0%
20%
60%
80%
100%
25%
35%
Obtaining a complete
application
Primary Source
Verification
File preparation, committee
review, appeals, etc.
• Manual process, usually
involving combination of
mail, fax, phone, and
sometimes even office
visits
• Requires long lead time,
and is primary reason why
process begins 4-6 months
before actual decision is
made
• Performed in
accordance with
accreditation
organization
guidelines
• Sometimes
involves
expensive
licensing fees
and strict sharing
restrictions
• Third-parties
often involved
• Major component of file
preparation is ensuring
time-sensitive information
meets freshness
standards when presented
to committee
40%
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40%
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Universal Provider Datasource® (UPD)
•
Vision: Be the trusted national standard for the effective and transparent
collection and distribution of accurate, timely and relevant provider data for the
healthcare industry.
•
Mission: Replace multiple organization-specific paper processes with a single,
uniform data collection system.
•
Current Status.
– More than 1.2 million unique providers have registered and are using the system
(approximately 7,000 new providers register each month).
– Close to 700 participating health plans, networks, hospitals, state Medicaid agencies
and other organizations.
– Twelve states and the District of Columbia have adopted the CAQH Standard Provider
Credentialing Application.
– Strong industry support, including AHIP, AAFP, ACP, AHIMA, AMA, and MGMA.
– Approved by NCQA, URAC and the Joint Commission for provider self-reported data
collection for credentialing.
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Key Features
Universal Provider Datasource
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•
Free for providers; revenue based on subscription
fee from organizations accessing data.
•
Providers can complete data entry online or via
fax.
•
Supporting documents are imaged and attached
to electronic record.
•
Participating organizations can access data in
electronic format at any time, when authorized by
provider.
•
Providers automatically reminded to refresh data
periodically to avoid re-credentialing cycle
problems.
•
Updates can be made at any time and are
immediately available to authorized organizations.
•
Toll-free help desk to assist providers.
UPD Provider Types
Provider Type
Abbreviation
MD*
DDS*
DMD*
DPM*
DC*
DO*
ACU
ADC
AUD
BT
CRNA
CSP
CNS
CP
CSW
DT
LPN
Provider Type
Description
Medical Doctor (MD)
Doctor of Dental Surgery (DDS)
Doctor of Dental Medicine (DMD)
Doctor of Podiatric Medicine
(DPM)
Doctor of Chiropractic (DC)
Osteopathic Doctor (DO)
Acupuncturist
Alcohol/Drug Counselor
Audiologist
Biofeedback Technician
Certified Registered Nurse
Anesthetist
Christian Science Practitioner
Clinical Nurse Specialist
Clinical Psychologist
Clinical Social Worker
Dietician
Licensed Practical Nurse
Provider Type
Abbreviation
MFT
MT
ND
NEU
MW
NMW
NP
LN
OT
OPT
OD
PHA
PT
PA
PC
RN
RNFA
RT
SLP
Provider Type
Description
Marriage/Family Therapist
Massage Therapist
Naturopath
Neuropsychologist
Midwife
Nurse Midwife
Nurse Practitioner
Nutritionist
Occupational Therapist
Optician
Optometrist
Pharmacist
Physical Therapist
Physician Assistant
Professional Counselor
Registered Nurse
Registered Nurse First Assistant
Respiratory Therapist
Speech Pathologist
47,000 enumerated DDS/12,000 enumerated DMD
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Provider Adoption
UPD Provider Adoption by Year
Formal Provider Support
Industry Recognition
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Provider Engagement
Rate of Attestation Compliance
Provider
Attestations
within Past Six
Months
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Reattestation Frequency
Data Quality
2009
Data Audit
Sample of 3,360 UPD
records audited by FTI
Consulting, Inc. in 2009
2011
User Survey
Online survey of 1,448
UPD users conducted by
OptumInsight in 2011
• Practice address, specialty and NPI were among the
analyzed data elements that scored greater than 95%
functional accuracy
• Only 4 out of 30 analyzed data elements scored less
than 90% functional accuracy: provider languages,
Medicaid provider (Y/N), practice languages and
practice name
• Survey responders indicated that key elements such
as practice name, address, phone, fax and provider
specialty were accurate more than 80% of the time
• Accuracy rates increase to 93%+ when nonresponders are excluded
• Specialty board status (67%), residency end year
(67%) and email (68%) were among the less accurate
elements
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Data Accuracy
Data Accuracy Measured by Provider Survey
• CAQH surveyed 1,448 providers in 2011
about the accuracy of their data in UPD
• Responders indicated that key elements
such as practice address, phone, fax and
specialty accuracy of data elements were
accurate more than 80% of the time
• Providers were less likely to respond to
questions about data accuracy for select
data elements (no response ranged from 23-34% for
these elements; <10% on others)
• Hospital Affiliation Type
• Medical School Grad Year
• Residency End Year
• Specialty Board Status
• Address Type
• Email
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UPD Participants
More than 700 health plans, hospitals and other participating organizations
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Stakeholder Association Support
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State Activities
• DC, IN, KY, KS,
MD, MO, NM, OH,
RI, and VT have
adopted CAQH's
form as the state
form.
• TN, LA and NJ
have adopted
CAQH's form as a
preferred option
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Provider Satisfaction Survey
•
•
Early in 2013 year CAQH retained KRC Research to conduct a UPD provider
satisfaction survey. Of the 18,000 providers surveyed, more than 1,700 (9%)
responded.
Key findings include:
–
–
–
–
Ninety-one percent report being satisfied with UPD.
Nearly nine-in-ten say they would recommend UPD to their peers.
Ninety-three percent say UPD is an easy-to-use resource.
They use UPD because it:
•
•
•
–
The most useful features of UPD noted include:
•
•
•
–
–
–
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Reduces paperwork (82%),
Saves them time (71%), and
Saves them money (39%).
There is no charge to use the system (77%),
The ability to enter information in one place (69%), and
The ability to enter information online (68%).
Two-thirds declare that UPD is an easy way to distribute data to health plans and more than
half say a useful feature is the ability to see and control which organizations receive their data.
Eighty-three percent update their information as a result of the UPD system’s reminder
messages.
More than one-third express interest in more organizations, including government entities,
participating in UPD.
State Initiatives
•
12 States and District of Columbia have designated the CAQH form to be
the mandated or suggested form for credentialing data collection.
•
Medicaid Agencies using UPD for Re-enrollment as required by ACA
– Kentucky – UPD form named as state's KAPER form
– Tennessee – customized electronic data format to be uploaded directly into state
enrollment portal
•
Other state uses
– Vermont – mandated use of UPD for Hospitals and Payers, hospital association
contracts with CAQH
– New Jersey – named UPD as a primary source for required annual directory
validation
– Massachusetts – voluntary shared services model uses UPD for front end data
collection
– Arizona – state Medicaid MCOs using UPD for front end data collection
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New York State Utilization
•
Over 106K providers currently using UPD
–
62K Physicians/Dentists/Chiropractors
– 43,000 Allieds
•
Sixty Two organizations currently using UPD including
– Empire Blue Cross Blue Shield
– Emblem
– Fidelis Care
– CDPHP
– MVP
– UnitedHealthcare of New York
– WellCare of New York
•
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NY Medicaid uses CAQH UPD to enroll and re-enroll participating
practitioners
Roadmap for UPD
1
Credentialing
Applications
Streamline and automate the legacy
paper credentialing application process.
2
Sanctions
Monitoring
Monitor state and national databases for
provider disciplinary actions.
3
EFT / ERA
Enrollment
Enable provider enrollment in health
plan EFT and ERA programs.
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CMS
4
Primary Source
Verification
Perform as an industry-wide credentials
verification organization.
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Hospital
Optimize UPD for hospital and medical
staff services customers.
5
Health Plan
Data Integration
Implement real-time data exchange with
health plans to drive broader and deeper
use of UPD.
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Provider
Directory
Deliver provider directory solution that
leverages UPD data and/or footprint.
6
Delegated
Providers
Enable delegated providers to use UPD
to send a limited data set to health
plans.
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Opt-In
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7
Medicaid
Optimize UPD to facilitate provider
enrollment for state Medicaid agencies.
8
Identity
Management
Build out an industry-wide identity and
access management service to increase
transactional trust and security.
Align UPD with PECOS to extend
applicability to Medicare-related
challenges.
Enable providers to leverage UPD to
enroll in adjacent programs and services.
Role of CAQH in Provider Data Collection and Validation
1.0
Data
Capture
Process /
Workflow
Distribution
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2.0
•
•
•
•
Credentialing attributes
Individual providers only
Self Reported Information
Sanctions
• Expanded attributes
• Hospitals and facilities
• Provider data upload
• Basic data validation
• Single state application
support
• Validation against 3rd party
industry data sources
• Multi-state application
support
• Expired information prompts
• File based sharing
• Web based query
• Customized extracts
• Real time services
• NPI based search
• Expand beyond traditional
users
www.CAQH.org
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