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CAQH Universal Provider DataSource

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Presentation on theme: "CAQH Universal Provider DataSource"— Presentation transcript:

1 CAQH Universal Provider DataSource
NYSAMSS April 25, 2014

2 Administrative Complexity in Healthcare
According to the Center for Health Transformation, in 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). Profile of the Issue National Coalition on Health Care In 2008, health care spending in US was $2.4 trillion, projected $3.1 trillion in , and $4.3 trillion by 2

3 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. CAQH Vision: A healthcare system in which administrative processes are efficient, predictable, and easily understood by patients, caregivers and providers.

4 CAQH Success Factors Focus on Critical Challenges. Inclusive Approach.
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. Experience. Lessons learned though development and implementation. Critical co-factors for success 4

5 CAQH Members

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. 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. COORDINATION OF BENEFITS

7 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

8 MGMA Survey 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

9 Credentialing: Data Collection Is the Most Inefficient Step
0% 20% 40% 60% 80% 100% 40% 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


11 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.

12 Universal Provider Datasource
Key Features Universal Provider Datasource 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.

13 47,000 enumerated DDS/12,000 enumerated DMD
UPD Provider Types Provider Type Abbreviation Provider Type Description MD* Medical Doctor (MD) DDS* Doctor of Dental Surgery (DDS) DMD* Doctor of Dental Medicine (DMD) DPM* Doctor of Podiatric Medicine (DPM) DC* Doctor of Chiropractic (DC) DO* Osteopathic Doctor (DO) ACU Acupuncturist ADC Alcohol/Drug Counselor AUD Audiologist BT Biofeedback Technician CRNA Certified Registered Nurse Anesthetist CSP Christian Science Practitioner CNS Clinical Nurse Specialist CP Clinical Psychologist CSW Clinical Social Worker DT Dietician LPN Licensed Practical Nurse Provider Type Abbreviation Provider Type Description MFT Marriage/Family Therapist MT Massage Therapist ND Naturopath NEU Neuropsychologist MW Midwife NMW Nurse Midwife NP Nurse Practitioner LN Nutritionist OT Occupational Therapist OPT Optician OD Optometrist PHA Pharmacist PT Physical Therapist PA Physician Assistant PC Professional Counselor RN Registered Nurse RNFA Registered Nurse First Assistant RT Respiratory Therapist SLP Speech Pathologist 47,000 enumerated DDS/12,000 enumerated DMD

14 UPD Provider Adoption by Year Formal Provider Support
Industry Recognition

15 Rate of Attestation Compliance Reattestation Frequency
Provider Engagement Rate of Attestation Compliance Reattestation Frequency Provider Attestations within Past Six Months

16 Data Quality 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 2009 Data Audit Sample of 3,360 UPD records audited by FTI Consulting, Inc. in 2009 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 non- responders are excluded Specialty board status (67%), residency end year (67%) and (68%) were among the less accurate elements 2011 User Survey Online survey of 1,448 UPD users conducted by OptumInsight in 2011

17 Data Accuracy Measured by Provider Survey
CAQH surveyed 1,448 providers in 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

18 UPD Participants More than 700 health plans, hospitals and other participating organizations

19 Stakeholder Association Support

20 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

21 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: Reduces paperwork (82%), Saves them time (71%), and Saves them money (39%). The most useful features of UPD noted include: 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.

22 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

23 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 NY Medicaid uses CAQH UPD to enroll and re-enroll participating practitioners

24 Credentialing Applications
Roadmap for UPD Credentialing Applications Streamline and automate the legacy paper credentialing application process. Medicaid Optimize UPD to facilitate provider enrollment for state Medicaid agencies. 1 7 Sanctions Monitoring Monitor state and national databases for provider disciplinary actions. Identity Management Build out an industry-wide identity and access management service to increase transactional trust and security. 2 8 EFT / ERA Enrollment Enable provider enrollment in health plan EFT and ERA programs. CMS Align UPD with PECOS to extend applicability to Medicare-related challenges. 3 9 Primary Source Verification Hospital Perform as an industry-wide credentials verification organization. Optimize UPD for hospital and medical staff services customers. 4 10 Health Plan Data Integration Implement real-time data exchange with health plans to drive broader and deeper use of UPD. Provider Directory Deliver provider directory solution that leverages UPD data and/or footprint. 5 11 Delegated Providers Enable delegated providers to use UPD to send a limited data set to health plans. Opt-In Enable providers to leverage UPD to enroll in adjacent programs and services. 6 12

25 Role of CAQH in Provider Data Collection and Validation
1.0 2.0 Data Capture Credentialing attributes Individual providers only Self Reported Information Sanctions Expanded attributes Hospitals and facilities Provider data upload Process / Workflow Basic data validation Single state application support Validation against 3rd party industry data sources Multi-state application support Expired information prompts Distribution File based sharing Web based query Customized extracts Real time services NPI based search Expand beyond traditional users


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