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 IssueNational Coalition on Health CareIn 2008, health care spending in US was $2.4 trillion, projected $3.1 trillion in , and $4.3 trillion by2
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 success4
6 COORDINATION OF BENEFITS Current InitiativesIndustry-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 SurveySimplifying 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 burdensCalls to verify insurance up to 25 times per dayUp to 50 incoming pharmacy calls per dayUp to three hours per day on each credentialing applicationTotal 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 yearsCompounding the redundancy, each health plan and other organization independently contacts primary sources such as state licensing agencies and hospitalsCompleting application for each payer can be a manual process, with followup via mail, fax, phone and sometimes in personRequires long lead time, and begins 4-6 months prior to due datePrimary Source Verification is performed in conjunction with accreditation standardsTime 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 applicationPrimary Source VerificationFile preparation, committee review, appeals, etc.Manual process, usually involving combination of mail, fax, phone, and sometimes even office visitsRequires long lead time, and is primary reason why process begins 4-6 months before actual decision is madePerformed in accordance with accreditation organization guidelinesSometimes involves expensive licensing fees and strict sharing restrictionsThird-parties often involvedMajor 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 FeaturesUniversal Provider DatasourceFree 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 TypesProvider Type AbbreviationProvider Type DescriptionMD*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)ACUAcupuncturistADCAlcohol/Drug CounselorAUDAudiologistBTBiofeedback TechnicianCRNACertified Registered Nurse AnesthetistCSPChristian Science PractitionerCNSClinical Nurse SpecialistCPClinical PsychologistCSWClinical Social WorkerDTDieticianLPNLicensed Practical NurseProvider Type AbbreviationProvider Type DescriptionMFTMarriage/Family TherapistMTMassage TherapistNDNaturopathNEUNeuropsychologistMWMidwifeNMWNurse MidwifeNPNurse PractitionerLNNutritionistOTOccupational TherapistOPTOpticianODOptometristPHAPharmacistPTPhysical TherapistPAPhysician AssistantPCProfessional CounselorRNRegistered NurseRNFARegistered Nurse First AssistantRTRespiratory TherapistSLPSpeech Pathologist47,000 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 EngagementRate of Attestation ComplianceReattestation FrequencyProvider Attestations within Past Six Months
16 Data QualityPractice address, specialty and NPI were among the analyzed data elements that scored greater than 95% functional accuracyOnly 4 out of 30 analyzed data elements scored less than 90% functional accuracy: provider languages, Medicaid provider (Y/N), practice languages and practice name2009Data AuditSample of 3,360 UPD records audited by FTI Consulting, Inc. in 2009Survey responders indicated that key elements such as practice name, address, phone, fax and provider specialty were accurate more than 80% of the timeAccuracy rates increase to 93%+ when non- responders are excludedSpecialty board status (67%), residency end year (67%) and (68%) were among the less accurate elements2011 User SurveyOnline 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 UPDResponders indicated that key elements such as practice address, phone, fax and specialty accuracy of data elements were accurate more than 80% of the timeProviders 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 TypeMedical School Grad YearResidency End YearSpecialty Board StatusAddress Type
18 UPD ParticipantsMore than 700 health plans, hospitals and other participating organizations
20 State ActivitiesDC, 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%), andSaves 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%), andThe 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 Initiatives12 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 ACAKentucky – UPD form named as state's KAPER formTennessee – customized electronic data format to be uploaded directly into state enrollment portalOther state usesVermont – mandated use of UPD for Hospitals and Payers, hospital association contracts with CAQHNew Jersey – named UPD as a primary source for required annual directory validationMassachusetts – voluntary shared services model uses UPD for front end data collectionArizona – state Medicaid MCOs using UPD for front end data collection
23 New York State Utilization Over 106K providers currently using UPD62K Physicians/Dentists/Chiropractors43,000 AlliedsSixty Two organizations currently using UPD includingEmpire Blue Cross Blue ShieldEmblemFidelis CareCDPHPMVPUnitedHealthcare of New YorkWellCare of New YorkNY Medicaid uses CAQH UPD to enroll and re-enroll participating practitioners
24 Credentialing Applications Roadmap for UPDCredentialing ApplicationsStreamline and automate the legacy paper credentialing application process.MedicaidOptimize UPD to facilitate provider enrollment for state Medicaid agencies.17Sanctions MonitoringMonitor state and national databases for provider disciplinary actions.Identity ManagementBuild out an industry-wide identity and access management service to increase transactional trust and security.28EFT / ERAEnrollmentEnable provider enrollment in health plan EFT and ERA programs.CMSAlign UPD with PECOS to extend applicability to Medicare-related challenges.39Primary SourceVerificationHospitalPerform as an industry-wide credentials verification organization.Optimize UPD for hospital and medical staff services customers.410Health PlanData IntegrationImplement real-time data exchange with health plans to drive broader and deeper use of UPD.ProviderDirectoryDeliver provider directory solution that leverages UPD data and/or footprint.511DelegatedProvidersEnable delegated providers to use UPD to send a limited data set to health plans.Opt-InEnable providers to leverage UPD to enroll in adjacent programs and services.612
25 Role of CAQH in Provider Data Collection and Validation 1.02.0Data CaptureCredentialing attributesIndividual providers onlySelf Reported InformationSanctionsExpanded attributesHospitals and facilitiesProvider data uploadProcess / WorkflowBasic data validationSingle state application supportValidation against 3rd party industry data sourcesMulti-state application supportExpired information promptsDistributionFile based sharingWeb based queryCustomized extractsReal time servicesNPI based searchExpand beyond traditional users