NYSAMSSApril 25, 2014

CAQH Universal Provider DataSource

2

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).

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

• 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.

• Experience.– Lessons learned though development and implementation.

CAQH Success Factors

5

CAQH Members

6

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%

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

• Major component of file preparation is ensuring time-sensitive information meets freshness standards when presented to committee

35%25%40%

•Performed in accordance with accreditation organization guidelines

•Sometimes involves expensive licensing fees and strict sharing restrictions

•Third-parties often involved

10

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

Key Features

• 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.

Universal Provider Datasource

13

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 AcupuncturistADC Alcohol/Drug CounselorAUD AudiologistBT Biofeedback Technician

CRNACertified Registered Nurse Anesthetist

CSP Christian Science PractitionerCNS Clinical Nurse SpecialistCP Clinical Psychologist

CSW Clinical Social WorkerDT Dietician

LPN Licensed Practical Nurse

Provider Type Abbreviation

Provider Type Description

MFT Marriage/Family TherapistMT Massage TherapistND Naturopath

NEU NeuropsychologistMW Midwife

NMW Nurse MidwifeNP Nurse PractitionerLN NutritionistOT Occupational Therapist

OPT OpticianOD OptometristPHA PharmacistPT Physical TherapistPA Physician AssistantPC Professional CounselorRN Registered Nurse

RNFA Registered Nurse First AssistantRT Respiratory Therapist

SLP Speech Pathologist

47,000 enumerated DDS/12,000 enumerated DMD

14

Provider Adoption

UPD Provider Adoption by YearFormal Provider Support

Industry Recognition

15

Provider Engagement

Rate of Attestation Compliance Reattestation Frequency

Provider Attestations within Past Six Months

16

Data Quality

2009 Data Audit

• 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

2011 User Survey

• 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 email (68%) were among the less accurate elements

Sample of 3,360 UPD records audited by FTI Consulting, Inc. in 2009

Online survey of 1,448 UPD users conducted by OptumInsight in 2011

17

Data Accuracy

• 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

Data Accuracy Measured by Provider Survey

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

• 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

State Initiatives

23

• 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

New York State Utilization

24

Roadmap for UPD

Delegated Providers

ProviderDirectory

Health Plan Data Integration

Hospital

Medicaid

Opt-In

Credentialing Applications

EFT / ERA Enrollment

Primary Source Verification

Identity Management

Enable delegated providers to use UPD to send a limited data set to health plans.

Enable providers to leverage UPD to enroll in adjacent programs and services.

Enable provider enrollment in health plan EFT and ERA programs.

Streamline and automate the legacy paper credentialing application process.

Build out an industry-wide identity and access management service to increase transactional trust and security.

Perform as an industry-wide credentials verification organization.

Implement real-time data exchange with health plans to drive broader and deeper use of UPD.

Optimize UPD for hospital and medical staff services customers.

Deliver provider directory solution that leverages UPD data and/or footprint.

Optimize UPD to facilitate provider enrollment for state Medicaid agencies.

CMSAlign UPD with PECOS to extend applicability to Medicare-related challenges.

Sanctions Monitoring

Monitor state and national databases for provider disciplinary actions.

1

2

6

3

5

12

7

9

4 10

11

8

25

Role of CAQH in Provider Data Collection and Validation

Data Capture

Process / Workflow

Distribution

• Credentialing attributes• Individual providers only• Self Reported Information• Sanctions

• Basic data validation• Single state application

support

• File based sharing• Web based query• Customized extracts

• Expanded attributes• Hospitals and facilities• Provider data upload

• Validation against 3rd party industry data sources

• Multi-state application support

• Expired information prompts

• Real time services• NPI based search• Expand beyond traditional

users

1.0 2.0

26

www.CAQH.org