Health Plan Industry Provider Domain Overview

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Health Plan And Provider Data

Health plans have functions for collecting provider data either via internal processes or through industry collaborations such as CAQH

Health plans use provider data for a wide variety of purposes such as credentialing, claims processing, quality assurance, emergency response, member services (directories and referrals), and more.

Strategies to streamline data collection electronically is a win-win proposition with reduced duplicative paperwork and millions of dollars of annual administrative costs .

Health plans use services via industry collaborations such as CAQH; the Council on Affordable, Quality Health Care. CAQH is supported by America’s Health Insurance Plans, the American Academy of Family Physicians, the American College of Physicians, the American Health Information Management Association, the American Medical Association, the Healthcare Administrative Simplification Coalition, the Medical Group Management Association and other provider organizations.

Other entities also are sources of provider data such as informatics companies (IMS Health) and other commercial vendors (Enclarity).

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CAQH Industry Collaboration

CAQH-an industry collaboration- collects data for more than 800,000 physicians and other health professionals, as well as over 550 participating health plans, hospitals and healthcare organizations.

• A single, standard online form is the centerpiece of the service. Providers in all 50 states and the District of Columbia are able to enter their information free of charge through an interview-style process.

• CAQH meets the data-collection requirements of URAC, the National Committee for Quality Assurance (NCQA) and the Joint Commission standards. Indiana, Kansas, Kentucky, Louisiana, Maryland, Missouri, New Jersey, New Mexico, Ohio, Rhode Island, Tennessee, Vermont and the District of Columbia have adopted the CAQH standard form as their mandated or designated provider credentialing application.

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Health Plan Provider Data Requirements

Typical data collected by health plans during provider database functions include:

• A List of all previous and current practice locations

• Identification numbers, such as UPIN, Medicare, Medicaid, and National Provider Identifier (NPI)

• Malpractice insurance face sheet

• Summary of any pending or settled malpractice cases

• Curriculum Vitae

• Medical license number

• DEA certificate and number

• CDS certificate

• IRS Form W-9• Health plans have not traditionally collected electronic

addresses such as email addresses or URLs of websites

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Health Plan Provider Data Overview

Health plans have a variety of systems that support provider management systems . There is significant variation in the level of modernization, the quality of data, and the use of these systems

Health plan provider systems vary significantly in basic definitions, functionality, and configuration

Health plans have variable levels of data quality housed within these systems. Improving data quality and operational processes is important to health plans as the cost of bad data is high and creates customer abrasion points

Health plans face substantial costs for remediating legacy systems for ICD 10 support

Fixing Provider Databases have the potential to lower operating costs, may lower cost of care, and may enable health plans to better deploy payment innovation, improved analytics, and new products and service offerings

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Sources of Value from Accurate Provider Directories

Activity Enhancement

Definition Summary

Auto Adjudication

Claims which do not require manual

interventions

•Poor provider data can cause claims to enter a pended status which require re-work, returned mail, and service

Provider Contracting

Contracts must be represented in

claim processing systems to enable

payment

•Improved provider data allows more accurate and timely payment and payments more consistent with contract requirements

•Accurate provider data is an enabler of Medicare Ambulatory Payment Classification system

Non-Par. Payments

Non Participating physicians are paid

at a different; often high rates

•Accurate provider data allows better determination of what contract to apply to a particular claim

•Accurate claim payment can reduce total claim costs

Staff & Vendor

Activities

Health plans spend significant amounts of

personnel and vendor resources

keeping files accurate

•Opportunities to reduce manual processes•Opportunities to pool costs of accurate provider data acquisition

•Previous industry activities via CAQH•Reduced system maintenance costs and SSCRs•Begins second half of 2010 with full run-rate by 2014

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Current Health Plan Industry Activities

• America’s Health Insurance Plan’s (AHIP) has been working with it’s members exploring a related “registry” concept for payers to advance the use of secure data exchange technology solutions focused on driving out unnecessary administrative costs and expanding the use of business to business (B2B), direct communication links.

• To expand such capabilities three things are needed: • Standard Communications Protocols: Improve existing framework for real-time

transactions and peer to peer exchange using generally accepted communications protocols such as:

Secure Multipurpose Internet Mail Extensions (MIME)/ Simple Mail Transfer Protocol (SMTP) /X.509 Digital Certificates Simple Object Access Protocol (SOAP), Web Services Description Language (WSDL)/X.509 Digital Certificates3 Secure File Transfer Protocol (FTP)

• Digital Certificates: Adopt commercial approaches to certificates and authentication to enable machine to machine secure transaction exchange

• Industry Directory (routing registry): “white pages” of internet routing addresses and digital certificate locations for healthcare

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Current Health Plan Industry Activities

AHIP Registry Goals:• The development of service architecture for access to payer routing information

through a multiparty registry;• The portal would also serve as the main “white pages” for providers /others to

seek information about all payers;• Manage Unique Payer Identifiers – e.g. HPIDs  • A standards based registry solution that adopts current best practices (SOAP,

X.509, SMTP, SFTP, NIST Requirements, HIPAA, CORE Phase I and II, etc.) while allowing for future industry innovation;

• Application Program Interface (API) publication to web portal that would allow for system queries/updates from an end node to the registry;

• Administrative portal that would allow payers to control the configuration of the routing;

• Automated service to check certificate status for enrolled payers;• Secured registry information residing in a secured data center.

This project is in the concept stage but seems to align with the “provider directory” projects under consideration.