5 Things You Need to Know Now About Provider Data, CAQH, and CAQH Enrollment and Integration

According to The Hill, "The country's health care tab came in at a whopping $3.3trillion in 2016 — 17.9 percent of GDP. We spend $10,348 per person, per year,nearly twice the average of other modern economies. Yet despite the fortunespent, we still don't have better health outcomes."

While the politicians debate the expenses and who should pay the tab, thehealthcare industry is taking action with the goal of reducing healthcare costs.One such effort is being driven by the Council for Affordable Quality Healthcare(CAQH), a non-profit alliance of health plans and related associations thathas banded together around the shared goal of streamlining the business ofhealthcare.

1. According to the CAQH, "Thve ongoing need to reduce healthcare costs—especially administrative expenses—while concurrently increasing informationaccuracy is at the heart of CAQH activities. In concert with a wide range ofhealthcare stakeholders, CAQH develops and implements shared, industry-wideinitiatives to eliminate long-term business inefficiencies, producing meaningful,concrete benefits for healthcare providers, health plans and patients." CAQHprojects that their initiatives will fundamentally change the direction of healthcareand redefine how the industry does business.

2. CAQH believes that provider data drives the most fundamental processes in thehealthcare system, and understands that although the industry spends more than$2 billion annually* to maintain provider data, inaccuracies and inefficiencies arestill pervasive. In the Industry Roadmap for Provider Data, CAQH identifies severalkey issues that contribute to the persistence of provider data inaccuracies. Theseinclude:

• Limited authoritative sources:
  • - For many data elements, no sufficiently accurate source exists. In some cases, multiple sources exist for a single data element - leading to conflict - and in others, sources advertised as authoritative have accuracy issues. Where there are no authoritative sources, users may be forced to interpret data in an inconsistent fashion.
• Variation of requirements and standards:
  • - Variations in the format, exchange, content and understanding of the uses of provider data lead to unreliable data.
• Frequent data changes:
  • - Providers are being subject to redundant and conflicting requests for data. These requests may be in different formats, on different schedules, and via different methods. The demand for real-time provider data has increased, but new procedures, tools and business processes to support this faster pace have not materialized.
• Lack of consistent provider engagement:
  • - Providers themselves have not been actively involved in provider data discussions and are thus not adequately engaged in efforts to ensure correct data is collected. As the burdens to produce data increase, they are turning to external resources for support, further complicating the compilation of accurate data.

...although the industry spends morethan $2 billion annually* to maintainprovider data, inaccuracies andinefficiencies are still pervasive.

3. Based on its analysis of provider data issues plaguing the industry, CAQHconvened the Provider Data Action Alliance (Alliance), a cross-industry group ofleaders representing health plans, hospitals and health systems, government,regulators and health information exchanges, to develop the Industry Roadmapfor Provider Data. The Roadmap presents a "collaborative approach for finallyaddressing the provider data challenge through industry alignment on a core setof principles, a vision for a healthy provider data ecosystem and recommendationsfor key steps forward."

The core principles identified to guide the development of an industry solutionstate:

• The time and attention of providers must not be wasted.
• The solution must be flexible and adaptable.
• The solution must be pragmatic and focused on near-term business realities.
• The solution should be industry-governed and standards-based.

The vision for a healthy provider data ecosystem centers on four criticalcomponents:

• Governance
• Defined set of "fundamental" provider data elements
• A centralized authoritative solution
• An incremental approach

4. CAQH's vision for a centralized authoritative solution is coming to fruition withthe development of solutions that authenticate the accuracy and completenessof provider information to support credentialing decisions. One such solutionis CAQH ProView®. A solution described by CAQH as: "A web-based solutionused by more than 1.4 million providers to self-report and share a wide range ofdemographic and professional information with more than 900 participating healthplans, hospitals, health systems and provider groups. This data is then used forcredentialing, network directories, claims administration and more."

5. At this point in time, participation in CAQH initiatives, including CAQH ProView isvoluntary. But some health plans and other healthcare organizations are beginningto request that their network providers use CAQH ProView for new recredentialingevents. We expect this trend to grow, and when it does, your medical grouppractice needs to be ready.

Preparing for CAQH Enrollment

Because provider data is involved in so many processes, the core set of"fundamental" provider data elements that you need to collect for CAQHEnrollment is vast. A sample of the information needed to begin CAQH Enrollmentis listed in the ProView Provider Quick Reference Guide and includes:

• CAQH-supplied Provider ID Number
• Previously completed credentialing application if available (for reference)
• List of all previous and current practice locations
• Identification numbers, such as Social Security Number, National Provider Identifier (NPI), DEA, UPIN, and License Number
• Electronic (scanned) copies of the provider's:
  • Curriculum Vitae
  • Medical License
  • DEA Certificate
  • CDS Certificate
  • IRS Form W-9
  • Malpractice Insurance Face Sheet
  • Summary of any pending or settled malpractice cases
  • Any other required supporting documents

Many of the medical group practices we work with believe that all this requireddata is somewhere, but that somewhere is usually not ‘right at their fingertips'.Just over half of the provider enrollment professionals we surveyed use sometype of software solution to help automate their enrollment processes. Therest continue to manage enrollment by keeping data in paper files, Excelspreadsheets, and Access or homegrown databases. If you don't have a singlesource of truth to collate and track your provider data, you'll struggle with CAQHintegration.

Putting technology to work for you is the key to successful CAQH integration.Solutions like Enroll can greatly simplify the enrollmentprocess. Enroll offers an easy approach to collecting accurate information onbehalf of your providers and sharing it with CAQH and every health plan thatneeds access to it. With Enroll you can dramatically accelerate the providerenrollment process, shrink enrollment timelines (by 65 percent or more), slashcosts (by 50 percent or more), and reduce aging receivables (by as much as 97percent)

Technology is the Key to CAQH Integration

For successful CAQH integration, seek a solution that checks the following boxes:

Features a comprehensive database of U.S. physicians, nursepractitioners, physician assistants, allied health professionals, andregistered nurses that includes data elements like demographics,addresses, specialties, licenses, affiliations, education, andexpertise details and is constantly updated.

Enables intuitive provider enrollment with functionality that allowsproviders to auto populate required forms with real-time validateddata from sources like AMA and CAQH.

Features a large content database of thousands of pieces ofinstantly deployable content to help you manage all of yourprocesses including; workflows for initial and recredentialing,expirables management, surveys, API, HL7 imports/exports,dashboards, and online applications.

Has the most up-to-date, standardized industry data tables thatput all the data you need within easy reach including data from:payers, hospitals, malpractice, insurance, taxonomy, Universities,States, DEA schedules, zip codes, FOL, diagnosis, and ICD10codes.

Offers a one-stop shop for providers and reviewers to share data.

If you're struggling with CAQH integration, HealthStream can help you get yourown house in order. Ultimately, a consistent process for collecting provider datawill improve your data quality, fill in missing gaps, and benefit your organizationand the healthcare industry as a whole. Request a free CAQH check-up with a HealthStream representative today.