provider data: a fundamental need for collaboration · provider data: a fundamental need for...

© 2016 CAQH, All Rights Reserved

Provider Data:

A Fundamental

Need for

Collaboration

February 4th, 2016


Accurate and timely provider data continues to be a foundational necessity for

both care delivery and financing of healthcare. With the US healthcare system

moving to value-based payment models, the needs surrounding provider-specific

information will only continue to expand.

Today, billions of dollars are being spent each year to collect and maintain this

information, yet the data quality and related processes have significant room for

improvement.

The reality of these overarching challenges are being experienced in all sectors

including provider organizations, Federal and state government entities and

health plans.

As the industry undergoes transformation, the time is right to seek public-private

collaboration.

2

Executive Summary


Panelists

Atul Pathiyal, Managing Director – Solutions, CAQH

Tim Kaja, SVP, United Healthcare

Mariann Yeager, CEO, The Sequoia Project

3

Topics each organization will cover:

How each organization has been using provider data.

Challenges they have been facing and areas where they have been able to

successfully resolve some of the challenges.

Opportunities and how they are working to solve the challenges by collaborating

within or outside their organization.


Panelist

Atul Pathiyal, Managing Director, CAQH

4


Provider Data Defined

Industry

Health System and

Health Plan Relationship

Organization

Personal

Information

First Name

Last Name

Date of Birth

Gender

Email

Languages

Phone Number

SSN

DEA #

CDS #

NPI #

Medicare #

Medicaid #

Highest Level

of Education

Degree

Internship/

Residency

Certifications

Specialty

Board

Work History

Reference

Disclosure

Malpractice

Ethnicity

Citizenship

PLI Carrier Name

Coverage Amount

Coverage Dates

PLI Carrier Name

Coverage Amount

Coverage Dates

Practice Name

Location/ Phone #

Hours

Accessibility

Languages/ Limitation

Tax ID

NPI

Coverage

Affiliations

Privilege

Status

Contact Name

Contact Type

Contact

Address

Contact Email

Accepting New Patients

Network Participation

Ratings

Contract Name

Contract Dates

Tier

Credentialing Status

Credentialing Dates

Fee Schedule

Quality Measures

Clinical Measures

Electronic

Credentials

Websites and Directories

Quality, Contracts and Payments

Privileging and Credentialing

Public Data Set

CAQH ID Sanctions

Malpractice

Medicare Opt-out

Medicaid Opt-out

ECP

5


Uses of Provider Data

6

Members / Patients

Provider

Databases

Provider

Provider Databases

Government

(Medicare / Medicaid)

Health Information

ExchangesFederal / State Marketplace

Members/ Patients

• Increase in time spent on admin

processes than patient care.

• Patient abrasion when cannot see

them due to out-of-network coverage.

• Bad collections due to out-of-network

costs regulation. (e.g. NY surprise bill)

• Submit provider-

network information

to exchanges on

frequent basis.

• Multiple formats

and channels for

data files

submission.

• Lack of provider

information at the

time of enrollment.

• Lack of

provider

information at

the time of

enrollment.

• Information collected

from providers to

support enrollment,

cost & quality

reporting, fraud &

abuse detection.

• Maintain multiple

systems to manage

provider information.

• Need to maintain same information at

multiple places for different business

purposes such as enrollment, ownership

declaration, quality submission.

• Incorrect or missing


• Unable to share /

receive timely patient

health information.

• Submit patient

and provider

information.

• Maintain same information

with multiple payers.

• Delayed enrollment,

onboarding,

reimbursement.

• Submit encounter and

provider information for

auditing.

• Submit network and


• Multiple systems

to maintain

provider

information.

• Redundant

process and high

manual

intervention to

maintain data.

• Source data

through multiple

channels

including

providers.

• Service denial due to out-

of-network info identified

at point of service.

• Incur unexpected out-of-

network costs due to lack

of necessary information.

Health Plan


Provider Data Challenges

7

Providers

Health plans

Members

Government/

Industry

• Expensive, manual, redundant and inefficient processes to manage data across different.

functional areas that require provider information.

• Lack of agility to respond to market forces with new business capabilities.

• Increase in penalties and brand erosion due to lack of compliance with regulatory requirements.

• Increase in provider and member abrasion.

• Calls and inquiries from multiple stakeholders to obtain and reconfirm provider information.

• Need to store and maintain information in multiple locations.

• Decrease in focus and time on patient care.

• Patient abrasion due to incorrect directory/network information.

• Impacts revenue cycle management due to decreased or delayed claims reimbursement.

• Lack of provider information at the time of enrollment impacts ability to make informed

healthcare decisions.

• Incorrect or missing provider information on the directory lead to service denial or delayed

services.

• Increased of out-of-pocket costs due to lack of transparency and visibility into payer network-


• Expensive, manual, redundant and inefficient processes to manage data across different.

functional areas that require provider information.

• Lack of agility to respond to market forces with new business capabilities.

• Increase in provider and member abrasion.

• Lack of transparency in overall care delivery processes and medical economics.


Emerging Market Forces

8

• Expansion of government-run programs increases scrutiny on network data.

• New regulations will result in increased burden on providers as health plans are required to validate provider information more frequently.

• Simplify provider data management to minimize administrative cost within provider organizations and health plans, reduce delays in related business processes, increase compliance and enhance the overall member and provider experience.

– Standardize protocols and establish data governance.

– Eliminate error-ridden paperwork through automation.

– Reduce technology spending through industry-wide ‘utilities’.

• Re-position provider data challenges as a shared responsibility among industry stakeholders.

• Incorrect provider data can cause administrative and operational inefficiencies across organizations that are dependent on the data.

• Industry participants are shifting from volume to value-based care models.

• Interoperability across provider organizations (e.g., HIEs) requires exchange of accurate provider data.

• New payment models require tighter cross-functional integration between systems and more accurate data for patient engagement, care management and analytics.

• Evolution of digital solutions in the industry require accurate provider data.

• There is an increased demand for network data transparency to improve consumer engagement.

.

Expansion of

Government

Programs

Cost Pressure

New Payment

and Delivery

Models

Transparency

Emerging Market Forces

Imperatives for Provider

Data Management


Value-Based Care

9

Provider Data

Functional AreasPay For Performance Bundled Payment ACO

Compliance &

Regulatory

Reporting

• Regulatory scrutiny on provider data will increase as new government-sponsored products emerge

and increase in popularity.

• Severe penalties for gaps in network.

Network

Management

• Accurate demographic information is needed within provider organizations and health plans for faster

setup of MCO and value-based networks.

• Increased contracting timeframes due to relationship complexity within and across provider

organizations.

Care Delivery• Member attribution within care management programs will require accurate provider information within

provider organizations and health plans.

Claims &

Payments

• Current claims-based approaches to acquiring provider data will no longer be effective as care is

measured using episodes or other non-claims based methodologies.

Member Service

• Demand for greater transparency, knowledge and choice from patients through digital tools.

• Regulatory requirements will extend to new reimbursement models.

• Greater need for accurate information for the directory so that members can contact and seek care

from preferred in-network providers.

Health Plan Risk Provider Risk

New reimbursement models and increasing network complexity

and will exacerbate the provider data management problem


Industry-wide utility focused on collecting provider-attested information

electronically in lieu of various credentialing and other forms used by health plans,

hospitals and other organizations.

- More than 1.3 million unique providers users of all types, including non-physicians

(~7,000 new providers register each month).

> Providers incur no fee for using ProView. All costs are covered by participating organizations.

- Over 800 participating health plans, hospitals, provider groups, state Medicaid agencies

and other organizations.

- Includes over 300 key data elements about each provider.

- Twelve states and the District of Columbia have adopted the CAQH Standard Provider

Credentialing Application.

- Strong industry support, including MGMA, AAFP, ACP, AMA, and AHIP.

- Approved by NCQA, URAC and the Joint Commission for provider self-reported data

collection for credentialing.

CAQH ProView was launched as a redesigned platform in March 2015 to

introduce new capabilities that address a wider array of provider data challenges,

including provider directory data confirmation.

CAQH ProView

10


How It Works

11

Submit / Attest to

Comprehensive

Data Set

CAQH ProView Solution

Healthcare

Providers

Health Plans

Govt. & State

Agencies

Hospitals and

Entities

• Self-Attested Data

Collection

• Supporting Documents

• Credentialing

Application Support

• Third Party Data

Validation

• Data Augmentation

Submit Roster

Extract Data FileData Upload

Real Time Web

ServicesAlerts,

Prompts and

Notifications

CAQH is working on features to address the needs of medical groups and delegated entities,

including the ability to bulk upload and manage a full panel of physicians.


Panelist

Tim Kaja, SVP, United Healthcare

12


Panelist

Mariann Yeager, CEO, The Sequoia Project

13

The Sequoia Project

Trusted Convener of Industry & Government to Address Health IT Interoperability

14

Provider Directory Functions for Clinical HIE

• A directory supports querying and management of healthcare provider information, including electronic endpoint to facilitate trusted communications among networks and providers

• Allows participants in a network to find and connect to other participants / providers, without the need to contact each other manually

• Retrieve participant and provider information in order to obtain connection technical information

• Query the directory to acquire information

– Of a subset of participants or providers in a particular geography or other target

– To acquire information for a particular participant / provider based on particular identifiers

15

Broad Provider Directory Use Cases

• White pages lookup (retrieve by name of the org or person)• Yellow pages lookup (query by a large number of criteria such as language spoken,

geography, certifications, etc.)• Automated consent (e.g. to indicate who the patient authorizes to receive a copy of the

information)• Disaster response (identify a specialist)• Referrals (e.g. identify a treating provider to route clinical document)• Electronic communication end point (e.g. look up by name, use case supported –

treatment, public health, types of content supported, version of specs supported, etc.)• Provider – network affiliations• Queries based upon a provider’s relationship to an organization to identify

– People associated with an organization (e.g. all providers in a hospital ED)– Organizations associated with a person (e.g. where providers practice) – Organizations associated with an organization (e.g. parent organization with

multiple locations) • Direct Project email and x.509 cert lookup

16

Challenges

• Data quality– Administration, maintenance of

data– Detecting, managing conflicting

data – Reconciling duplicate data from

multiple sources• No clear, unified national strategy for

provider directories– Industry focused on particular

technical approaches instead of defining common use cases

– Unclear direction on which standards to employ

– Differing views on federation vs centralized approaches

– Immature specifications

• Federal leadership in a national strategy for provider directors

• Collaborate with other industry efforts to solidify a common direction

• Active engagement in standards development efforts (e.g. IHE, HL7 –Argonaut)

• Leverage lessons learned from existing efforts (e.g. admin, clinical HIE, etc.)

17

Opportunities

For more information: www.sequoiaproject.org

18

http://www.sequoiaprojct.org/


Q&A for the Panel

What should the industry do to better accommodate growing complexity of

provider organizational, relationship and contracting structures?

In two years, where do we envision the national strategy for provider data

will or can be?

Which stakeholders should be at the table when developing this national

strategy?

19

To get involved in this conversation, contact

Mano Kalathil: [email protected]