what’s new with caqh proview? - namss.org proview resources for credentialing specialists and...

© 2017 CAQH, All Rights Reserved.

What’s New with CAQH ProView?

May 2018

Antoinette CumminsSenior Manager Provider Engagement


About Us.

CAQH ProView resources for credentialing specialists and practice managers.

Improvements made to CAQH ProView in the past year.

Industry forces are driving stakeholders to solve for inaccurate provider directories.

Untapped providers: delegated groups

Increase in dental sector for credentialing and primary source verification.

What you will learn today

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CAQH, a non-profit alliance, is the leader in creating shared initiatives to streamline the business of healthcare.

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Through collaboration and innovation, CAQH accelerates the transformation of business processes, delivering value to providers, patients, dental and health plans.


CAQH has a proven history of designing and executing industry-wide initiatives that solve complex, foundational, and systemic problems through collaboration

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.

UPD(2002)

SanctionsTrack(2004)

EnrollHub(2013)

CAQH – as a CVO

(2017)Groups

(2018 / 2019)Directory

(2016)

CAQH ProView(2015)


900Participating organizations

The CAQH ProView community of providers, payers and other healthcare organizations continues to grow.

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1.5 MUnique providers

1 MAttestations every 120 days

12States embraced


In 2017, CAQH made investments in Provider Engagement to more strategically market and educate users on the additional benefits to CAQH ProView.

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Increase provider user

adoption of all CAQH

Solutions.

Build relationships with

providers and credentialing

specialists.

Research and catalog

important feedback from

CAQH ProView® to support

current, and future,

enhancements.

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About Us.




The Delegated Group Module in CAQH ProView.

The American Dental Association (ADA) & CAQH strategic alliance.


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Looking for a refresher, or getting started, with CAQH ProView? www.caqh.org/proviewtrainings

Activity DetailsEmail Notification Emails to providers and practice managers

explaining the changes.

Broadcast Message in Provider and PM Portals

New feature that displays a pop-up at login with information about upcoming changes.

Webinar Live webinars for providers and practice managers.

Recorded Demo Webinar will be recorded for reference in emails and broadcast message.

User Reference Materials (User Guide, FAQs, Quick Reference Guide)

Guidance for providers that can be used in response to emails or phone inquiries.

The CAQH ProView Help Desk continues to develop extensive on-demand trainings, along with videos and user guides.


American Optometric Association Optometry's MeetingJune 20 - 24, 2018 | Denver, CO

Verity Town Hall MeetingJuly, 2018 | Virtual

DecisionHealth Fall National Provider Enrollment WorkshopSeptember 16 - 19, 2018 | Nashville, TN

NAMSS Annual Conference and ExhibitionSeptember 29 - October 3, 2018 | Long Beach, CA

MGMA - Medical Group Management Association Annual ConferenceSeptember 30 - October 3, 2018 | Boston, MA

America's Dental MeetingOctober 18 - 22, 2018 | Honolulu, HI

CAQH is committed to attending conferences and collaborating with our stakeholders in the industry.

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https://www.caqh.org/solutions/learning-opportunities

Conferences / Discussions where CAQH will be in attendance:


About Us.







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CAQH’s commitment to streamlining the business of healthcare requires feedback from all industry stakeholders; providers, payers, state and governing bodies.

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1 Attestation workflow.



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Hospital affiliations.


Participating Organization Concerns:

Because ProView only asks for admitting privileges, plans currently do not receive a complete picture of a provider's hospital affiliations.

If data is incomplete or conflicts, additional provider outreach is needed to clarify admitting privilege status.

Plans have created outside forms/processes that they require of providers in order to declare admitting arrangements and non-admitting affiliations.

Provider/Practice Manager Concerns:

Providers are not required to enter in complete information on non-primary hospitals, which leads plans to perform additional outreach to obtain the data.

Providers are not able to clearly indicate admitting privilege status and type, which leads to provider and health plan confusion.

Providers are not able to enter in admitting arrangements and non-admitting affiliations, which leads to outreach and additional forms to fill out from health plans.

CAQH is updating Hospital Affiliations to address provider and health plan concerns

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CAQH hosted multiple user feedback sessions with providers, practice managers, and plans and leveraged the feedback for the new design.


QUESTIONProviders were previously bombarded with

supplemental information requests regarding

hospital affiliation information that had already

been entered in CAQH ProView.

Since the enhancements were released to this

section, have you seen a decrease in the

frequency of outreach from plans requesting this

information?

Enhancement Discussion: Hospital affiliations

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A YES

B NO

C NOT SURE



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3 Authorization workflow.



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4 Username self-service.


About Us.







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© 2017 CAQH, All Rights Reserved.Confidential & Proprietary.

Only 45% of directory information is accurate based on a recent CMS analysis.

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Industry forces are driving industry stakeholders to solve for inaccurate provider directories


CMS has reported that 66% of location deficiencies, identified in provider directory monitoring efforts, fall into the category “provider is not practicing at location”

* Results reported by CMS Medicare Drug & Health Plan Contract Administration Group on September 8, 2016. N=11,646 practice locations

Locations with error

45%

Locations without errors55%

Provider not practicing at

location66%

Inaccurate phone numbers

10%

Incorrect address9%

Not Accepting New Patients

6%

Incorrect suite number

4%

Other errors5%

Overall CMS Error Rate Breakdown of CMS Error Types

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CMS has reported that 66% of location deficiencies, identified in provider directory monitoring efforts, fall into the category “provider is not practicing at location”

* Results reported by CMS Medicare Drug & Health Plan Contract Administration Group on September 8, 2016. N=11,646 practice locations

Locations with error

45%

Locations without errors55%

Provider not practicing at

location66%

Inaccurate phone numbers

10%

Incorrect address9%

Not Accepting New Patients

6%

Incorrect suite number

4%

Other errors5%

Overall CMS Error Rate Breakdown of CMS Error Types

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The implication to providers, hospitals and health systems are causing significant increase in outreach made my plans to provider organizations, often times monthly to confirm the same information.

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Current State Future StateWith CAQH ProView®

Aetna Aetna

Cigna Cigna

BCBS BCBS


Outreach occurs through both email and phone call communication with providers and meets CMS quarterly directory outreach requirements

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$19MTotal outreaches on behalf of 28 participating health

plans

Quarterly

Every provider is emailed once each quarter (volume of providers is distributed equally throughout

the quarter).

Provider must review and attest to their information to remain in a current status.

If provider enters a non-current status, then CAQH

staff call the provider.

All communication attempts and responses are logged and delivered in a monthly Outreach Compliance Report for audit purposes.

2.9M Estimated savings from

reduced health plan outreach costs



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Plan participation.

A few heath plans currently participating in CAQH ProView directory.


In January 2018, a large national payer pushed their directory listings for a provider to their CAQH ProView profile. This new functionality allows the provider to suppress or accept listings they may have not been aware the plan had published.

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Plan Directory

123 Main Street

987 Maple Avenue

231 Broad Street

CAQH ProView

123 Main Street

987 Maple Avenue

No match in CAQH

Keep in Plan Directory

123 Main Street

987 Maple Avenue

Suppress from Plan Directory

231 Broad Street

Providers are actively communicating practice locations that should be removed via CAQH ProView.

Two national health plans independently validated these results and determined 80%+

confidence.

When a provider has not communicated to a health plan that a location should be removed


Texas, and select states in the Midwest, have been exposed to this new functionality.

CAQH is working closely with six national payers to make this available to more providers in their network.

Users will be notified no less than 3 business days prior to seeing the new functionality in their profile. You will be required to complete before attestation.

Practice Managers in Maryland have not been exposed to this new functionality in CAQH ProView, as of today. However, national payers are using it in other markets.

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Providers who have been rostered by health plans to submit directory updates via CAQH ProView will now see a reconciliation prompt.

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The health plan will upload practice locations they have on file for the provider.


Providers will accept, reject, or indicate “I don’t know” for each health plan provided location, and then confirm the selection.

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If a provider accepts a health plan location or adds any new location, practice address, TIN and NPI information will be entered through a wizard.

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Providers who archive a location will explain why the location should be archived. Once archived, the location will live in the Archived and Rejected Locations table.

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Archived locations can be restored.


While the industry works together to solve for directory, provider organizations are still carrying the burden of maintaining and addressing accuracy in directory updates.

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Directory Resources: www.caqhproviderdirectory.org


About Us.







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To extend CAQH ProView capabilities to the entire provider universe, CAQH is initially focusing efforts on delegated provider groups.

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Improve usability for large group practice managers.

Improve the practice manager and vendor experience to reduce administrative burden and solidify user loyalty to CAQH.

Increase data quality to improve confidence in provider data and encourage automation.

Develop production solution forfacilities and ancillary provider types.

Enhance the group capabilities to increase value-add, such as implementing data usage acknowledgements from health plans.

Delegated Groups*

Create a standard process for delegated groups to submit information in bulk.

Support features which provide additional value to motivate group adoption.

Deliver meaningful, contextually relevant data to health plans to enable efficient ingestion.

Expanded Group Capability Additional Provider Types

Phase 1 Phase 2 Phase 3

*Delegated groups are those that are responsible for credentialing providers in the group, instead of the health plan credentialing the group’s providers. Generally, all providers affiliated with the group are rolled into one contract with the health plan.

Launch Date TBD Launch Date TBDLaunch Expected by September 2018


The current state of delegated group data management is highly manual and error-prone.

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Group staff maintain various Excel documents with large amounts of provider data in different formats for each contracted health plan.

Health plan staff review these disparate files and manually enter the data into internal systems.

Health plan 2

Current State

Health plan 1 Current State Outcomes

High administrative burden

Low data quality

Group 2

Group 3

Group 5

Group 6

Group 4

Group 1


During the design of this solution, the hypothesis has been confirmed that delegated data exchange will benefit from industry standardization.

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Q4 2016 – Q2 2017 Q3 2017 – Present

Analyzed 50+ sample files from CAQH Member Plans.

Catalogued commonalities in data structure and elements.

Audited directory-specific data points.

File Analysis

Design Discussions

High-Level Definition

User Feedback

Conducted 150+ phone conversations with 35+delegated groups and 9Founders.

Facilitated 4 on-site meetings with delegated groups and Founders.

Reviewed results of 9 Data Quality on-site ethnographies.

Refined proposed requirements with feedback from groups and Founders.

Revised user experience workflows based on first-hand feedback.

Defined high-level business requirements.

Onboarded design team to develop enhanced portal workflows.


The Delegated Group Module will reduce administrative burden and address the market problems of delegated groups and health plans.

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Market Problems for Delegated Groups Delegated Group Module

Groups are maintaining complex files for each health plan with group entity, location, provider demographic and plan-

specific directory data.

Groups are required to send updated files at varying times to health plans, depending on the contracting requirements.

Health plans have to manually review and enter the data from the disparate files into internal systems.

Group data is cumbersome for groups to maintain and health plans to process, which can lead to

low quality provider data.

CAQH will support the transition to a standard input file format with group data for multiple health plans.

CAQH will allow groups to maintain data in one place for all authorized health plans to access on-demand.

CAQH will support standard output file formats for health plans to automatically process into internal systems.

CAQH will simplify maintenance and processing to reduce manual error, and utilize scoring algorithms to improve

data quality.

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© 2017 CAQH, All Rights Reserved. 36

CAQH has created an industry standard Delegated Group Roster.

The Delegated Group Roster file supports and validates the many-to-many relationships in group data.

Overview of Delegated Group Roster file format:- Microsoft Excel.- ~150 Fields.- 3 Data Tabs:

> Providers: Demographic information for delegated providers.> Locations: Demographic information for service locations.> Provider-Locations: Directory information for providers at each location, for each affiliated Participating Organization.

When a delegated group submits a roster for upload, the solution will check real-time for the following critical errors prior to allowing the data to save to the group profile:

- All required fields are entered.- All fields entered are in the correct format.- If applicable, a field contains only an acceptable value from a Reference Table.- Data is logical. Examples:

> All locations listed with a provider practicing there must also be listed in the demographic Locations tab.> A provider was in the previous roster, is not in the current roster, and has never been flagged for termination.

- If the roster contains any critical errors, the group will not be able to save the data.

© 2017 CAQH, All Rights Reserved. 37

Groups in the testing phase have already seen data quality improvements when converting their files into the CAQH standard format.

For a group in DC Metropolitan Area (~780 providers, 96 locations), the simple act of converting to the standard Delegated Group Roster format resulted in the following data quality improvements:

Groups are also reporting the following in terms of file usability and easy transition:

15 32Invalid taxonomy codes

removed.Duplicate practice

addresses removed.

974Provider at location

relationships updated.

777Degrees and provider

specialties converted to industry standard.

“This is really straight-forward, especially in the logical way the data comes together.” “I was able to make just a few changes in Echo, and then auto-populate our data into the new format.” “This is definitely going to help with directory information. I can change data at the plan level, so only the

correct locations and providers go to them.”


About Us.







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Two industry recognized organizations collaborating to streamline administrative simplification for dentists.

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+• Data on more 200,000 dentists

in the US• 67% of dentists are ADA

members• Connects national, state and

local ADA chapters• Member portal with strong

dentist engagement• Well recognized, strong brand

and endorsement

• Existing CAQH ProView system to collect provider data, already used by more than 1.4M providers

• Resources to sell, contract and service dental plans that need dental provider data

• Strong, trusted brand with payers and providers

• Current relationships with member plans that have dental businesses

CAQH and the American Dental Association (ADA) have formed an alliance on a joint credentialing data collection application solution for the dental industry.


The ADA and CAQH alliance is focused on achieving five objectives to advance administrative simplification in the dental industry.

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Accelerate dentist adoption of a single electronic solution to improve dentists’ administrative processesand reduce the cost associated with submitting documentation multiple times for credentialing bymultiple payers.

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Streamline the dental plan credentialing data collection process by replacing cumbersome paper basedapplications with an automated provider application ready to be primary source verified.

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Establish the ADA & CAQH alliance as the best-in-class solution for the dental industry to efficientlycollect dentist data that can be utilized for credentialing, directory maintenance and other purposes.

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Preserve and augment the ADA commitment to their members to deliver an industry solution thatachieves administrative simplification and improves practice efficiency.

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Accelerate delivery on CAQH commitment to plans to obtain robust dental provider data through CAQHProView.

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New and existing dental providers in CAQH ProView can now sync their MyADA.org professional information with their CAQH ProView profile to simplify the credentialing application.

Member Portal Dental Plans

• ADA has relationships and basic provider data for over 200k dentists.

• Dentists login on the ADA member portal using their member ID.

• ADA will actively market the joint solution to all of its members.

• Dentists within the ADA portal can single sign-on (SSO) directly into CAQH ProView with the need to establish new credentials to log on.

• Basic information from ADA will be pre-populated into the profile to eliminate the need to re-key data into CAQH ProView.

• 30+ dental plans are contracted with CAQH, and the list of interested plans is growing.

• Dental plans receive information via existing extract channels.


Over 30 dental plans as participating organizations, including:

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Stay connected!

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Antoinette CumminsSenior Manager, Provider Engagement

Questions and feedback? Email, and Follow Us on Twitter (@CAQH) and LinkedIn

what’s new with caqh proview? - namss.org proview resources for credentialing specialists and...

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