Although healthcare provider data is crucial for the effective operation of health plans, including insurance claims processing and directories, payers continue to struggle with acquiring and maintaining such accurate, complete, and timely data.
Central to the problem is the fact that provider data is continually changing and as a result is nearly impossible to keep up to date. A 2016 IDC Health report notes that 2 percent of provider demographics change each month, an estimated 20 to 30 percent of physicians change affiliations each year, while 5 percent of doctors change their “status”—lose licenses, die, retire or are sanctioned annually.
At the center of the industry’s efforts to overcome these data maintenance challenges is the Council for Affordable Quality Healthcare (CAQH), a non-profit alliance of health plans and trade associations established in 2000.
“Provider data is a critical component to the healthcare system as a whole” impacting quality, costs and care delivery, says Sorin Davis, CAQH’s managing director of industry relations. “There are lots of data sources out there, but there are very few authoritative data sources. For some of the data, the only authoritative source is the provider.”
Sorin DavisRecently, CAQH convened the Provider Data Action Alliance, an industry-wide group of stakeholders that seeks to address the challenges of collecting and maintaining accurate, timely data on healthcare providers. “How do we as an industry start to deal with this, because it’s only going to get harder?” exclaims Davis. “The goal is really to address the gamut of provider data needs that are increasing.”
The Provider Data Action Alliance is currently working on a “roadmap of strategies” intended to advance the industry toward reliable, accurate provider data. The final roadmap will be available this fall.
According to Davis, CAQH got its start as a nonprofit alliance of health plans and trade associations with a focus on payer credentialing. CAHQ’s ProView is a data-collection platform for providers to self-report professional and practice information to payers, hospitals, large provider groups and health systems. With a single, uniform online application, providers can enter their information free of charge using a standard electronic form.
“We have just about every payer in the United States using it as a receiving entity,” says Davis. “Hospitals have started to use it. We even have one state Medicaid agency using it as part of their enrollment system.”
In April, CAQH launched a new electronic solution called VeriFide that streamlines primary source verification of the healthcare provider information required as part of the health plan credentialing process. Under the credentialing process, health plans must verify 14 key provider data elements with third-party sources.
“Credentialing is a three-step process,” adds Davis, who notes that “credentialing is not a once-and-done activity—you do it once, and then you have to re-credential.” For instance, he says the National Committee for Quality Assurance requires plans to re-credential participating healthcare providers every three years. “Because credentialing is repetitive in nature, we built into our system the ability for us to ‘touch’ the provider and remind them to come back into the system to re-attest, even if nothing has changed.”
CAQH’s ProView is currently used by more than 800 health plans and other organizations for a range of provider data needs besides credentialing. CAQH has leveraged these same methods of provider outreach to overcome ongoing directory data maintenance challenges.
“There’s traditionally been very little provider engagement,” laments Davis. “How do you build a profile on a provider without actually engaging them?”
Last year, CAQH launched a new electronic solution—called DirectAssure—to improve the quality of provider data in health plan directories by enabling the more than 1.3 million providers participating in ProView to easily review and update their self-reported professional data for use in directories.
Some health plans require quarterly outreach to providers, while federal regulations require Medicaid managed care organizations to update directories monthly. CAQH’s DirectAssure eliminates the need for health plans to frequently reach out to providers in their network to obtain updates by enabling providers to update and confirm their directory information in one place and then make it available to participating health plans.
“We live in a mobile society where everybody moves around,” Davis says. “Most of the data changes on an annual basis are within contact information, practice locations, and affiliations.” He adds that among the charges of the newly created Provider Data Action Alliance is to identify authoritative data sources for such information.
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