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CAQH ProView SanctionsTrack

Overview

An add-on feature of CAQH ProView is SanctionsTrack. Used in conjunction with CAQH ProView, SanctionsTrack is intended to eliminate the redundant processes employed by health plans, hospitals, and other managed care organizations to collect disciplinary action information on healthcare providers. CAQH believes participating organizations can streamline internal processes by eliminating redundant data gathering and follow-up research for sanction notices. By centralizing this function within CAQH ProView, participating organizations will be able to focus their resources on review and evaluation of sanctions, instead of collection, provider matching and data entry.

  • Audience -- this service provides sanctions information that is reviewed by the Credentialing department during and in between credentialing events and by Fraud & Abuse departments for certain types of claims payments.
  • Provider Types -- sanctions information is captured for standard (MD, DO, DPM, DC, DDS, DMD) and allied (all ancillary provider types) and stored in UPD.
  • Boards Reviewed -- sanctions and/or disciplinary actions against providers are queried from all state licensing boards, the Office of Inspector General, Office of Personnel Management and Medicare/Medicaid sources. 400+ sources in total. A listing of the boards reviewed will be provided upon request.
  • Certified Vendor -- SanctionsTrack information is provided by @Credentials, Inc., a NCQA-certified organization.

Cost Effective

  • Savings -- SanctionsTrack streamlines costs by deploying resources more effectively with improved workflow.

Process Flow

  • Typical Sanction Review Process -- a very manual effort performed by health plans requiring one or more designated staff to query state and national boards, both electronically and via paper on a regular basis. Staff must manually match the published sanction information to participating and non-participating providers before any action can be initiated by the health plan related to the sanctions. Process is heavily reliant on staff knowledge and availability.
  • CAQH SanctionsTrack Process -- a centralized data collection process of querying national and state boards on a weekly basis and loading data to CAQH ProView on a nightly basis. Sanctions are matched to unique providers in the database. Health plans can search and extract sanction information electronically for all CAQH providers -- flagged as on or off roster -- automatically through standard extracts, manually with custom extracts or the provider search as PDF files. Health plans get up-to -date information to use in their evaluation and decision processes. 

Projected ROI

  • Time savings
    • Improved effectiveness of review with sanctions being matched to unique providers automatically and proactively reported to a participating organization.
    • Increased efficiency with the frequency of data and updates available on single source.
    • Enhanced early warning system of sanction information for new provider recruitment.
  • Reduced reliance on off-line tracking log(s)
    • Centralized process of collecting, matching and linking sanction information from national and state sources with specific providers.
      • National health plan -- Opportunity to centralize data collection processes and improve staff efficiency.
      • Regional / single state plan -- Greatly improved ability to track providers across state boarders with provider sanction data available from all states.
  • Reallocation of resources
    • Significant reduction of data collection, provider matching and data entry.
    • Staff focused on review, evaluation, recommendation and action.
    • Reduce paper files with electronic sanction information and board orders storage.

Accreditation Compliance

  • NCQA Review and Assessment
    • The agreement between CAQH and @Credentials was reviewed by NCQA and is found to meet all factors for a delegation agreement as stated in CR 12, Element A of the 2004/2005 MCO, PPO and MBHO Standards and Guidelines.
    • CAQH will act as a delegated entity for ongoing monitoring of sanctions and @Credentials as a sub-delegate, providing the sanction information to CAQH for distribution to clients.
    • Since @Credentials is NCQA-certified as a CVO, organizations will not be required to conduct pre-delegation evaluation (Element D) and annual evaluation (Elements E and F) of CAQH.
  • CAQH will communicate feedback from accreditation bodies that review and comment on SanctionsTrack.
  • CAQH will post and distribute any oversight documentation required by the accreditation bodies.