September 2019
For health plans, coordinating benefits is challenging under the best of circumstances. Due to the complexity of payment systems, and a lack of data uniformity, interoperability and transparency, most plans rely on recovery vendors to identify third-party liability after claims are paid. It is a highly manual and inefficient system that results in overpayments going uncollected and significant increases in costs and labor efforts. In many ways, Medicaid plans face the greatest challenges. In spite of ongoing efforts to improve the integrity of these programs, and a legal obligation for… Read more »

This summer, CAQH spoke to members of the NCSL Insurance Task Force on initiatives to streamline the business of healthcare and improve provider data.

September 2019
This summer, CAQH spoke to members of the NCSL Insurance Task Force on initiatives to streamline the business of healthcare and improve provider data. In August, CAQH Director of State Relations, Randi Chapman, addressed the task force at the NCSL summit, which was attended by legislators from across the country, AHIP, BCBSA, the American Dental Association and other industry groups. While at the summit, Chapman also participated in sessions on hot-button issues in healthcare such as rising costs, surprise billing, Medicaid innovation and others. Also last month, the public affairs team… Read more »

Industry momentum increases as additional provider groups participate and a leading third party vendor integrates Groups-compatible rosters

July 2019
Webinar: Improving the Delegated Roster Process Health plans and delegated provider groups are invited to an August 14 webinar to hear from industry peers who are using CAQH ProView for Groups to share delegated data. Presenters from a regional health plan and delegated group will explain how the solution is changing their approach to delegated data and best practices for implementing a similar process. Learn more or register here. MD-Staff generates CAQH ProView for Groups-compatible rosters Now delegated provider groups can automatically generate rosters to upload directly into CAQH… Read more »

Paper highlights barriers to automation and a roadmap to a streamlined electronic process

July 2019
CAQH CORE has released a new white paper on automating prior authorization. The paper identifies six barriers to automation: Lack of integration between clinical and administrative systems. Lack of federally-mandated standards for attachments and clinical documentation. Limited availability of vendor products that readily support the standard transaction. The need for consistency in data content. State requirements for manual intervention. Lack of provider awareness. The paper also summarizes industry work focused on improving the prior authorization process, including collaborative… Read more »
July 2019
The National Committee for Quality Assurance (NCQA) recently completed a review of CAQH ProView, DirectAssure, and CAQH ProView for Groups. In a letter to CAQH, NCQA states, “In addition to increasing efficiency in credentialing and network operations, these solutions are beneficial to NCQA customers in supporting accreditation.” NCQA also reviewed SanctionsTrack, the automated, continuous sanctions monitoring solution from CAQH that seamlessly integrates with CAQH ProView. Through a new relationship with Verisys, CAQH is expanding SanctionsTrack capabilities and will include additional… Read more »

Plans across the state align efforts to improve provider data

June 2019
Texas is the latest state where leading health plans are adopting CAQH ProView to improve the accuracy of provider data. Participating organizations include Amerigroup, Superior HealthPlan and UnitedHealthcare, whose combined membership represents nearly 4 million Texans and more than 50 percent of the Medicaid covered population. More than 100,000 healthcare providers in Texas already use CAQH ProView to share professional and practice information with health plans. By selecting the solution to update provider data, plans in the state can deliver better information and a positive experience… Read more »

Machine learning is improving provider data quality 

June 2019
CAQH led a discussion on “Artificial Intelligence and the Future of Data Quality” at AHIP Institute & Expo 2019 in Nashville. In the session, Hassaan Sohail, Manager, Product Innovation at CAQH, explained how the organization is using AI to improve the accuracy of health plan directories. AI technology draws on multiple sources of information to predict data accuracy. Using machine learning techniques, CAQH has created scores that can be reliably used to assess the quality of provider-locations records. These scores may be referenced to identify and correct erroneous or out-of-date… Read more »

Health plan professionals gather to discuss provider data and other pressing topics 

June 2019
The 2019 CAQH ProView Symposium was held last month in Washington, DC. The event, titled “Achieving Provider Data Excellence,” was attended by representatives from nearly 50 health plans across the nation. Over the course of two days, attendees participated in sessions that explored some of the most pressing issues in healthcare, including approaches for improving provider data, health plan directories and primary source verification for credentialing. The Symposium offered a setting for attendees to network with their peers and learn how others in the industry are addressing provider data… Read more »

New rules aim to improve prior authorization process

May 2019
Today, 88 percent of prior authorizations are conducted either partially or entirely manually. CAQH CORE has released the Phase V Operating Rules to strengthen the accuracy and trustworthiness of the prior authorization process and move the industry toward full automation. These new rules build upon the Phase IV Rules and enhance and standardize the data shared between plans and providers, eliminating the unnecessary back-and-forth, accelerating adjudication timeframes and freeing staff resources that are today spent on manual follow-up. In particular, the data that the Phase V Rules address… Read more »

CAQH CORE releases new white paper

May 2019
The healthcare industry has made significant progress in adopting electronic transactions for common business practices. However, the lack of a standard for attachments has contributed to cumbersome processes for exchanging patient-specific medical information and supplemental documentation. A new CAQH CORE white paper, which summarizes insights from more than 250 healthcare organizations, identifies five opportunity areas to move the industry toward the electronic exchange of attachments: Workflows Data Variability Exchange Mechanisms Connectivity, Security and Infrastructure Utilities… Read more »