With 13 percent of beneficiaries reporting that they have additional coverage, the coordination of benefits process for Medicaid plans can be complicated and costly.

October 2019
CAQH estimates that administrative inefficiencies associated with coordination of benefits cost the industry $800 million each year. At the Medicaid Health Plans of America (MHPA) Annual Conference, Morgan Tackett, Senior Product Manager of COB Smart, and Laura Carraway, Senior Vice President of Cost Optimization-Program Integrity Coordination of Benefits at Anthem, shared recommendations for how to make this process more efficient and accurate.   The session, “Claims processing and coordination process benefits,” provided an overview of how health plans are currently approaching this… Read more »

A coordinated approach to provider data management fosters data accuracy and adds efficiency to healthcare administration.

October 2019
Members expect their health plan to deliver reliable and accurate provider information so they can find the care they need. Yet maintaining up-to-date, high-quality provider directories is challenging. About half of all provider location listings have at least one inaccuracy, according to the Centers for Medicare and Medicaid Services (CMS). Provider data standardization can help ensure accurate provider information is available to use for connecting patients with providers, provider licensing and paying for services. High-quality provider information also has the downstream benefit of… Read more »

Even as many dentists retire, a greater number of dental providers are continuing to enter the field.

October 2019
Today, more dentists are practicing each year as the U.S. dental industry is growing1. According to the Health Policy Institute (HPI), the number of practicing dentists is expected to increase between 2.6 and 4.5 percent between 2017 and 20372. The increase in dentists is a positive change for consumers, who need a larger dental population to serve what the American Dental Association (ADA) has identified as a steady increase in demand for dental services. However, the rapid growth of this market also means an influx of dental provider data to manage. Maintaining high quality dentist data… Read more »
September 2019
CAQH CORE and Health Level Seven International (HL7) have come together to accelerate automation and improve interoperability between healthcare administrative and clinical systems. Though this is the first time that these organizations have collaborated on solutions specific to technical and administrative burdens, their complementary individual work has helped improve the electronic exchange of data across the healthcare industry. Together, the organizations will address some of the most pressing issues in the industry, starting with: Prior Authorization Exchange of Medical… Read more »
September 2019
In response to a request for information (RFI) from HHS and CMS, CAQH CORE submitted comments on “Reducing Administrative Burden to Put Patients over Paperwork,” an initiative to focus the healthcare delivery system on patient-centered care, innovation and outcomes. In the response, CAQH addressed: Modification or streamlining of reporting requirements, documentation requirements or processes to monitor compliance to CMS rules and regulations. Aligning Medicare, Medicaid and other payer coding, payment and documentation requirements and processes. Enabling operational flexibility,… Read more »
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 »

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 »