CAQH CORE announced that it has awarded more than 300 CORE Certifications to health plans, hospitals and health systems, clearinghouses and vendors with recent Aetna and Cigna awards. The continued increase in the number of organizations seeking and receiving certification underscores the value they place on demonstrating that they meet – and exceed – the CORE operating rules and underlying standards for electronic business transactions.
CAQH efforts to convene the industry to solve provider data challenges were discussed in a recent article in AIS Health Plan Week. The article explored the problem from different stakeholder perspectives amid a changing healthcare environment and increased regulations for directory maintenance.
The healthcare industry spends a collective $2.1 billion on inefficient processes maintaining provider data, two-thirds of which are health plan expenses. The lack of trusted sources of information have led to the proliferation of highly-individualized databases and tools, which have, over time, increased costs and increased the administrative burden for both health plans and healthcare providers.
Are we doing all we can to maximize administrative savings in healthcare? What are the biggest opportunities to cut costs for healthcare providers, health plans and other industry stakeholders? On Feb. 16, CAQH (@CAQH) held a Twitter chat with Health Populi blogger Jane Sarasohn-Kahn (@healthythinker) to discuss the topic.
Widespread adoption of electronic business transactions in healthcare continues to grow but a significant opportunity for $9.4 billion in annual savings remains, according to the 2016 CAQH Index®, released earlier this month. Conducting resource-intensive manual transactions costs U.S. health plans and healthcare providers as much as $11 more per transaction and on average $6 more than when conducted electronically. Millions of these transactions are exchanged daily.
The fourth annual CAQH Index measures adoption, costs and, for the first time, provider labor time associated with the most common administrative transactions conducted between health plans and providers. These include verifying a patient’s insurance coverage, sending and receiving payment, inquiring about the status of a claim and obtaining prior authorization for care.
New findings show that medical providers could save at least 1.1 million labor hours per week by transitioning to fully electronic transactions. Providers now spend 8 minutes on average, and up to 30 minutes on manual tasks, which include making phone calls, sending faxes and mailing correspondence. Prior authorization offers providers the greatest time savings potential if conducted electronically, reducing the time per transaction from 20 to 6 minutes and the cost from $7.50 to $1.89.
More than 1.4 million healthcare providers currently enter and maintain a wide range of information within CAQH ProView®, the industry’s trusted electronic solution for capturing and sharing self-reported provider data. Providers and practice managers enter data free-of-charge into the secure central database and authorize healthcare organizations to access the information, eliminating redundant paperwork and reducing administrative burden.
User feedback is crucial to drive innovation and enhance developing and existing features to optimize CAQH ProView. Various outreach activities are conducted throughout the year to ensure that ideas and suggestions from healthcare providers and health plans are integrated into the solution.
CAQH partnered with dental plan MetLife to host a webinar on their success in increasing provider enrollment in Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) through EnrollHub®. This industry-wide CAQH solution makes it easier for providers to receive claim payment and remittance advice electronically from multiple health and dental plans.
A new two-minute video by CAQH Commitee on Operating Rules for Information Exchange (CORE®) provides an overview of CORE Certification. This e-program enables entities to demonstrate that they are adhering to the CAQH CORE Operating Rules and underlying standards for administrative data sharing across the healthcare system. Developed by industry for industry, the CORE Certification program is widely recognized as the industry gold standard for testing conformance to the operating rules.
A unified approach to collecting, maintaining and disseminating accurate and timely provider data is critical to improving the quality and cost of healthcare delivery, according to a new CAQH white paper, “Defining the Provider Data Dilemma: Challenges, Opportunities and Call for Industry Collaboration.”
Provider data is used to perform a number of essential functions in the healthcare system, such as referring a patient to a specialist, paying insurance claims, credentialing providers and determining sanctions. The real-world effect of poor-quality data on consumers and patients has been recently highlighted through increased regulation to address the quality of health plan directories.
More than 100 industry leaders from health plans, healthcare provider organizations, government, consumer groups and others participated in a CAQH-convened Summit on Sept. 29th to develop a path forward for solving healthcare provider data challenges.
The discussion was informed by the CAQH White Paper describing the current state of provider data accuracy and efforts to maintain reliable, high-quality data.
Keynote speaker Shantanu Agrawal, M.D. (pictured above), deputy administrator and director of the Center for Program Integrity at the Centers for Medicare and Medicaid Services, and panelists throughout the day, highlighted areas of concern and described why there is an imperative to address these challenges now. Common themes included the rising costs of healthcare, an evolving provider landscape, new uses for data—such as testing new payment models—and a growing regulatory environment.
From greater implementation of the CAQH CORE operating rules to research on the operational needs of the industry to support value-based payments, CAQH CORE continues to identify and implement opportunities that drive the industry toward true interoperability and electronic data exchange. These topics, among others, were highlighted in a recent Town Hall webinar in which CAQH CORE provided progress updates and discussed initiatives underway to enhance the exchange of electronic data in healthcare business transactions.
2020 K Street, NW
Suite 900
Washington, DC 20006
