How It All Began

July 2020

Beginning in July 2000, the founding CAQH members launched a series of initiatives to improve the quality of healthcare and reduce administrative burdens for physicians, patients and payers. These first programs were designed by work groups of health plan and CAQH staff, developing tools and technologies to support physicians and educate patients about vital health issues and insurance benefits.

While today CAQH is focused on streamlining business challenges, some of the early initiatives addressed clinical issues. Here are a few examples:

Health Outcomes.

CAQH members leveraged their collective reach to support providers in educating patients on appropriate usage of critical drug therapies. Two areas were targeted for awareness campaigns – appropriate antibiotic usage and long-term adherence to beta blockers after a heart attack. Both campaigns worked closely with key clinical partners, including the CDC, for antibiotic use, and the American Heart Association, American College of Cardiology, American Academy of Family Physicians and American College of Physicians for beta blocker adherence. CAQH also partnered with NCQA to develop new standardized HEDIS measures to track antibiotic and beta blocker prescribing. Data was collected across states using the CAQH-developed measures to determine if improvements were being achieved.

Access to Care.

When CAQH was formed, HMOs, point-of-service plans and other gatekeeper products were emerging as a cost management strategy. These offerings provided consumers with options, but they also created confusion about how to access specialty and emergency care. To address this, CAQH member health plans committed to allow direct access to Ob-Gyn care, provide coverage for emergency visits that a reasonable person would consider an emergency and require binding independent review of medical necessity decisions. These commitments have become foundational in health coverage today.

Formulary Transparency.

As health plans adopted formularies to manage rising costs for prescription medicines, providers often struggled to determine which drugs were included in each plan’s formulary. This resulted in high levels of rework if a drug was not covered once the patient arrived at the pharmacy. CAQH addressed this challenge by creating a first-of-its-kind, real-time industry database that allowed providers to search during the patient visit and quickly understand the formulary status by health plan. As nascent e-prescribing applications gained a foothold, CAQH partnered with RxHub (now SureScripts) to expand and imbed its formulary database in the e-prescribing workflow. This partnership resulted in a single source of formulary data for the majority of commercially insured Americans.

Credentialing Applications.  

Each health plan required its network providers to submit detailed information about their practices, demographics, licensure and training upon application to the network and every three years thereafter. For a provider under contract with 10 or more health plans, each with its own way of collecting the information, this was a significant administrative burden. To address this challenge CAQH worked across health plans, providers, and other stakeholders to build and adopt a common industry provider data collection platform, now known as CAQH ProView. The platform standardized, centralized and automated paper credentialing forms so that providers completed the process once instead of multiple times for the various health plans with which they worked. In launching this service, CAQH set the foundation for developing trust with providers as they realized the cost-saving benefits of the centralized platform while maintaining control of their data.

By the end of 2004, CAQH had eliminated over 400,000 paper credentialing applications and saved hundreds of thousands of hours of provider staff time.

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