CAQH White Paper Calls for Industry Collaboration to Solve Provider Data Challenges

Accurate Provider Data Critical to Improving Quality, Costs of Healthcare Delivery

WASHINGTON, DC - 09/28/2016

Full industry collaboration is required to develop an effective approach to collecting, maintaining and disseminating accurate, high-quality data from healthcare providers, according to a new white paper from the non-profit alliance CAQH. “Defining the Provider Data Dilemma: Challenges, Opportunities and Call for Industry Collaboration,” will inform the discussion when healthcare industry leaders gather in Washington on Sept. 29 at the 2016 Provider Data Summit, hosted by CAQH, to explore the topic.

“The poor quality of provider data has created one of the most pressing challenges in this era of healthcare reform,” said CAQH Executive Director Robin J. Thomashauer. “The industry will be much more successful in solving this problem if we can do so collectively, breaking down barriers and developing consensus on how to move forward.”

Healthcare provider data forms the foundation of many important processes in the nation’s healthcare system. This information is necessary to conduct a number of essential functions, such as referring a patient to a specialist, paying insurance claims, determining provider sanctions and credentialing providers. For example, the highly-publicized findings around inaccurate information found in health plan directories demonstrated the potential that unreliable data has to cripple everyday interactions between providers and health plans.

Obtaining accurate, timely provider data has long been an issue within healthcare. New market and policy forces, including those driven by the Affordable Care Act and the Medicare Access & CHIP Reauthorization Act, have put additional pressure on the industry to resolve the problem, according to the white paper. The increase in the number of health plan products developed for healthcare exchanges, as well as additional regulatory reporting requirements for health plans and healthcare providers, require new data elements and formats. In the absence of an industry-wide “source of truth,” stakeholders have developed highly individualized approaches to maintaining data, which has led to redundancy across the industry. One analysis cited by the paper estimated that commercial health plans and providers alone spend at least $2.1 billion annually to maintain provider databases.

While the job of collecting and maintaining provider data may appear straightforward, the white paper details many of the complexities. Pain points include a lack of reliable sources of data, standard definitions of providers, quality benchmarks and accountability measures. Since there is not consensus on an authoritative source for provider data, organizations have historically defined their own standards and processes for collecting data, perpetuating costly, redundant systems. The very definition of “provider” has shifted with the increase of healthcare teams, and naming conventions for many professionals remain inconsistent. Finally, there are no widely adopted measures for what constitutes “high-quality” provider data, and little consensus on how both data producers and users can be held accountable for their roles.

CAQH developed the white paper in collaboration with Manatt Health, a leading healthcare policy and research firm. According to Thomashauer, CAQH has long been engaged in the issue of provider data accuracy, which they see as integral to their mission of streamlining business processes in healthcare.

CAQH proposes four areas of collaboration that would enable stakeholders to maintain and share accurate, reliable provider data:

  • Create multi-stakeholder alignment to expedite progress, avoid fragmented investments and ensure sustainable and reliable results.
  • Define a minimum data set and quality thresholds to ensure all stakeholders are collectively working toward the same goal of producing and using “high-quality” data.
  • Establish provider data governance and accountability.
  • Institute constructive policies that can support resolutions to provider data problems.

An executive summary of the discussion at the conference will be developed and shared to help define potential next steps for industry collaboration.

Download “Defining the Provider Data Dilemma: Challenges, Opportunities and Call for Industry Collaboration.”


About CAQH

For more than 20 years, CAQH has helped nearly 1,000 health plans, 1.6 million providers, government entities and vendors connect, exchange information and operate more efficiently. CAQH technology-enabled solutions and its Committee on Operating Rules for Information Exchange (CORE) bring the healthcare industry together to make sharing business information more automated, predictable and consistent. CAQH Explorations researches opportunities to reduce the burden of manual processes in healthcare administration. Visit and follow us on Twitter: @caqh.