- About CAQH CORE
- Operating Rules
- New Operating Rule Structure
- Eligibility & Benefits
- Claim Status
- Payment & Remittance
- Prior Authorization & Referrals
- Health Care Claims
- Benefit Enrollment
- Premium Payment
- Mandated Operating Rules
- CORE Certification
- Priority Topics
- Join CAQH CORE
- Resource Library
- CAQH ProView
- CAQH ProView for Groups
- CAQH ProView - Dental
- Provider Directory - DirectAssure
- Credentialing Solutions Suite
- COB Smart
New Industry Roadmap Lays Path to Address Provider Data Inaccuracies in Healthcare
Provider Data Action Alliance makes recommendations to address pressing issue impacting providers, patients and health plans
WASHINGTON, DC - 5/30/18–
A diverse cross-section of healthcare leaders today released recommendations to develop an efficient, sustainable system for accurate provider data. In its report, “An Industry Roadmap for Provider Data,” the Provider Data Action Alliance, a group convened by CAQH, concluded that broad industry collaboration is needed to improve provider data.
“Inaccurate provider data has long been a significant challenge for healthcare,” said CAQH Executive Director Robin Thomashauer. “Individual providers, provider organizations, patients and health plans are all affected by this issue, and it requires a collaborative effort to achieve real change. This Roadmap lays the foundation for the actions required to move forward.”
Healthcare provider information required by payers and other users has hundreds of data elements such as education, medical specialty, license number, hospital privileges, practice location and hours, performance and quality measures, and whether the provider is accepting new patients. There are few authoritative, easily verified data sources for most of the information, much of which is self-reported. There are also no standard definitions for data elements and a lack of accountability between data producers and users to keep the data current.
Although the industry spends more than $2 billion annually[i] to maintain provider data, access to high quality data remains elusive. Despite existing Federal and state regulations, available data often contains multiple errors or is incomplete. The resulting problems include patients who are unable to locate a provider because of inaccurate directories, health plans that cannot quickly identify sanctioned providers, and providers who have difficulty finding in-network providers for patient referrals or whose claims payments are incorrectly denied or delayed.
The Roadmap details principles to guide the development of an industry solution, an overall vision for what the provider data ecosystem should look like and a three-phase plan to implement the vision. Specifically, the roadmap identified five major recommendations:
- Declare commitment to the vision: The industry must publicly commit to taking joint action to catalyze momentum and achieve industry alignment.
- Form a not-for-profit, multi-stakeholder governance structure: To succeed, this endeavor requires governance by a diverse set of stakeholders capable of defining and shaping the necessary solution details.
- Define an initial dataset and establish standards: Participating stakeholders should align on scope by defining the initial dataset on which to focus, as well as the standard against which to measure data quality.
- Engage regulators and other essential groups to inform transformation: Educate regulators, accreditors and other stakeholders on the industry commitment so that, over time, any regulations and/or standards can be aligned with the industry solution.
- Begin to formally measure and share the impact of industry efforts: Establish measures for value, cost and overall data accuracy so that the results of the industry-led effort can be assessed.
The Provider Data Action Alliance – which includes over 20 participants representing industry stakeholders, including public and private payers, hospitals, provider groups, regulators, accreditors and health information exchanges -- contributed to the Roadmap over a nine-month period. Individuals from more than 100 organizations reviewed the recommendations.
“We were pleased to be part of this effort and hopeful that the clearly articulated vision in the roadmap will result in real change in the way all segments of healthcare obtain and use provider data,” said Ben Holliday, Director, Provider Data Management, BlueCross BlueShield of Tennessee, and a participant in the Alliance. “It is time to finally solve this long-standing problem.”
Another Alliance participant, Michael Dowling, Chief Administrative Officer of CMO, Montefiore Care Management, which handles the credentialing for the Montefiore Health System employed and affiliated providers in New York City and the Hudson Valley, said, “We are delighted that this pressing issue is now closer to finally being addressed. Healthcare providers – both individuals and organizations – are eager to reduce the amount of time reporting their data, improve the accuracy of that information, and focus on patients instead of paperwork.”
Both Holliday and Dowling will be discussing the Roadmap at an industry briefing on June 21 during the upcoming AHIP Institute in San Diego.
Provider data management and exchange has been a priority for CAQH for more than a decade. Over the past eighteen months, the organization developed a white paper on the issue and convened an industry-wide summit to inform the process, which resulted in a recommendation to create the Roadmap.
As industry awareness grows, CAQH and the Alliance will solicit additional support for the Roadmap and determine the next steps required to achieve consistent, high-quality healthcare provider data for all stakeholders. Organizations and individuals interested in the issue can access the full Roadmap here, and sign up to receive updates on how they can become involved.
[i] Issue Brief: Administrative Provider Data. CAQH [Analysis completed by Booz & Co., now Strategy&, Inc.] (December 2011).
CAQH, a non-profit alliance, is the leader in creating shared initiatives to streamline the business of healthcare. Through collaboration and innovation, CAQH accelerates the transformation of business processes, delivering value to providers, patients and health plans. Visit www.caqh.org and follow us on Twitter: @caqh.
# # #