CAQH CORE: Bridging the Clinical and Administrative Divide in Value-based Payments
Value-based payment models are transforming a sizable portion of the U.S. healthcare economy by aligning provider compensation with improvements in care and cost controls. However, innovation and experimentation are ongoing and operational challenges may create barriers to adoption. Processes and systems in place to administer fee-for-service payment models do not always support value-based payments. Consequently, a patchwork of proprietary approaches and work-arounds is emerging.
Without collaboration to minimize these variations, the current environment is ripe for repeating the scenario that emerged in the fee-for-service environment more than two decades ago. Much like the operational challenges being encountered today in value-based payments, initial adoption of electronic transactions for fee-for-service payment models was slow, complicated and more costly due to a lack of common rules for uniform use.
CAQH CORE was originally created by industry to address this challenge and is now applying lessons learned to help streamline administration of value-based payments. As the healthcare industry moves towards value-based care, stakeholders remain hampered by the fact that the features of value-based payment models do not align with current fee-for-service revenue cycle operational workflows, including the convergence of clinical and administrative data. CAQH CORE is working to strengthen the operational processes and systems supporting it.
In 2018, CAQH CORE published the report All Together Now: Applying the Lessons of Fee-for-Service to Streamline Adoption of Value-Based Payments, which analyzes operational challenges that may slow or add costs to the implementation of value-based payments. The research found that industry collaboration is needed to minimize variations and identified five operational opportunity areas that, if improved, would smooth implementation.
CAQH CORE Value-based Payments Advisory Group
Building on the report findings, in 2019 CAQH CORE launched a multi-stakeholder Advisory Group consisting of 12 executive leaders representing health plans, providers, vendors, government entities and advisors. The group evaluated pain points caused by value-based payments across the traditional revenue cycle work flow, developing a list of 19 draft opportunity areas for streamlining administration of these arrangements.
After careful consideration, the group condensed the original list down to five opportunity areas for administrative simplification and clinical integration in value-based payments. Three of these opportunity areas will be considered by a CAQH CORE Value-based Payments Subgroup or via a pilot launching this fall and the remaining opportunities align with existing CAQH CORE efforts related to clinical alignment for prior authorization and attachments.