Opportunity: Adopting Operating Rules with Attachment Standards
Introduction and Opportunity
Introduction and Opportunity
As the current and immediate past Chairs of the CAQH CORE Board, we are excited to discuss the operating rule package currently under consideration for federal mandate. Below we will review the path to federal mandate, the proposed rules, and what to expect next.
Value-based payment (VBP) models pay providers based on the outcomes of the care they deliver, not the volume. VBP models are recognized for their potential to lower costs, increase quality, and promote equity. Almost 60% of healthcare payments are tied to some form of value, be it through pay-for-performance incentives - such as payment add-ons for controlling chronic conditions in a patient population - or shared-risk arrangements between providers and payers, like population-health models that measure performance against a total cost of care benchmark.
The healthcare industry has seen several laws and regulations related to price transparency over the last years, including the Centers for Medicare & Medicaid Services (CMS) Hospital Price Transparency Rule, CMS Transparency in Coverage Rule, the No Surprises Act, and related regulations. The purpose of these policies is to increase consumer awareness of the cost of care and limit surprise billing practices.
More than half of patients use health plan provider directories to find an in-network clinician that is right for them. Despite industry efforts, however, directory inaccuracies have been a persistent challenge. When directory information is incorrect, patients can be inconvenienced and face financial consequences. To address these issues, policymakers at the federal and state levels are requiring health plans and practices to put processes in place to improve provider directory data.
CAQH CORE Participating Organizations help ensure that operating rules continue to meet evolving business needs, by engaging in the rule development process and maintenance of existing operating rules. Work groups are open to all CAQH CORE Participating Organizations, and multiple individuals from the same Participating Organization may join. Because each organization has only one vote, participants collaborate with their colleagues to submit an organizational-level response during voting periods.
The Attributed Patient Roster Operating Rules establish consistent expectations for the electronic exchange of a roster of patients attributed to a provider under a value-based contract.
The CAQH CORE FAQs are in the process of being updated. CAQH CORE appreciates your patience as these updates are made.
CAQH CORE has produced a variety of online resources to provide education on operating rule implementation and CAQH CORE initiatives.
CAQH CORE has developed interactive tools and dashboards on topics of interest to industry stakeholders.