Universal Credentialing DataSource Overview for Participating Organizations

1
Universal Credentialing DataSourceOverview for
Participating Organizations
2
An Introduction to CAQH

• The Council for Affordable Quality Healthcare
  (CAQH) is a not-for-profit
• alliance of health plans and networks that
  promotes collaborative
• initiatives to
• Make healthcare more affordable
• Share knowledge to improve quality of care
• Make administration easier for physicians and
  their patients

3
Member Organizations
4
Areas of Focus

• CAQH is working in two major areas with focus on
  designing and
• implementing achievable, concrete initiatives
• Administrative Simplification Making
  administration easier for physicians and
  consumers
• Universal Credentialing DataSource
• Formulary DataSource
• Industry Standard Terminology
• Quality of Care and Patient Safety Working with
  physicians and professional organizations
  to improve overall health care quality through
  national initiatives
• Save Antibiotic StrengthSM
• HeartBBEAT for LifeSM

5
Administrative Simplification Universal
Credentialing DataSource
6
What Is Credentialing Today and Why Is It Done

• Systematic process employed by health plans,
  hospitals and other healthcare organizations to
  determine whether providers meet each
  organizations respective quality standards for
  participation.
• Performed by virtually all organizations for
  network quality, risk management and
  accreditation reasons.
• Data collected via credentialing processes may be
  used within other business areas such as
  contracting, provider directories, member
  services and claims processing.
• Return on investment is difficult to measure.

7
What Steps Are Involved
1 Credentialing Data Collection
3 Credentialing Review and Decision
2 Credentials Verification (PSV)

1. Health plans, hospitals and other organizations
   typically use paper applications to collect
   self-reported data from providers (education,
   training, experience, etc.).
2. Each organization then verifies certain
   provider-reported data against primary sources
   (Primary Source Verification or PSV) either
   internally or via a Credentials Verification
   Organization (CVO).
3. The organization presents the verified
   information to a review committee who makes an
   independent decision about whether the provider
   in question meets that organizations standards
   for participation.

8
Data Collection Is the Most Inefficient Step
40 Obtaining a complete application
25 Primary Source Verification
35 File preparation, committee review, appeals,
etc.
0
20
40
60
80
100

• Manual process, usually involving combination of
  mail, fax, phone, and sometimes even office
  visits
• Requires long lead time, and is primary reason
  why process begins 4-6 months before actual
  decision is made
• Once application is complete, remaining steps
  proceed quickly

• Automated process in most larger plans
• Sometimes involves expensive licensing fees and
  strict sharing restrictions
• Third-parties often involved

• Moving toward automation business rules enable
  plans to identify providers who require further
  research
• Major component of file preparation is ensuring
  time-sensitive information meets freshness
  standards when presented to committee

Based on discussions with health plan
representatives
9
Problems with Traditional Data Credentialing
Processes

• The first step of the credentialing process has
  the following problems
• Redundancy Providers are asked to complete
  multiple forms essentially requesting the same
  information.
• Follow-up Omitted and illegible responses
  requires significant resources and result in
  delays to timely processing.
• Misalignment Different credentialing cycles
  exacerbate the problem by requiring providers to
  complete the process at different points in time
  for different health plans and other
  organizations that perform credentialing.
• Off-cycle updates Diligent follow-up is required
  to maintain accurate data between credentialing
  events so that provider directories, referral,
  claims and other provider and member services are
  effective.
• Turnaround Providers are frustrated with time
  between application submission and when a
  decision is finally communicated back despite
  significantly improved processing by health plans

10
The Solution Universal Credentialing DataSource

• One physician, One application, One source
• Replace multiple plan-specific paper processes
  with a single, uniform data collection system
• Key features include
• Completely free for providers to use
• Providers can complete application online via
  interview-style questions or fax paper copy
• Supporting documents are collected, imaged and
  attached to electronic record
• Participating organizations can access data in
  electronic format at any time if authorized by
  provider
• Data maintained in a Perpetual State of
  Readiness to avoid problems with differing
  recredentialing cycles refreshed every 90 days
• Updates can be made at any time and are
  immediately available to authorized organizations
• 128-bit Secure Socket Layer Encryption (SSL)
• Toll-free help desk to assist providers

11
Basic Overview
User Group
Provider Advisory Panel
CAQH
Via Internet or Fax
Physicians
CAQH Universal Credentialing DataSource
Health Plans
Chiropractors
Podiatrists
Hospitals
Practice Administrator Module
Data Access System (DAS)
Online Application System (OAS)
Mid-level Providers
Other Healthcare Organizations
Allied Health Providers
- - - - - To be implemented in 2004
12
Benefits for Participating Organizations

• Participation in the Universal Credentialing
  DataSource initiative offers the
• following benefits to health plans, hospitals and
  other healthcare organizations
• Flexibility Participating organizations are free
  to independently determine best options for
  primary source verification, including internal
  and third-party avenues.
• Affordability Not-for-profit status ensures that
  fees are kept low, and any revenue beyond
  expenses are redirected toward further system
  improvements.
• Efficiency Typically redundant data collection
  efforts are replaced with single, industry-wide
  system that allows participating organizations to
  focus on using data rather than chasing
  applications.
• Automation Availability of electronic data
  enables participating organizations to move away
  from manual, paper-based processes.
• Provider Relations Participation in initiative
  demonstrates leadership in industry and
  willingness to alleviate key factors in provider
  dissatisfaction.

13
Areas of Impact for Participating Organizations

• Data errors and inconsistencies across
  departments
• Inefficient claims processing due to erroneous
  billing information
• Lack of electronic contact information for
  provider relations activities
• Hassle factor for providers

Tier 3 Other Inefficiencies

• Provider directory maintenance
• Other member service functions
• Recruiting and network development paperwork
• Provider data maintenance and other plan-wide IT
  operations
• Application and supporting document storage and
  retrieval

Tier 2 Non-Credentialing Costs

• Tier 1 Direct and Indirect Costs
• Pre-population and preparation of application
• Mailing/handling of application (send-out and
  receipt)
• Follow-up contacts to providers, chasing of
  application
• Application completeness review
• Data entry and/or scanning of applications and
  supporting documents
• Archiving and offsite paper storage
• IT support for application database maintenance
• Provider relations field activity associated with
  follow-up
• Management

14
Early Results from Current Participants

• Reduced Mailings After 20 months of aggressively
  promoting the CAQH credentialing initiative, 72
  of a plans providers in Colorado have
  successfully completed their applications no
  more outreach required
• Result 36 fewer providers to contact via mail
  each month during remaining 16 months of 3-year
  recredentialing cycle
• Turnaround One plan has found that applications
  submitted via the CAQH system usually require
  little follow-up with provider offices
• Result Quicker plan credentialing decisions on
  CAQH applications

• Paperless While an automated solution is being
  developed, a plans data entry personnel
  currently toggle between CAQH-supplied electronic
  images and their respective data entry screens
• Result Reductions in printer costs, paper
  procurement, filing needs and offsite archiving
  because applications can be viewed and stored
  electronically
• Automation One plan downloads raw data directly
  from the CAQH system into its provider data
  system, which in turn feeds other systems.
• Result Reductions in data entry resources, and
  improvement in data quality

15
Media Coverage Highlights to Date
Healthplan Magazine
16
How It Works

• 1. Participating health plans and other
  healthcare organizations submit a roster of their
  respective providers to CAQH. Alternatively,
  health plans can create their roster online via
  the participating organization side of the system
  called the Data Access System (DAS).

Online tool to help participating organizations
add providers to their roster
17
How It Works

• 2. CAQH mails Registration Kits to all unique
  providers appearing on at least one submitted
  roster. The Registration Kit contains a unique
  CAQH Provider ID, as well as instructions on how
  to access the provider side of the system
  called the Online Application System (OAS).

Welcome screen for Online Application System
(OAS) where new users can register
18
How It Works

• 3. Once in the system, the provider creates a
  username and confidential password. With this
  username and confidential password, the provider
  can begin to complete the application online. If
  the provider prefers, a paper application can be
  requested from the toll-free help desk.

Interview-style questions help providers navigate
application one section at a time
19
How It Works

• 4. Before the completed application is available
  to any participating organization, the provider
  must authorize release of his or her data. All
  of the organizations who have included the
  provider on their respective rosters are listed
  here for the provider to review and authorize.

Authorization screen ensures providers have
complete control over which organizations have
access to their information
20
How It Works

• 5. The provider must then generate a fax cover
  sheet and fax any required supporting documents
  to a toll-free fax number. These documents are
  imaged and attached electronically to the
  providers file.

The last step for providers is to fax all
necessary supporting documentation
21
How It Works

• 6. Once the application is complete, authorized
  participating organizations are sent data in
  their preferred format (A) ASCII (B) XML or,
  (C) static PDF images of applications.
  Subsequent updates to data are also available in
  the same formats.

A
Complete applications can be retrieved by
participating organziations in the format of
their choice
B
C
22
Who Is Involved So Far?
The list of participating organizations continues
to grow, and includes non-member organizations
(as of 2/12/04)

• Aetna
• Anthem Blue Cross and Blue Shield
• AultCare
• Blue Cross Blue Shield of Georgia
• Blue Cross Blue Shield of Kansas City
• Blue Cross Blue Shield of Michigan
• Blue Cross Blue Shield of Missouri
• Blue Cross Blue Shield of North Carolina
• Blue Cross of California
• CareFirst Blue Cross Blue Shield
• CIGNA Healthcare
• Culpeper PHO
• Community Care Physicians
• Empire Blue Cross Blue Shield
• Excellus Health Plan
• The First Health Network

• Great-West Healthcare / One Health Plan
• Health Net, Inc.
• HealthLink
• HealthPlan of Michigan
• Horizon Blue Cross Blue Shield of New Jersey
• Independent Health
• Kaiser Foundation Health Plan of the Mid-Atlantic
  States
• MAMSI Health Plans
• MultiPlan, Inc.
• Oxford Health Plans
• Preferred Care
• Rocky Mountain Health Plans
• Sentara Healthcare
• UNICARE
• Virginia Premier
• Part of WellPoint Health Networks

23
Progress to Date

• Over 42,000 providers have already successfully
  completed the CAQH application via the paper or
  online process and the numbers are increasing
  daily
• Launched in 43 states and District of Columbia
  (as of 2/12/04 remaining states to launch
  shortly)
• Over 69,000 providers have already registered
  with system in all launched markets
• Providers who have used the Universal
  Credentialing DataSource thus far have
  relationships with an average of 4 participating
  organizations over 160,000 legacy credentialing
  applications have been eliminated
• Once complete, providers will no longer need to
  submit additional credentialing paperwork as new
  organizations join initiative

24
Costs

• The CAQH credentialing solution is completely
  free for providers to use.
• Participation is offered to all organizations
  membership in CAQH is not required.
• Participating organizations are charged a
  standard fee per provider per year for unlimited
  access to data and any updates received, plus a
  small annual administrative fee for the
  organization overall just enough to cover the
  operating costs
• Organizations will only be charged for providers
  whose applications are complete and are
  authorized for release
• Automation and timely provider data will likely
  result in
• organizational savings that offset the costs to
  participate

25
How to Get Started

• Contact CAQH for more information
• Atul Pathiyal Project Director,
  Credentialing apathiyal_at_caqh.org 202-778-3285
• Schedule system demonstration
• Review and execute contract
• Prepare roster of providers and submit to CAQH
• Begin downloading provider information from
  Universal Credentialing DataSource

26

• www.CAQH.org