1. CAQH Provider Data Discussion for NCF
February 8, 2019

2. About CAQH
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.
Member Organizations:

3. CAQH Provider Data Management History
2017
2018
2002
2004
2013
2015
2016
For more than 15 years, CAQH has delivered solutions that solve industry-level challenges in provider data management.
ProView for Groups and Enhanced Data Quality within ProView
A single channel for delegate rosters for provider groups.
Increase accuracy of directory data through machine learning predictive modeling.
VeriFide
Centralized verification of provider credentialing applications to meet NCQA and other standards.
DirectAssure
Provider outreach and reporting to meet Medicare Advantage and other provider directory data validation requirements.
CAQH ProView
Next generation of UPD system.
EnrollHub
Electronic payment and remittance advice information for providers.
SanctionsTrack
Tracking and reporting of disciplinary actions.
UPD
Industry standard self-reported provider database.

4. Directory data accuracy has been a longstanding issue that challenges both providers and health plans
Provider Challenges
Health Plan Challenges
Similar inquiries from different health plans.
Varied data submission requirements.
Incorrect provider contact information.
Provider unresponsiveness.
Incomplete information provided. 1 2 3
Lack of standardized questions.

5. Federal regulatory activity began calling for states to establish specific requirements around provider directories
Regulation
Requirement
HHS Final 2016 Letter to Insurers in the Federally-Facilitated Marketplaces
QHP issuers must update their provider directory information at least once a month.
Includes field-level requirements for data.
Medicare Advantage 2016 Advance Notice
MA organizations must maintain regular, ongoing communications and/or contact providers quarterly.
Medicaid Managed Care 2017 Final Rule
Managed Care Plans must make available provider directories in paper and electronic formats and sets update standards for each.
Requires collection of certain data elements for provider directories.
21st Century Cures Act, 2017
States must publish a directory of physicians participating in the Medicaid program and update it annually (if the program participates in Fee-for-Service or case management).
21st Century Cures Act, 2018 Guidance to State Medicaid Directors
Includes optional and required pieces of information to be included in provider directories (called data elements)
Emphasizes the importance of reuse in the Medicaid Information Technology Architecture (MITA), interoperability, and provider directory ability to support multiple health initiatives.

6. CMS Provider Directory
CMS developed a three pronged approach to directory improvement; initial and subsequent survey results demonstrate high levels of inaccuracy
* Online Provider Directory Review Report.
Centers for Medicare and Medicaid Services, January 31, 2018.
55% of provider directory locations are inaccurate.
55% of providers have at least one deficiency.
60% of errors identified are where the “Provider is not practicing at location.”
Majority of Medicare Advantage plans have between 30 and 60% inaccurate locations.
CMS Provider Directory
Survey Results*
Location inaccuracy remains the most common type of directory error in survey results published in 2018
Direct
Monitoring 2
Compliance/
Enforcement
Actions 3
CMS is using an outside vendor to verify the accuracy of online provider directories.
Assess penalties and enrollment sanctions. 1
Monitoring
Protocol
Developed to advance oversight of the validity and accuracy of online directories, accessibility of network providers, and provider network adequacy standards.

7. Survey results highlight that practice location errors are most commonly fall into the category “provider not practicing at this location”
Breakdown of error types
Overall error rate
‘Provider not practicing at location’ represents the most prevalent directory deficiency and is weighted most heavily in terms of deficiency scoring by CMS.
* Online Provider Directory Review Report. Centers for Medicare and Medicaid Services, January 31, 2018.

8. The industry must lead to improved provider data quality before additional regulations or requirements are implemented
The latest CMS directory review report included language referencing the need for a “centralized repository for provider data”. Excerpt below:
“CMS continues to feel MAOs are in the best position to ensure the accuracy of their provider directories. The active participation and engagement of plan contracted providers is key to improving directory accuracy. Through the insight gained from our reviews, it has become clear that a centralized repository for provider data is a key component missing from the accurate provider directory equation. CMS is currently looking at the provider data the agency collects to determine how it may be used to foster a collaborative industry approach to achieving a centralized location for provider data.
This approach would make data collection and verification more efficient and less burdensome for MAOs and providers, and result in more accurate and timely data sharing. Moreover, a centralized database could allow the current inward facing MAO efforts to have a broader impact. For example, when an MAO identifies a directory error, it is fixed only for their own directory, whereas a corrected error in a centralized database would improve directory accuracy for all MAOs using that system. A centralized database, however, will take time and does not obviate the short-term, immediate need of MAOs to improve directories.” 1
1CMS Medicare Advantage Online Provider Directory Review Report -November 28, 2018.

9. Correcting practice location errors are key for achieving high quality directory data
Prioritized Errors in Directories Based on CMS Data:
Prevalence and Weighting
Increasing audit risk
Decreasing audit risk
Health plans receiving warning letters
Practice Locations
Phone number
Incorrect address
Accept new patients
Incorrect suite
Other errors
Average health plan (2017)
40%
50%
30%
60%
70%
80%
90%
100%
Percentage of practice locations that are accurate

10. Keys to solving challenges in provider data gathering and validation1 2 3
Standardize the
requested content
Streamline the number of requests to update or submit information.
Simplify the data submission and reconciliation requirements.

11. The practice location reconciliation feature allows health plans to receive provider responses specific to health plan location data
Implementation results to date:
780K provider at location records have been processed into ProView from health plans.
To date, providers have responded to 144K practice location records.
Reject rate = 63% (91K addresses)
I don’t know rate = 23%
Accept = 14%
Of the rejected addresses, providers select “No longer practice here” for 55% of the rejected locations.
Providers select “Never practiced here, location is part of my group” for 16% of the rejected locations (locations overreported by provider).
Key Insights
We as an industry are good at adding location
records, but not at terminating them
(55% reject due to no longer practicing at address).
Due to the low “Accept” rate (14%), it appears that most provider are already adding new records in ProView on their own.
By leveraging DirectAssure, the average health plan should see a % accuracy increase.

12. Client case study Challenge: Improve provider data directory quality.
Health Plan Directory Process (prior to implementing DirectAssure):
From Nov – Mar. 2018, 1.2 million phone calls were completed nationally.
The calls resulted in only modest directory improvement.
The process was costly and unsustainable.
Frequent calls resulted in significant provider abrasion.
DirectAssure Goal:
Improve provider data quality to improve member satisfaction through the removal of outdated practice addresses from provider directories and to reduce CMS audit risk.
Decrease operational costs and provider abrasion by limiting calls to targeted use cases.

13. The health plan submitted practice location data to DirectAssure to initiate the practice reconciliation location feature
Health plan systems send provider data to DirectAssure every month.
DirectAssure compares plan practice location data with provider self-attested data in CAQH ProView.
Providers see and reconcile location data CAQH ProView.
Health plans retrieve reports with focus on cleaning up existing records.
Plans keep/publish records that match with CAQH attested data.
Run network check to flag any network adequacy concerns.
Plans terminate locations from DirectAssure results and update their databases.
Plans call providers with unclear data to confirm or terminate locations.

14. Results: 84% Data Accuracy.
Based on an audit post-implementation, plan directory accuracy improved to 84% within the market where DirectAssure 2.0 was implemented
Because providers responded to plan locations on CAQH ProView profiles, the directory records were more accurate.
The health plan performed an internal CMS-style audit of the provider directory records from their DA workflow.
~20K incorrect directory records were terminated using CAQH Location Reconciliation data.
The plan leveraged responses in ProView to replace phone outreach.
Plan regularly reviews data for network adequacy.
Results: 84% Data Accuracy.