Provider Data: A Fundamental Need for Collaboration

Transcription

1 Provider Data: A Fundamental Need for Collaboration February 4 th, 2016

2 Executive Summary Accurate and timely provider data continues to be a foundational necessity for both care delivery and financing of healthcare. With the US healthcare system moving to value-based payment models, the needs surrounding provider-specific information will only continue to expand. Today, billions of dollars are being spent each year to collect and maintain this information, yet the data quality and related processes have significant room for improvement. The reality of these overarching challenges are being experienced in all sectors including provider organizations, Federal and state government entities and health plans. As the industry undergoes transformation, the time is right to seek public-private collaboration. 2

3 Panelists Atul Pathiyal, Managing Director Solutions, CAQH Tim Kaja, SVP, United Healthcare Mariann Yeager, CEO, The Sequoia Project Topics each organization will cover: How each organization has been using provider data. Challenges they have been facing and areas where they have been able to successfully resolve some of the challenges. Opportunities and how they are working to solve the challenges by collaborating within or outside their organization. 3

4 Panelist Atul Pathiyal, Managing Director, CAQH 4

5 Provider Data Defined Websites and Directories Privileging and Credentialing Quality, Contracts and Payments Industry CAQH ID Sanctions Malpractice Medicare Opt-out Medicaid Opt-out ECP Health System and Health Plan Relationship Accepting New Patients Network Participation Ratings Contract Name Contract Dates Tier Credentialing Status Credentialing Dates Fee Schedule Quality Measures Clinical Measures Electronic Credentials Organization Practice Name Location/ Phone # Hours Accessibility Languages/ Limitation Affiliations Privilege Status Tax ID NPI Coverage Contact Name Contact Type Contact Address Contact PLI Carrier Name Coverage Amount Coverage Dates Personal Information First Name Last Name Date of Birth Gender Languages Phone Number Highest Level of Education Degree Internship/ Residency Certifications Specialty Board SSN DEA # CDS # NPI # Medicare # Medicaid # Work History Reference Disclosure Malpractice Ethnicity Citizenship PLI Carrier Name Coverage Amount Coverage Dates Public Data Set 5

6 Uses of Provider Data Federal / State Marketplace Lack of provider information at the time of enrollment. Members/ Patients Submit providernetwork information to exchanges on frequent basis. Multiple formats and channels for data files submission. Health Plan Submit encounter and provider information for auditing. Submit network and provider information. Multiple systems to maintain provider information. Redundant process and high manual intervention to maintain data. Source data through multiple channels including providers. Provider Databases Submit patient and provider information. Maintain same information with multiple payers. Delayed enrollment, onboarding, reimbursement. Health Information Exchanges Incorrect or missing provider information. Unable to share / receive timely patient health information. Members / Patients Lack of provider information at the time of enrollment. Service denial due to outof-network info identified at point of service. Incur unexpected out-ofnetwork costs due to lack of necessary information. Government (Medicare / Medicaid) Increase in time spent on admin processes than patient care. Patient abrasion when cannot see them due to out-of-network coverage. Bad collections due to out-of-network costs regulation. (e.g. NY surprise bill) Information collected from providers to support enrollment, cost & quality reporting, fraud & abuse detection. Maintain multiple systems to manage provider information. Provider Databases Provider Need to maintain same information at multiple places for different business purposes such as enrollment, ownership declaration, quality submission. 6

7 Provider Data Challenges Providers Health plans Members Government/ Industry Calls and inquiries from multiple stakeholders to obtain and reconfirm provider information. Need to store and maintain information in multiple locations. Decrease in focus and time on patient care. Patient abrasion due to incorrect directory/network information. Impacts revenue cycle management due to decreased or delayed claims reimbursement. Expensive, manual, redundant and inefficient processes to manage data across different. functional areas that require provider information. Lack of agility to respond to market forces with new business capabilities. Increase in penalties and brand erosion due to lack of compliance with regulatory requirements. Increase in provider and member abrasion. Lack of provider information at the time of enrollment impacts ability to make informed healthcare decisions. Incorrect or missing provider information on the directory lead to service denial or delayed services. Increased of out-of-pocket costs due to lack of transparency and visibility into payer networkprovider information. Expensive, manual, redundant and inefficient processes to manage data across different. functional areas that require provider information. Lack of agility to respond to market forces with new business capabilities. Increase in provider and member abrasion. Lack of transparency in overall care delivery processes and medical economics. 7

8 Emerging Market Forces Expansion of Government Programs Cost Pressure New Payment and Delivery Models Transparency Emerging Market Forces Expansion of government-run programs increases scrutiny on network data. New regulations will result in increased burden on providers as health plans are required to validate provider information more frequently. Incorrect provider data can cause administrative and operational inefficiencies across organizations that are dependent on the data. Industry participants are shifting from volume to value-based care models. Interoperability across provider organizations (e.g., HIEs) requires exchange of accurate provider data. New payment models require tighter crossfunctional integration between systems and more accurate data for patient engagement, care management and analytics. Evolution of digital solutions in the industry require accurate provider data. There is an increased demand for network data transparency to improve consumer engagement.. Imperatives for Provider Data Management Simplify provider data management to minimize administrative cost within provider organizations and health plans, reduce delays in related business processes, increase compliance and enhance the overall member and provider experience. Standardize protocols and establish data governance. Eliminate error-ridden paperwork through automation. Reduce technology spending through industry-wide utilities. Re-position provider data challenges as a shared responsibility among industry stakeholders. 8

9 Value-Based Care Health Plan Risk Provider Risk Provider Data Functional Areas Compliance & Regulatory Reporting Network Management Care Delivery Claims & Payments Member Service Pay For Performance Bundled Payment ACO Regulatory scrutiny on provider data will increase as new government-sponsored products emerge and increase in popularity. Severe penalties for gaps in network. Accurate demographic information is needed within provider organizations and health plans for faster setup of MCO and value-based networks. Increased contracting timeframes due to relationship complexity within and across provider organizations. Member attribution within care management programs will require accurate provider information within provider organizations and health plans. Current claims-based approaches to acquiring provider data will no longer be effective as care is measured using episodes or other non-claims based methodologies. Demand for greater transparency, knowledge and choice from patients through digital tools. Regulatory requirements will extend to new reimbursement models. Greater need for accurate information for the directory so that members can contact and seek care from preferred in-network providers. New reimbursement models and increasing network complexity and will exacerbate the provider data management problem 9

10 CAQH ProView Industry-wide utility focused on collecting provider-attested information electronically in lieu of various credentialing and other forms used by health plans, hospitals and other organizations. - More than 1.3 million unique providers users of all types, including non-physicians (~7,000 new providers register each month). > Providers incur no fee for using ProView. All costs are covered by participating organizations. - Over 800 participating health plans, hospitals, provider groups, state Medicaid agencies and other organizations. - Includes over 300 key data elements about each provider. - Twelve states and the District of Columbia have adopted the CAQH Standard Provider Credentialing Application. - Strong industry support, including MGMA, AAFP, ACP, AMA, and AHIP. - Approved by NCQA, URAC and the Joint Commission for provider self-reported data collection for credentialing. CAQH ProView was launched as a redesigned platform in March 2015 to introduce new capabilities that address a wider array of provider data challenges, including provider directory data confirmation. 10

11 How It Works Submit / Attest to Comprehensive Data Set CAQH ProView Solution Submit Roster Self-Attested Data Collection Health Plans Supporting Documents Healthcare Providers Data Upload Credentialing Application Support Third Party Data Validation Extract Data File Hospitals and Entities Alerts, Prompts and Notifications Data Augmentation Real Time Web Services Govt. & State Agencies CAQH is working on features to address the needs of medical groups and delegated entities, including the ability to bulk upload and manage a full panel of physicians. 11

12 Panelist Tim Kaja, SVP, United Healthcare 12

13 Panelist Mariann Yeager, CEO, The Sequoia Project 13

14 The Sequoia Project Trusted Convener of Industry & Government to Address Health IT Interoperability 14

15 Provider Directory Functions for Clinical HIE A directory supports querying and management of healthcare provider information, including electronic endpoint to facilitate trusted communications among networks and providers Allows participants in a network to find and connect to other participants / providers, without the need to contact each other manually Retrieve participant and provider information in order to obtain connection technical information Query the directory to acquire information Of a subset of participants or providers in a particular geography or other target To acquire information for a particular participant / provider based on particular identifiers 15

16 Broad Provider Directory Use Cases White pages lookup (retrieve by name of the org or person) Yellow pages lookup (query by a large number of criteria such as language spoken, geography, certifications, etc.) Automated consent (e.g. to indicate who the patient authorizes to receive a copy of the information) Disaster response (identify a specialist) Referrals (e.g. identify a treating provider to route clinical document) Electronic communication end point (e.g. look up by name, use case supported treatment, public health, types of content supported, version of specs supported, etc.) Provider network affiliations Queries based upon a provider s relationship to an organization to identify People associated with an organization (e.g. all providers in a hospital ED) Organizations associated with a person (e.g. where providers practice) Organizations associated with an organization (e.g. parent organization with multiple locations) Direct Project and x.509 cert lookup 16

17 Challenges Data quality Administration, maintenance of data Detecting, managing conflicting data Reconciling duplicate data from multiple sources No clear, unified national strategy for provider directories Industry focused on particular technical approaches instead of defining common use cases Unclear direction on which standards to employ Differing views on federation vs centralized approaches Immature specifications Opportunities Federal leadership in a national strategy for provider directors Collaborate with other industry efforts to solidify a common direction Active engagement in standards development efforts (e.g. IHE, HL7 Argonaut) Leverage lessons learned from existing efforts (e.g. admin, clinical HIE, etc.) 17

18 18 For more information:

19 Q&A for the Panel What should the industry do to better accommodate growing complexity of provider organizational, relationship and contracting structures? In two years, where do we envision the national strategy for provider data will or can be? Which stakeholders should be at the table when developing this national strategy? To get involved in this conversation, contact Mano Kalathil: 19