The Fifth National Medicaid Congress Plug-and-Play Resources for State Medicaid Programs

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1 The Fifth National Medicaid Congress Plug-and-Play Resources for State Medicaid Programs Sorin Davis, CAQH June 8, 2010

2 Agenda CAQH Overview CORE UPD Case Study: Kentucky State Medicaid Industry Collaboration MITA HIEs CAQH and State Medicaid Programs - Recap Questions & Answers 2

3 An Introduction to CAQH CAQH, an unprecedented nonprofit alliance of health plans and trade associations, is a catalyst for industry collaboration on initiatives that simplify healthcare administration for health plans and providers, resulting in a better care experience for patients and caregivers. CAQH Solutions: Help promote quality interactions between plans, providers and other stakeholders Reduce costs and frustrations associated with healthcare administration Facilitate administrative healthcare information exchange Encourage administrative and clinical data integration Current Initiatives: CORE Committee on Operating Rules for Information Exchange UPD Universal Provider Datasource 3

CAQH Solutions: Help promote quality interactions between plans, providers and other stakeholders Reduce costs and frustrations associated with healthcare administration

4 Committee on Operating Rules for Information Exchange CORE is a multi-stakeholder collaboration of more than 115 participating organizations developing industry-wide operating rules, built on existing standards, to streamline administrative transactions MISSION: To build consensus among the essential healthcare industry stakeholders on a set of operating rules that facilitate administrative interoperability between health plans and providers Enable providers to submit transactions from the system of their choice (vendor agnostic) and quickly receive a standardized response from any participating stakeholder Enable stakeholders to implement CORE phases as their systems allow Facilitate stakeholder commitment to, and compliance with, CORE s long-term vision Facilitate administrative and clinical data integration CORE is not: Building a database Replicating the work being done by standard-setting bodies, e.g., X12 or HL7 4

administrative interoperability between health plans and providers Enable providers to submit transactions from the system of their choice (vendor agnostic) and quickly receive a standardized

5 The CORE Rules are Developed in Phases 5 CORE Phase I Approved Implemented CORE Phase II Approved Implemented CORE Phase III In development CORE s first set of rules are helping: Electronically confirm patient benefit coverage and co-pay, coinsurance and base deductible information Provide access to this information in real-time via common internet protocols and with acknowledgements, etc. CORE s second set of rules expand on Phase I to include: Patient accumulators (remaining deductible) Rules to help improve patient matching Claim status infrastructure requirements (e.g., response time) More prescriptive connectivity requirements with submitter authentication CORE s third set of rules focus on: Claim status data requirements (276/277) Claim Payment/Advice (278), Prior Authorization/Referral (835) infrastructure requirements Standard Health Benefit/Insurance ID Card More prescriptive connectivity requirements as well as digital authentication More eligibility financials

CORE s second set of rules expand on Phase I to include: Patient accumulators (remaining

6 CORE Participation and Certification Participation: Over 115 multi-stakeholder organizations, including CMS, representing all aspects of the industry CORE participants maintain eligibility/benefits data for over 150 million lives, or approximately 75 percent of the commercially insured plus Medicare and state-based Medicaid beneficiaries Certification is achieved by organizations voluntarily operating in accordance with the CORE rules: To date, nearly 50 healthcare organizations are CORE certified Approximately one-third of all commercially insured lives are covered by CORE-certified health plans eservices Group, the first vendor exclusively providing Medicaid service, achieved CORE Phase I and II certification in

achieved by organizations voluntarily operating in accordance with the CORE rules: To date, nearly 50 healthcare organizations are CORE certified Approximately one-third of all

7 Universal Provider Datasource UPD is a utility that replaces multiple health plan and hospital paper processes for collecting provider data with a single, electronic, uniform, Web-based datacollection system (e.g., credentialing) UPD is recognized as the industry standard for self-reported provider data collection Over 820,000 providers are registered in UPD; growing by over 8,000/month Based on the Federation of State Medical Boards (FSMB) 2008 data, more than half of all MD and DO physicians in the United States are registered with UPD UPD has over 550 participating organizations No cost for providers to participate Data refreshed by provider three times each year to support re-credentialing cycles Twelve states and the District of Columbia have adopted the CAQH Standard Provider Credentialing application Adopted by a number of state Medicaid agencies: Kentucky, New York, and Pennsylvania 7

, credentialing) UPD is recognized as the industry standard for self-reported provider data collection Over 820,000 providers are registered in UPD; growing by over 8,000/month Based on the

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9 UPD Case Study: Kentucky Medicaid History In 2007, the state mandated the use of the CAQH UPD form, known in Kentucky as the KAPER (Kentucky Application for Provider Evaluation and Reevaluation) form, for credentialing submissions In 2009, EDS selected UPD to assist with Kentucky Medicaid provider data collection for credentialing and re-credentialing Status Over 16,000 providers in KY are registered with UPD Kentucky Medicaid covers approximately 750,000* or 18% of lives in the state More than 10,000 providers are sharing their CAQH application data with Kentucky Medicaid *Source: Kentucky Cabinet for Health and Family Services Fiscal Year

credentialing and re-credentialing Status Over 16,000 providers in KY are registered with UPD Kentucky Medicaid covers approximately 750,000* or 18% of lives in

10 UPD Case Study: Kentucky Medicaid Current benefits Kentucky Medicaid is using UPD to streamline their credentialing and recredentialing processes and move away from paper submissions and manual data entry Providers that work with commercial plans and Medicaid plan do not need to maintain their information in two systems One set of secure data with uniform update schedule Managed Medicaid growth Missing data can be retrieved more quickly through the CAQH system than old method of provider follow up Considering collection of enrollment data through UPD Will be using CAQH Sanction Track to find unreported provider actions 10

two systems One set of secure data with uniform update schedule Managed Medicaid growth Missing data can be retrieved more quickly through the CAQH system

11 UPD Case Study: Kentucky Medicaid Perspective Physicians Allied Health Vision/Dental Behavioral Providers enter data Online Application System (OAS) Practice Administrator Module (PMM) Kentucky Medicaid Authorized organizations receive data Data Access System (DAS) 11

Application System (OAS) Practice Administrator Module (PMM)

12 Industry Collaboration Overview Activities within CORE and UPD support and integrate with recent state, regional and Federal efforts HITECH: Health Information Technology for Economic and Clinical Health Act Meaningful use (draft specifications currently reference CORE rules) State health information exchange (HIE) efforts MITA: Medicaid Information Technology Architecture Complement direction of ONC office CORE rules have been recommended to legislature by state-sponsored, multistakeholder committees, e.g., TX, OH, and CO The UPD credentialing form is required or designated in 12 states and DC; it is utilized by providers in every state in the U.S. 12

MITA: Medicaid Information Technology Architecture Complement direction of ONC office CORE rules have been recommended to legislature by state-sponsored,

13 Why MITA and CAQH Are Collaborating 13 CAQH and MITA share many key objectives Reduce costs, achieve interoperability, improve efficiency, streamline processes Collaboration allows both efforts to meet their shared vision for increasing efficiency and streamlining the healthcare system Creating baseline requirements for commercial payers has similar challenges to creating baseline requirements for the 50+ Medicaid plans Every provider office has a mix of commercial, Medicaid and Medicare patients Complementary approaches: Like CORE, MITA Technical Architecture Committee (TAC) does not create standards, instead both MITA and CORE recommend the use of existing industry standards MITA TAC is embracing a phased approach, and CAQH has shared lessons learned about its similar approach Given status of UPD and CORE, CAQH has firm understanding of the industry needs for provider data and electronic revenue-cycle related transactions, and MITA is addressing these areas and can meet the identified needs MITA and CAQH both have a guiding principle of keeping business needs in mind

for the 50+ Medicaid plans Every provider office has a mix of commercial, Medicaid and Medicare patients Complementary approaches: Like CORE, MITA Technical Architecture Committee (TAC) does not

14 Health Information Exchange Objective: Align health data exchange at Federal and local levels Creates interoperability among commercial, Medicaid, and Medicare Many state Medicaid agencies are or will be involved in state HIE efforts HIE planning can integrate with CAQH efforts UPD provider data can serve as a content resource for statewide directories A funding opportunity announcement (FOA) from the Office of the National Coordinator (ONC) established an explicit requirement that states offer, as part of their information architectures, statewide provider directories that aggregate provider practice locations, specialties, health plan participation, and disciplinary actions 14

directories A funding opportunity announcement (FOA) from the Office of the National Coordinator (ONC) established an explicit requirement that states offer, as part of

15 CAQH and State Medicaid Programs - Recap CAQH initiatives support Medicaid administrative simplification efforts CORE operating rules support not only commercial, but also Medicaid interests Bringing streamlined administrative services to Medicaid lives; simplifies eligibility check Contributes to uniform and secure data exchange The UPD service can be adopted by state Medicaid agencies as a solution for provider data collection Kentucky, New York, and Pennsylvania have implemented MITA is working closely with CAQH to ensure complementary approaches to industry changes e.g., MITA referencing UPD data schema to ensure alignment as it develops standard UPD can offer content for statewide provider directories, such as those required by HIEs, while facilitating alignment with Medicaid 15

as a solution for provider data collection Kentucky, New York, and Pennsylvania have implemented MITA is working

16 Questions & Answers Sorin Davis 16

Developing Best Practices for Exchanging Healthcare Payment Data

Developing Best Practices for Exchanging Healthcare Payment Data Gwendolyn Lohse, CAQH Jeff Barnett, VeriSign April 28, 2010 Please turn off all cell phones or mobile devices All conference attendees will