TABLE 19-2Policy-Related Approaches—CAQH Examples

Policy-Related Approach and ExampleApproachTacticsBenefit
Phase in efforts with existing priorities
Example: CORE and 5010
CORE builds on existing standards (e.g., HIPAA, HTTP) and encourages a uniform and more extensive adoption of the standards based on business prioritiesCORE Phase I and II rules related to eligibility data content (YTD deductibles, copays, service-level financials) were developed with the 5010 regulation in mind; although at the time, the deadline for 5010 compliance was not yet established. Moreover, CORE certification required attestations from entities that they were HIPAA compliant, and tested them that they were using aspects of 5010 that were needed by providers but would not be required under HIPAAEntities becoming CORE Phase I and II certified are assured CORE certification testing aligns well with the now established 5010 compliance date of January 2012, and thus CORE assists these entities in reaching an existing priority. CMS, along with CAQH, BCBSA, and HIMSS, supported a demonstration of this at HIMSS 2009. This demonstration communicated to the industry that the established deadline for 5010 was reachable and certain entities were already deciding to go further than the minimum requirements
Align efforts with federal HIT policies
Example: CORE and HITECH
A key CORE guiding principle is alignment with federal HIT policiesCORE was launched a few months after the ONC was established. As the federal HIT clinically focused landscape evolved, CORE alignment evolved
  • Prior to HITECH, CORE rules were recognized by HITSP, and the CMS Medicaid Information Technology Architecture (MITA) effort had a goal to collaborate with CORE
  • As HITECH unfolded, CAQH communicated regarding the need for providers to use HITECH dollars for administrative simplification efforts and clinical or administrative interoperability. CAQH also participated in HITSP Tiger Team efforts; CORE rules—data content and connectivity—are incorporated into draft meaningful-use technical requirements
HITECH sends a message that administrative and clinical interoperability is a goal; furthermore, data show that providers can use administrative simplification savings to further clinical efforts
Gain multistakeholder support through state, federal, and industry leaders and policy makers
Example: Leaders Guide UPD and CORE
Both CORE and UPD were designed and continue to evolve based on the essential involvement of federal, state, and industry leadersDirect leadership involvement (e.g., UPD scope) was driven based on feedback from national provider associations; director of CMS E-Health Office serves on CORE Steering Committee
Early adopters (e.g., UPD, CORE) were driven by top-down commitments from health plan CEOs
State outreach (e.g., range of CORE and UPD participants are presenting to state-sponsored committees regarding ways to achieve their regional goals using existing national efforts rather than creating state-specific administrative simplification efforts; HIEs are critical to this)
Federal outreach (e.g., CORE chair met with Senate Finance Committee and Congressional Budget Office)
Through collaboration and sharing ideas on what drives change, leaders are actively encouraging a more streamlined and effective U.S. system that does not promote duplication or add unnecessary cost
Surmount barrier posed by inevitable changes to current business practices
Example: UPD and PSV
State government, providers, and health plans have asked CAQH to consider if the next stage for UPD is to offer PSVCAQH met in-person with key entities that currently conduct PSV. The purpose of these meetings was to understand their strategic drivers and cost structures and gain their opinions on potential industry approaches to remove costs and reduce administrative burden. As a result of these meetings, CAQH developed a white paper outlining the opportunities and challenges in centralizing PSV for the industry. In September 2009, a meeting will be held with key stakeholders to discuss the opportunity as well as the challengesStakeholders currently conducting PSV are openly discussing the benefits and challenges of creating a uniform approach, including impact on their internal strategies and financials. Without such openness, a lasting industry change could not be identified as a potential short-term industry goal

NOTE: BCBSA = Blue Cross and Blue Shield Association; CAQH = Council for Affordable Quality Healthcare; CEO = Chief Executive Officer; CMS = Centers for Medicare & Medicaid Services; CORE = Committee on Operative Rules for Information Exchange; HIE = health information exchange; HIMMS = Healthcare Information and Management Systems Society; HIPAA = Health Insurance Portability and Accountability Act; HIT = health information technology; HITECH = Health Information Technology for Economic and Clinical Health; HITSP = Healthcare Information Technology Standards Panel; HTTP = hypertext transfer protocol; PSV = primary source verification; UPD = Universal Provider Datasource; YTD = year-to-date.

From: 19, Administrative Simplification

Cover of The Healthcare Imperative
The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary.
Institute of Medicine (US) Roundtable on Evidence-Based Medicine; Yong PL, Saunders RS, Olsen LA, editors.
Washington (DC): National Academies Press (US); 2010.
Copyright © 2010, National Academy of Sciences.

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