Prior authorization (PA) is a common source of frustration in healthcare. According to a recent survey from the American Medical Association, 28 percent of providers reported that the PA process has affected care delivery and led to a serious adverse event. Notably, 88 percent said the burden associated with prior authorization has increased over the last five years for their practice.

Accurate provider directory information is an imperative for the U.S healthcare system. It impacts the ability to find a healthcare provider and plays an important role in access to care. Yet, maintaining up-to-date provider directories is too often a burdensome and highly manual process for both health plans and providers.

The credentialing process can be cumbersome for both healthcare providers and health plans. After provider data collection, health plans defer credentialing decisions until they complete primary source verification (PSV). The PSV process is often time-consuming and results in redundant outreach as multiple plans request the same information from a provider.

CAQH recently announced that Humana has joined the organization as a member health plan and is now represented on the CAQH board of directors. Humana has participated in CAQH initiatives for many years and is strengthening its commitment to streamline healthcare business processes by becoming a member.

In response to the growing need for more streamlined and accurate provider credentialing, CAQH established an end-to-end process that simplifies data collection, primary source verification and sanctions monitoring.

CAQH CORE has continued to work and educate industry leaders on the importance of improving the prior authorization process. At the end of September, the Prior Authorization Subgroup completed the development of draft operating rules, which will now go through the Formal Voting Process.

Last month, the CAQH CORE Board submitted an open letter in support of the Consensus Statement on Improving the Prior Authorization Process, which shares many CAQH CORE goals, such as improved transparency and communications, continuity of patient care and automation and efficiency. Committed to collaborating with industry stakeholders, CAQH CORE is eager to work with the statement’s authoring organizations, which include the American Hospital Association (AHA), America’s Health Insurance Plans (AHIP), American Medical Association (AMA), American Pharmacists Association (APhA), Blue Cross Blue Shield Association (BCBSA) and Medical Group Management Association (MGMA). The 2017 CAQH Index found that healthcare provider and health plan adoption of standard prior authorization transactions was only eight percent--one of the lowest adoption rates of all transactions measured in the report. The proportion of prior authorization transactions conducted using that standard actually declined by more than 10 percentage points in comparison to the 2016 CAQH Index. However, automating prior authorization could result in savings of $6.84 per transaction.

HealthCare Administrative Solutions (HCAS), a non-profit organization of Massachusetts-based health plans, has chosen DirectAssure® after an extensive search for a solution to improve healthcare provider directories in the state. With DirectAssure, providers enter their directory information changes once and share them with multiple plans. The solution works in concert with CAQH ProView®, an online database used by more than 1.4 million providers nationwide to maintain their professional and practice information. DirectAssure asks providers to compare and verify practice location information within health plan records and confirm whether they accept specific insurance plans and if they are accepting new patients.

CAQH has achieved Certified status for information security by the Health Information Trust (HITRUST) Alliance. The HITRUST certification validates that CAQH meets key healthcare regulations and requirements for protecting and securing sensitive private healthcare information. The certification applies to CAQH infrastructure, security and privacy programs and the entire portfolio of CAQH Solutions (CAQH ProView, DirectAssure, VeriFide, EnrollHub, SanctionsTrack and COB Smart).

The Provider Data Action Alliance (PDAA), a diverse group of 20 healthcare leaders convened by CAQH, has released a roadmap outlining recommendations to address provider data issues impacting healthcare providers, patients and health plans. The industry spends $2 billion annually to maintain provider data, yet errors and inefficiencies remain, disrupting many crucial processes in the healthcare system. “An Industry Roadmap for Provider Data” outlines a core set of principles that can guide the development of an industry solution, a model for what the provider data system should look like and a plan to implement the vision and ensure industry support.