CAQH Provider Data Discussion for NCF February 8

About 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: ©. 2018 CAQH, All Rights Reserved. 2

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

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. 1 Incorrect provider contact information. Varied data submission requirements. 2 Provider unresponsiveness. Lack of standardized questions. 3 Incomplete information provided. © 2018 CAQH, All Rights Reserved. 4

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. 21 st 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). 21 st 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. ©. 2018 CAQH, All Rights Reserved. 5

CMS developed a three pronged approach to directory improvement; initial and subsequent survey results demonstrate high levels of inaccuracy 3 1 2 Monitoring Protocol Direct Monitoring Compliance/ Enforcement Actions CMS is using an outside vendor to verify the accuracy of online provider directories. Assess penalties and enrollment sanctions. Developed to advance oversight of the validity and accuracy of online directories, accessibility of network providers, and provider network adequacy standards. CMS Provider Directory Survey Results* Location inaccuracy remains the most common type of directory error in survey results published in 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. * Online Provider Directory Review Report. Centers for Medicare and Medicaid Services, January 31, 2018. © 2018 CAQH, All Rights Reserved. 6

Survey results highlight that practice location errors are most commonly fall into the category “provider not practicing at this location” Breakdown of error types Incorrect suite number [VALUE] Overall error rate Other errors [VALUE] Not accepting new patients [VALUE] [CATEGORY NAME] [VALUE] Incorrect address [VALUE] [CATEGORY NAME] [VALUE] Provider not practicing at location [VALUE] Inaccurate phone numbers [VALUE] ‘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. © 2018 CAQH, All Rights Reserved.

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 1 CMS Medicare Advantage Online Provider Directory Review Report -November 28, 2018. ©. 2018 CAQH, All Rights Reserved. 8

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 Accept new patients Average health plan (2017) Phone number Health plans receiving warning letters Other errors Incorrect address Incorrect suite Practice Locations 30% 40% 50% 60% 70% 80% Percentage of practice locations that are accurate © 2018 CAQH, All Rights Reserved. 9 90% 100%

Keys to solving challenges in provider data gathering and validation 1 Standardize the requested content ©. 2018 CAQH, All Rights Reserved. 2 3 Streamline the number of requests to update or submit information. 10 Simplify the data submission and reconciliation requirements.

The practice location reconciliation feature allows health plans to receive provider responses specific to health plan location data Implementation results to date: § § 780 K provider at location records have been processed into Pro. View from health plans. Key Insights To date, providers have responded to 144 K practice location records. v We as an industry are good at adding location records, but not at terminating them (55% reject due to no longer practicing at address). Reject rate = 63% (91 K addresses) I don’t know rate = 23% Accept = 14% § v Due to the low “Accept” rate (14%), it appears that most provider are already adding new records in Pro. View on their own. 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). ©. 2018 CAQH, All Rights Reserved. v By leveraging Direct. Assure, the average health plan should see a 20 - 25% accuracy increase. 11

Client case study Challenge: Improve provider data directory quality. Health Plan Directory Process (prior to implementing Direct. Assure): § § From Nov. 2017 – 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. Direct. Assure 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. ©. 2018 CAQH, All Rights Reserved. 12

The health plan submitted practice location data to Direct. Assure to initiate the practice reconciliation location feature Health plan systems send provider data to Direct. Assure every month. Direct. Assure compares plan practice location data with provider self-attested data in CAQH Pro. View. Providers see and reconcile location data CAQH Pro. View. 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 Direct. Assure results and update their databases. Plans call providers with unclear data to confirm or terminate locations. ©. 2018 CAQH, All Rights Reserved. 13

Based on an audit post-implementation, plan directory accuracy improved to 84% within the market where Direct. Assure 2. 0 was implemented Because providers responded to plan locations on CAQH Pro. View 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. ©. 2018 CAQH, All Rights Reserved. ~20 K incorrect directory records were terminated using CAQH Location Reconciliation data. The plan leveraged responses in Pro. View to replace phone outreach. 14 Plan regularly reviews data for network adequacy. Results: 84% Data Accuracy.