Achieving CAQH Adoption in Rhode Island
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1 Achieving CAQH Adoption in Rhode Island Christopher Dooley, MBA, FACHE Executive Director Women & Infants PHO, Inc. & Kent County Health Services, Inc.
2 Rhode Island Health Care Market Overview 11 Acute Care Hospitals 2 large hospital systems Care New England (3 hospitals) Lifespan (4 hospitals) 4 Independent smaller community hospitals 3,000 licensed physicians 6,000 allied health providers 2
3 Rhode Island Region 3
4 Journey to CAQH Adoption in Rhode Island PHO responsible for centralizing payer application/credentialing process for 200+ Hospital employed physicians RI legislation establishes Health Insurance Commissioner CAQH mandated as universal credentialing application for RI payers CAQH invites PHO to Co-chair national user group forum RI HMO Association failed attempts to create a single credentialing application CAQH Application announcement PHO initiates payer provider discussions locally OHIC Professional Provider-Health Plan Work Group established by legislation. CAQH conducts information sessions in RI Local payers transition provider networks to CAQH PHO initiates local CAQH User Group 4
5 Journey to CAQH Adoption in Rhode Island December 2002 PHO responsible for centralizing payer application/credentialing and contracting for 200+ Hospital employed providers February 2003 CAQH Universal application announcement March 2003 PHO initial contact Atul Pathiyal from CAQH March 2003 PHO surveys 15 regional health plans (RI and MA) about plans to accept CAQH September 2003 PHO hosts CAQH information meeting for the regional health plans. 5
6 Journey to CAQH Adoption in Rhode Island July 2004 The Office of the Health Insurance Commissioner (OHIC) was established by legislation in 2004 to broaden the accountability of health insurers operating in the State of RI. Under this legislation, the Office is dedicated to: Protecting consumers Encouraging fair treatment of medical service providers Ensuring solvency of health insurers Improving the health care system s quality, accessibility and affordability 6
7 Journey to CAQH Adoption in Rhode Island January 2005 RI Health Care Reform Act of 2004 was amended to establish the Professional Provider-Health Plan Work Group a subcommittee of the Health Insurance Advisory Council, which was chartered to develop a plan to implement the specific activities as outlined in (RI Health Care Reform Act of 2004): By January 1, 2006, a method whereby health plans shall disclose to contracted providers the fee schedules used to provide payment to those providers for services rendered to covered patients By April 1, 2006, a standardized provider application and credentials verification process, for the purpose of verifying professional qualifications of participating health care providers By September 1, 2006, a uniform health plan claim form to be utilized by participating providers By December 1, 2006 contractual disclosure to participating providers of the mechanisms for resolving health plan/provider disputes By February 1, 2007 a uniform process for confirming in real time patient insurance enrollment status, benefits coverage, including co-pays and deductibles A report on the work of the subcommittee shall be submitted by the health insurance commissioner to the joint legislative committee on healthcare oversight on March 1, 2006 and March 1,
8 Journey to CAQH Adoption in Rhode Island Pursuing the Legislative Route Governor Legislature RI Health Insurance Commissioner Joint Legislative Committee on Health Care Oversight Health Insurance Commissioner Advisory Council Professional Provider Health Plan Work Group 8
9 Journey to CAQH Adoption in Rhode Island February 2005 Sorin Davis, CAQH presents the Universal Data Application to Professional Provider-Health Plan Work Group April 2005 Sorin Davis, CAQH presents to RI MGMA April 2006 RI Health Insurance Commissioner mandates health plans to accept the CAQH Universal application as of October 1,
10 10
11 Legislative Advocacy Efforts for CAQH Adoption in Rhode Island Christopher Koller, RI Health Insurance Commissioner and Pat Huschle, OHIC Provider-Health Plan Liaison discussing administrative simplification and CAQH option with Professional Provider-Health Plan Work Group. Chris Dooley meeting with U.S. Senator Sheldon Whitehouse and U.S. Senator Jack Reed to gain support for CAQH adoption efforts in RI. Chris Dooley meeting with RI Senator, Elizabeth Roberts, Chairperson of the Joint Legislative Comm. on Health Care Oversight to gain support for CAQH adoption efforts. 11
12 12
13 After 3-year journey, Rhode Island accepts CAQH October
14 RI Health Insurance Commissioner Commenting on CAQH adoption efforts: "The CAQH standards were very useful for us in RI. They were industry-accepted and from a reliable third party. We did not have to develop them ourselves. The small RI market and the broad powers of the Health Insurance Commissioners Office created the opportunity for collaboration and their implementation - which was much preferable to more traditional legislative or regulatory mandates. It is a model for how to achieve the administrative efficiencies that purchasers - facing cost pressures - are demanding of health plans and providers. Christopher Koller 14
15 CAQH Selects WIPHO as Co-chair for National User Group 2007 PHO initiated local RI CAQH Users group to support adoption and provide tips tools for new users 2008 User Group expands to include MA and CT practice managers 2009 CAQH invites Jacalyn LaTorre, PHO CAQH Specialist to serve as the Co-Chair for CAQH National User Group effort 15
16 Challenges Payers reluctant to change internal processes Providers need to complete CAQH data completely and accurately Attesting to CAQH every 120 days is difficult, but important Next Steps Advocate for Hospital Medical Staff Offices in RI region to accept CAQH 16
17 CAQH adoption reduces paperwork! Administrative Simplification any questions? 17
18 CAQH Adoption in Rhode Island (all eligible physicians and allied professionals) , , , , ,136 Enumerated/Unregistered Complete 18
19 We cannot change the direction of the wind, but we can adjust our sail 19
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