Episode 18: CAQH Driving Standards & Transaction Adoption to Address Industry Challenges


On this episode of the Dish on Health IT podcast, guests April Todd VP at the Council for Affordable Quality Healthcare (CAQH) and Erin Weber Committee on Operating Rules for Information Exchange (CORE) Director at CAQH discuss driving adoption of transactions and standards in pharmacy and medical benefit, FHIR use cases such as prior authorization, burden reduction and return on investment as well as value-based care. 

April opens the discussion by giving a brief overview of her professional career. She has worked in almost every sector of the healthcare and healthcare policy space. April has had experience in government, the health plan side working in the consultant and IT space, and now with CAQH within the nonprofit sector. She greatly appreciates the diversity of perspectives and the need for agreement and alignment to make progress within the industry. 

Erin says her experience is in strategic revenue cycle consulting. She has done work with the Veterans Health Administration as well as with an advisory board company where she worked with hospitals and health systems around the country to identify and implement best practices. The mission of CORE speaks to April. She is passionate about bringing together disparate stakeholders to have difficult conversations around driving interoperability. 

Ken asks April and Erin to give some background on CAQH and its activities. They explain CAQH is a nonprofit organization focused on streamlining and simplifying the business of healthcare, mainly in the administrative space. CAQH can be divided into three parts. The research arm, called Explorations, works with the industry to gauge the progress towards automation and to identify areas of improvement. There is also a policy arm, called CORE, which works towards consensus on how to operate between plans and providers on transactions and standards. CAQH also brings solutions (utilities) to the industry, a central place to do things where a competitive approach doesn’t make sense. Overall, the organization is really trying to bring people together to drive consensus.  

Ken asks how the industry is managing recent technological transformation. April states that as technology advances, the industry is going to need to learn to adapt more quickly. She believes we are always going to have a push and pull between existing standards/technology and new standards/technology. CORE is trying to facilitate organized industry advancement where there are common expectations. April notes there are always going to be organizations way ahead and others that trail behind. Aligning stakeholders and moving in the same direction using similar processes proves to be the biggest challenge. 

Erin adds that there is a lot of partially electronic and manual work being done to exchange documentation for both prior authorization and claims, which is a significant source of administrative burden. A CAQH subgroup just completed the development of draft operating rules for prior authorization related to the exchange of attachments. The hope is those rules will be finalized later in the year. A key aspect of the draft rules was to consider how both X12 and FHIR transactions can work well together. We know this is what will have to happen for a successful transformation, so the group looked at the various exchange formats, and both are included in the draft rules. 

Jocelyn notes that as we see transformation happening, we must be cognizant of our massive investment in X12 and the fact that it runs a large part of the world we operate in. However, we need to bring administrative and clinical data together to make the shift to value-based care. Looking at stakeholder roadmaps and pipelines, what is being prioritized is what’s pushed from a regulatory standpoint. We need to make sure we’re meeting everyone where they are today. We’ve seen that if we don’t acknowledge the current state, then we don’t get the adoption we expect. Jocelyn says the work CAQH and others are doing will be incredibly important for regulators to look at to make sure they have an inclusive answer, taking advantage of existing technology.

Ken asks April about CAQH’s methods for determining cost reductions, time savings and burden reduction for standardized transactions. What are the findings? April says one of their methods is through their explorations program, particularly the CAQH Index that surveys payers, providers and vendors. The goal is to understand the volume of different types of transactions. How are they conducted? Are they done manually? Are they done electronically using the standards that have been established? What is the cost of staff time to do all the transactions? More recently, the survey included questions about value-based care, the use of FHIR and the impact of COVID on transactions. 

Jocelyn reinforces the importance of the survey noting that we must measure things in order to understand where we’re making progress and where there are barriers. The goal is to get people to move to automation. 

Ken asks the group why prior authorization has the lowest level of adoption and what efforts could be made to improve the current situation. Erin says there is a lack of understanding around the breadth of information available in the transaction. She was surprised by the number of providers who were unaware of the HIPAA transaction, despite the work that had been done to educate the industry. Erin did see a bit of an uptick in the automation of prior authorization in the CAQH Index from 2019 to 2020. CORE has developed a set of prior authorization operating rules addressing things like additional data content needs to convey documentation needs. The industry needs to continually adopt and align expectations across various transactions and standards available.  

Ken asks what role CAQH plays in the adoption of value-based care. Erin notes that, just as when CORE was founded and HIPAA transactions were first being implemented, the board is feeling some of the same pain points. Even though you may have standard processes and ways of doing things, everyone will still do things just a little bit differently, which makes it hard to automate and can create real burdens. The board proposed conducting research to really understand where there might be opportunity to create some more uniformity in the industry and reduce that administrative burden, improving information change and enhancing transparency across the clinical and administrative verticals. Erin says you can’t look at value-based care and fee for service as two separate worlds, it’s a continuum. They approached research by looking at the revenue cycle, across fee for service and value-based payments, and tried to understand where there needed to be differences based on different data needs. 

April discusses next steps. She says they have a priority list from the advisory group and attribution was identified as the most important. They are also monitoring FHIR, and progress being made there. April says they are currently working on things we can do in the exchange of information to support quality measures and gaps in care. They are conducting an environmental scan to gauge what is happening and what could be done to simplify. Overall, she thinks CAQH’s role is aligning and bringing stakeholders together to create common expectations.  

Erin gives her final thoughts. She asks that if you see a request for their CAQH Index, please respond. She also brings up the fact that they have been working to help put a utility out to support the CMS and ONC interoperability rules and to help people connect to have a trusted place of information around FHIR. 

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