CAQH seeks to expand definition of providers

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The meaning of the word "provider" in the healthcare industry is changing, which will require a more expansive definition of "provider," according to CAQH, a stakeholder organization working to improve business processes.

As providers and payers face new challenges in using data to support core business functions and related transactions, an alliance of health plans and trade associations wants to start a national conversation on standardizing the terms, definitions and measures of accuracy of data.

It’s a far-ranging challenge that impacts claims management, referrals, credentialing, provider directories, program integrity and information exchange, contends the Council for Affordable Quality Healthcare (CAQH).

“There are so much independent efforts and waste in how we handle data,” says Robin Thomashauer, executive director at CAQH, which hopes to bring discussions together at a summit it’s currently hosting in Washington on the topic.

The discussion even extends down to how the industry defines what it means to be a provider. As reimbursement approaches change, a more expansive definition of the term “provider” is needed, CAHQ says.

“In the age of accountable and value-based care, ‘provider’ extends beyond physicians, hospitals and allied health professionals to other practitioners who deliver or coordinate healthcare services,” the group notes in a new report. These other providers include social workers, addiction counselors, community health centers, behavioral health agencies, home health providers, transportation providers and community-based organizations. And all these provider types have different types of data and different ways of using it.

The impact of the definition of a provider has a wide-ranging impact. For example, claims with missing or wrong provider data results in payment denials. Referrals with inaccurate provider contact information slow the referral process. Credentials that are not submitted on a timely basis could result in a delay when a provider can start working. Inaccurate provider directories hurt consumer efforts to find providers and make insurers vulnerable for costs of out-of-network care. Poor data integrity hurts fraud and abuse prevention efforts. And, incorrect electronic addresses slow clinical data exchange.

Also See: CAQH effort aims to clean up insurers’ provider directories

“Without better coordination and alignment, we will further fragment the industry and provide bad data,” says Atul Pathiyal, managing at CAQH. “This is a long-term effort to develop a roadmap to address challenges.”

In preparation for the work ahead, CAQH has published a white paper outlining the issues and challenges of improving data management across the nation. “We need to start determining how to deal with proprietary terminologies and different processes,” says Raynard Washington, CAQH’s director of research and development.

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