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December 2006
CAQH Data-Collection Initiative
CAQH CORE Rules Allow Providers to Rapidly Verify Insurance Coverage, Eligibility
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Providers Eliminating Redundant Forms, Saving Nearly $56 Million Annually
Through CAQH Data-Collection Initiative
The National Committee for Quality Assurance (NCQA) has released a set of draft measures of ambulatory care quality that will help health plans measure the quality of care at the physician level. These proposed measures will form the foundation of a new Health Plan Employer Data and Information Set ® (HEDIS) designed to assess clinical quality at the physician level.
“By adding physician-level measures to our existing measures, we add another layer of health care quality information to use in health plan comparison,” said NCQA Executive Vice President Greg Pawlson, M.D., M.P.H. “ We hope the public comment will allow stakeholders to weigh in on how to appropriately collect and implement measures for physicians.”
The measures are designed to allow health plans to report physician performance for their network. Not only do the measures provide technical specifications, but they also include implementation methods, such as appropriate sample sizing. NCQA is interested in how well these measures can be implemented in a health plan setting.
The measures contain six prevention measures, such as breast cancer screening and influenza vaccination, as well as coronary artery disease, depression and asthma measures. Measures addressing overuse and misuse are also included.
The draft measures represent a broad-based consensus of what quality care is from several respected organizations. Developed by NCQA, the measures were included in the National Quality Forum-endorsed National Voluntary Consensus Standards for Physician-Focused Ambulatory Care. The Ambulatory Care Quality Alliance (AQA) adopted these measures as part of the Recommended Starter Set of Clinical Performance Measures for Ambulatory Care. Draft measures are available at NCQA’s Web site, www.ncqa.org.
The measures will frame an electronic HEDIS Physician starter set to be released this month as well as a complete HEDIS Physician volume to be released early 2007.
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CAQH CORE Rules Allow Providers to Rapidly Verify Insurance Coverage, Eligibility
CAQH announced that U.S. healthcare providers are now one step closer to eliminating their office insurance clipboards. According to the nonprofit healthcare alliance, administrative data communication rules created by its Committee on Operating Rules for Information Exchange (CORE) have been included in the Health Information Technology Standards Panel (HITSP) Consumer Empowerment specifications recommendation to the U. S. Department of Health and Human Services.
HITSP provides a process for stakeholders to identify, select and harmonize standards for communicating healthcare information throughout the healthcare spectrum. As defined by the panel, consumer empowerment is the active involvement of consumers (i.e., individuals) in managing their healthcare and gaining the benefits of having their health information in a format easily accessible to them. This includes having a personal health record (PHR) to track patient information, insurance, family history, medications, and other special conditions.
PHRs will allow consumers to establish and manage access to their medical and insurance information by designated caregivers and healthcare providers without having to repeat the information at every step in the care process. Currently, HITSP’s Consumer Empowerment specifications address two key areas of the PHR: patient registration data and medication history. The CORE rules will help deliver consistent and robust patient insurance information to the patient’s PHR for provider use in patient registration, CAQH said.
CAQH launched CORE to promote health plan-provider interoperability and improve provider access to administrative information. To date, the voluntary industry-wide initiative has brought together nearly 100 industry stakeholders, including health plans, providers, vendors, CMS and other government agencies, associations, regional entities, standard-setting organizations and others, that cover more than 130 million lives, or more than 75 percent of the commercially insured plus Medicare and state-based Medicaid beneficiaries. In collaboration, they have built consensus on a set of operating rules to:
- Enhance interoperability between providers and payers
- Streamline eligibility and benefits data transactions
- Reduce the amount of time and resources providers spend on administrative functions – time better spent with patients
CORE Operating rules build on existing standards, such as HIPAA, to make electronic transactions more predictable and consistent, regardless of the technology.
CAQH previously announced that 20 leading national healthcare organizations will become CORE certified and begin exchanging select eligibility and benefits information with providers according to the CORE rules by March 31, 2007. Those organizations include Aetna, Inc.; AultCare; Blue Cross Blue Shield of North Carolina; Emdeon; Health Plan of Michigan; Health Net, Inc.; Humana Inc.; Mayo Clinic; McKesson Provider Technologies; Montefiore Medical Center; Siemens; and WellPoint, Inc. and its 14 Blue-licensed subsidiaries.
More than 20 additional organizations, including Accenture; the American Academy of Family Physicians; the American College of Physicians; the American Health Information Management Association; the Healthcare Financial Management Association; the Healthcare Information and Management Systems Society; the Medical Group Management Association; Microsoft Corporation; and the Workgroup for Electronic Data Interchange, have endorsed the CORE Phase I rules.
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If you have any questions or would like any additional information about the NAMSS Government News Center, please contact NAMSS GR Representatives at
(202) 367-2389 or email cperez@smithbucklin.com
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