Simplification Success Story: An Interview with Robin Thomashauer and Gwen Lohse of CAQH

I had the opportunity to interview Robin Thomashauer, Executive Director of The Council for Affordable Quality Healthcare (CAQH) and Gwen Lohse, Project Director, for CAQH’s Committee on Operating Rules for Information Exchange (CORE).

CAQH is a not-for-profit alliance of health plans, networks and trade associations, serving as a catalyst for industry collaboration on initiatives that simplify healthcare administration and seeks affordable healthcare and quality healthcare. Robin Thomashauer, their Executive Director, tell us CAQH was launched approximately seven years ago, for the purpose of identifying opportunities for administrative simplification between payors and providers, and then moving ahead in a disciplined way those initiatives of the greatest value. CAQH works to engage their member health plans with providers, government organizations, vendors, networks, and trade associations.

Robin points to their Universal Credentialing Data Source as a major success story. “If you're a provider today, you have to be credentialed by each health plan you contract with every two to three years. Five years ago, we consolidated and got agreement on one standard form. Now providers can go online and enter this information one time, and won't have to get subsequent requests from organizations using data,” Robin tells us. The participating organizations pay to use the service on the back-end, it is free to providers. She proudly states that over 540,000 providers now use the service, 12,000 new providers are added every month, and the initiative has eliminated over two million paper applications. “The initiative has reached the tipping point where it has become the standard for the industry.”

CAQH’s Committee on Operating Rules for Information Exchange (CORE) is a newer initiative now making news in the industry. Gwen Lohse, CORE Project Director, tells us “we launched CORE about two and a half years ago, through CAQH's desire to really improve the patient and health plan interaction, around eligibility and the other  administrative transactions that make up the claims status process. The goal is to provide  all-payor solutions at the point of care, for those administrative transactions to the providers, to reduce all the inefficiencies that exist right now, and really save the time and energy on those functions and apply them to other areas. We're doing this through CORE by creating operating rules, which are basically agreements for the plans to follow, the vendors, the clearinghouses, and the providers, about the exchange of administrative data transactions, so everyone is on the same page about what the transaction means, who is responsible, and how fast it will flow, when the systems are up. The concept of operating rules are used by many other industries for transaction processing, such as the financial industry on ATMs and direct deposits. We have a lot of lessons learned by other industries, that we're applying to healthcare where appropriate.”

Gwen notes that 75% of commercially insured health plans are participating in CORE, and that 63 million Americans are covered by CORE phase one rules with their health plans. They are now drafting phase two rules for adoption in the first quarter of 2008.

I asked Robin how they managed to get such disparate groups of competing health plans, and other stakeholders, to work together on these initiatives. She conceded that in the early days, it was hard to get agreement on where to focus, but over time there was an evolution in agreement around what was “proprietary”, getting competitors to agree what isn't competitive and agreement was reached on various processes that can be standardized. Robin felt a broad success has been to achieve definition of what they can work on together to get simplification – and common agreement on process, workgroups, and structure.

I asked how do you get hundreds of health plans together, logistically for this undertaking. Robin credits technology- they don't ask people to travel a lot. “95-98% of our work is done through conference calls, webex, and e-mail. There is little travel. We have also developed a process, and created a structure with steering groups, and sub groups that roll-up, and have found this successful.”

When I asked who else needs to be pushed to the table to move things along with their simplification, it was interesting that they had a three letter answer: CMS (the federal agency that  administers Medicare and Medicaid.)

Want to find out more about CAQH? Go to http://www.caqh.org. You can listen to the full twenty two minute interview with Robin and Gwen, in which we talked about much more, at http://community.changenow4health.com/media/caqh111607.mp3