$11.1 Billion. That’s how much, according to the 217 CAQH Index, the healthcare industry could save by transitioning to fully electronic administrative transactions. The transactions are for things like claim submission, eligibility and benefit verification, pre-authorization, etc. These are clearly defined standards and many of them are widely adopted. This is real interoperability in healthcare and it’s in place today. Yet, not everyone is participating. Why is that? How can we expand adoption and realize the tremendous value that’s available for the taking? And what can we learn from this process to help us achieve real interoperability in other areas of healthcare?

My guests today Dr. Kristine Burnaska, Director of Research and Measurement at CAQH and Reid Kiser, Lead Researcher of the 2017 CAQH Index tell us how the CAQH Index measures the cost of administrative transactions in healthcare and gives us a detailed look into the industry’s progress. More importantly, they help us to understand the tremendous opportunity we have in front of us.


NOTE: This is also the topic for the #HITsm chat on Friday, August 17th at 12 EST that I’m co-hosting with CAQH: The Cost Savings Opportunities on the Business Side of Healthcare – #HITsm Chat Topic


0:00 This is real interoperability in healthcare. Why isn’t everyone on board?

2:13 Background on CAQH – Nonprofit alliance of health plans that acts as the convener, collaborator and catalyst for streamlining the business of healthcare.

5:34 The CAQH Index – The best measure of efficiency in the cost of administrative transactions between doctors and health plans.

10:11 The CAQH Index has informed operations staff how their facility measures up to the competition and makes the business case for administrative technology investments.

14:35 What did the 2017 report say? What are the types of transactions being tracked?

The 13 metrics: Claim Submission, Eligibility and Benefit Verification, Claim Status Inquiry, Claim Payment, Remittance Advice, Prior Authorization, Referral Certification, Coordination of Benefits Claim, Claim Attachment, Prior Auth Attachment, Enrollment and Disenrollment, Premium Payment, and Acknowledgements.

18:30 Electronic vs Manual Transactions.

22:20 What are Partially Electronic Transactions? An introduction to portals.

25:25 The 2017 Report: Why is claims submission 95% electronic?

30:04 The 2017 Report: Why have prior authorizations not improved since 2008?

33:21 The dollar savings opportunity for improving prior authorization is $11.1B, $9.5B from provider side, and it’s still growing. What are the numbers really telling us?

37:51 Why have high deductible health plans increased the number of manual transactions? Are we still going in the right direction?

39:05 Why certain organizations are adopting, and some aren’t, who’s doing well, and what we learn from best practices.

42:55 Portals and Passover – why is this metric different than all other metrics? The increase in portal use is driving increase in manual transaction rates. Are portals a bridge or barrier to full automation?

48:13 Where does the report focus on in 2018? New topics include: Portal use, value-based payments, vendor fees, and call inquires.

Like all CAQH initiatives, the CAQH Index is the result of an industry-wide collaborative effort. Health plans covering more than half of the commercially insured U.S. population and a wide range of healthcare providers contribute data on how many of the studied transactions they conducted throughout the year and how they conducted them. They are joined by vendors and other business partners in offering insights about dynamic market conditions driving decisions about use of administrative transactions. Government agencies and policymakers often contribute data and insight to the Index as well.

  • Advance the Effort. Health plans and healthcare providers can advance the effort by contributing data. For the 2018 CAQH Index, more data is needed to more completely benchmark the transactions currently tracked and to reveal insights about the evolving use of administrative transactions.
  • Every Contribution Adds Value. Every data contribution enriches the overall quality of the Index dataset. With richer data, CAQH can deliver increasingly useful insights, more precise measures of progress, and more accurate estimates of cost savings. All health plans and providers, regardless of adoption status, are encouraged to participate.
  • Receive a Customized Benchmark Report. Health plans and healthcare providers that contribute data receive customized benchmark reports. CAQH prepares and delivers a detailed analysis of organizational performance alongside national results to each data contributor.

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About Kristine Burnaska, Ph.D.
Director, Research and Measurement, CAQH

Kristine Burnaska, Ph.D. is Director, Research and Measurement, at CAQH, a non-profit alliance of health plans and related associations working together to achieve the shared goal of streamlining the business of healthcare. Kristine manages CAQH Explorations and in that capacity is the lead researcher for the annual CAQH Index, which tracks the healthcare industry transition from manual to electronic business transactions and the related cost savings. Before joining CAQH in 2018, Kristine was the Director of Operations at the Health Care Cost Institute, where she focused on understanding and guaranteeing smooth daily operations of its price transparency initiative. She previously served the Health Industry Distributors Association as Director of Research and Market Intelligence and Abt SRBI as Director of Analytics / Consumer Insights. Kristine holds a Ph.D. in statistics and research methods from the University of Illinois at Urbana-Champaign.

Reid Kiser, MS
Lead Researcher, 2017 CAQH Index

Reid Kiser was the lead researcher for the 2017 CAQH Index in his former capacity as Interim Director of CAQH Explorations, the research arm of CAQH, a nonprofit alliance of health plans and related associations. An independent consultant with Kiser Healthcare Solutions, Reid is a former employee of CAQH. He managed the transition of the U.S. Healthcare Efficiency Index, the predecessor to the CAQH Index, to CAQH in 2012. Prior to his role at CAQH, Reid served in several capacities involving quality measurement and improvement for health plans and providers. He was an executive lead for Inovalon’s HEDIS Advantage™ and served as UnitedHealthGroup’s National Director of Clinical Excellence. He also served in a variety of capacities at NCQA. He holds a Master of Science in evaluative clinical sciences from Dartmouth.

About CAQH and The CAQH Index

CAQH is a non-profit alliance of health plans and related associations working together to achieve the shared goal of streamlining the business of healthcare. The CAQH Index is the industry source for tracking health plan and provider adoption of electronic administrative transactions. It also estimates the industry cost savings opportunity, an amount that should decline as adoption and efficiency grows.

The CAQH Index is the authority on:

  • Claims-related administrative costs for medical and dental providers and health
  • Time consumed by providers.
  • Savings potential from conversion to fully electronic administrative transactions.
  • Trends in use of fully electronic (HIPAA), online portal, phone, fax, mail and
    interactive voice response (IVR) transactions.

Related and/or Mentioned on the Show

All resources below are complimentary and available at the CAQH website.

About the CAQH Index

The 2017 CAQH Index Report

Participate in the CAQH Index!

Follow and engage with CAQH on:
Twitter @CAQH
LinkedIn CAQH
Email at Explorations@CAQH.org

CAQH Solutions collaborates for shared utilities.

COB Smart helps coordinate your benefits.

CAQH Proview uses an intuitive, profile-based design, for providers to easily enter and maintain their information for submission to selected insurance organizations.

Enrollhub helps payers send providers electronic payments.

SanctionsTrack for automated sanctions monitoring.

CAQH CORE drives the creation and adoption of healthcare operating rules that support standards, accelerate interoperability, and align administrative and clinical activities among providers, payers and consumers.

Use the Savings Calculator to estimate potential organizational savings by transitioning to electronic administrative transactions!

In addition, CAQH invites those who share its passion for reducing the cost, time and frustration associated with the business of healthcare to stay informed about this and other work at CAQH by signing up for its email newsletter.

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