Understanding CAQH as an ABA Therapist

Anyone running their own practice can tell you: they spend entirely more time than they’d like to on paperwork when they could be focusing on helping their patients.
Every healthcare organization and provider has their own processes in place, and becoming an expert on them can feel like a whole other full-time position.
Thankfully, CAQH has drastically helped to streamline that process. What is CAQH? Read on as we cover the ins and outs of this powerful platform, like what does CAQH mean for your practice, and how you can become credentialed in their database.

What Does CAQH Stand For in the Medical Field?

CAQH stands for Council for Affordable Quality Healthcare. The council was originally founded in 1998 as the Coalition for Affordable, Quality Healthcare. But, what is CAQH, exactly? The mission of this non-profit business is to streamline the many time-consuming processes associated with providing healthcare.
Today, the majority of the healthcare industry works closely with CAQH. Their members include insurance providers like Aetna, Blue Cross Blue Shield, Anthem, Priority Health, Cigna, UnitedHealth and many more.

How Does CAQH Work?

As we mentioned briefly above, the goal of the CAQH is to streamline healthcare processes and the clerical work so many of these processes rely on to make it easier for insurance companies and practitioners to get on the same page regarding patient treatment and medical billing. They have several initiatives designed to facilitate this goal.

CAQH CORE

Demonstrating a love for acronyms, CAQH created CAQH CORE (the Committee on Operating Rules for Information Exchange) in 2005 to develop universal operating rules that define how administrative transactions are handled within the healthcare field.
CORE-certified health care organizations represent more than 75% of the insured in America, in addition to Medicare and Medicaid beneficiaries.
CORE’s influence has further expanded after their 2012 designation by the Department of Health and Human Services (HHS) as an author of ACA operating rules.
The standards developed by CORE have made it much easier for healthcare providers and practitioners to get on the same page regarding patient care and medical billing. The developments made by CORE are especially critical to other initiatives within the program, which rely on standardized information being made available to all parties involved in any given medical transaction.

CAQH ProView

ProView, the initiative most relevant to practitioners has been around since 2002. At that time, it was known as the Universal Provider DataSource, but the concept remains the same today.
Over 1.4 million healthcare providers use ProView to provide professional and demographic information. This information can then be used by health plans, hospitals and providers for their network directories, credentialing, and claim payment needs.
ProView greatly streamlines these processes, which in turn reduce duplicate paperwork, and all of the headaches that come with additional paperwork for both healthcare practitioners and providers.
Within ProView, practitioners use a program called DirectAssure to self-report and certify information about their practice. Another solution called VeriFide integrates with this information in ProView to standardize the credentialing process used by health plans to verify practice information.
EnrollHub, an initiative which debuted in 2013 makes it much easier for providers to receive payment through EFT (electronic funds transfer.) The adoption of EFT has been an issue for the healthcare industry, and this process allows providers and health plans alike to streamline the process, making it easier to get paid.

COBSmart

In 2014, CAQH launched their most recent initiative, which is used to identify patients with overlapping health coverages. This service identifies patients, determines which should be the primary and secondary insurance plan, and ensures that health services are correctly billed the first time, which cuts down on errors and paperwork.

CAQHExplorations

CAQH also has a research arm, which is home to the CAQH Index. The Index provides information about the progress the healthcare industry is making as it moves away from traditional means in favor of electronic transactions.
Unsurprisingly, CAQH estimates that billions could be saved on a yearly basis if the healthcare industry were to fully adopt electronic transactions.

The Importance of Credentialing

The information above should answer your questions on what CAQH is. But, we also need to cover why it’s important for practitioners to be credentialed with the CAQH.
In short, the entire industry is lumbering towards complete compliance with the CAQH. The earlier you become credentialed, the better off your practice will be. Beyond the “move with it or get moved over” argument, there are several benefits that come with being credentialed.
For patients with insurance, their search for healthcare providers is typically centered around the question of “is this practice in my network?” For patients, out of network providers represent higher out-of-pocket costs and the headache of paperwork. As such, patients try to find in-network care whenever it’s possible.
By credentialing with different insurance companies, you can greatly increase your potential patient pools, as patients will be much more likely to see you if you’re a participating provider within their insurance network.
In the past, this process was tedious and required practitioners to fill out a litany of different forms for different insurance companies. Thanks to CAQH, that process is largely a thing of the past.
By credentialing within ProView, providers can complete one credentialing process, which will serve the needs of nearly all health plans and insurers. Providers complete their credential profile, which contains all of the relevant information a health plan needs to know about the provider before accepting them into the network.
If you’re interested in joining an insurance providers network, they’ll be able to find all the information they need through ProView, and that same information can be used by all of the health plans and insurers who participate with CAQH.
Occasionally, a health plan will require some additional information that isn’t available through CAQH, and you’ll still run into the rare outlier that doesn’t participate with CAQH, therefore requiring you to credential with them if you wish to join the network.
While it’s rare to run into a carrier that doesn’t participate, it’s fairly common to encounter a carrier that requires additional information beyond what’s provided in your ProView profile. But, it’s still much easier to provide whatever additional information is necessary compared to the work you’d have to do to become a credentialed provider with each carrier.

The Application Process

Considering how much CAQH has streamlined the healthcare industry, and the amount of processes CAQH eliminates, it should come as no surprise that the CAQH application process is a bit more involved than setting up a Facebook profile.
In fact, there’s an entire cottage industry that exists to help walk providers through the long and sometimes involved process of credentialing with the CAQH. If you’re feeling particularly uneasy about the application process, you may wish to hire a consultant who can hold your hand through the process.
But, it’s something you can certainly handle on your own with a bit of determination, and we can help walk you through the process.

Before you get Started

Before you begin your application, there are several different things you should have available to you to streamline the process. Having this information at the ready will make it easier for you to complete the application process in one shot, instead of having to constantly stop to hunt for old information.
Of course, some of the information required will be second nature to you, but certain things, such as insurance certificates, ID numbers or hospital affiliation data may not be so easy to recall off the top of your head.
According to the CAQH Registration site, this is the information you’ll need to complete your application:

• Basic Personal Information
  • Education and Training
  • Medical/Professional school
  • Graduate school
  • Internships and residencies
  • Fellowships and preceptorships
  • Teaching appointments
  • Specialties and Board Certification
• Practice Information
  • Practice name and type
  • Address and contact information
  • Billing, office manager, and credentialing contact
  • Services, certifications, limitations and hours of operation
  • Partners and covering colleagues
• Hospital Affiliation Information
• Malpractice Insurance Information
• Work History and References
• Disclosure and Malpractice History

Filling Out the Application

The actual process of completing your CAQH profile breaks down into six steps:

• Register with CAQH
• Fill out all application questions
• Audit your application to ensure its accuracy and completeness
• Authorize organizations that participate with the CAQH to access your data
• Attest to the data in your application
• Provide documentation (insurance certificates, BCBA certificate, etc.)

For the most part, CAQH does a fantastic job of making it easy to understand the application process. The accuracy of all your information is critical to the success of CAQH, so they have just as much of a vested interest in getting you set up properly as you do.
But, if you run into any snags as you’re completing the process, the ProView user guide is a valuable resource that should be able to answer any outstanding questions you may have about applying.

CAQH Tips

While we’ve covered most of the info you need to get the ball rolling with CAQH, there are a few things to keep in mind that will make it easier for you to become credentialed, and stay up to date in a changing healthcare landscape.

Don’t Wait to Apply

In the past, you needed to wait for an invite from a participating insurer to join the CAQH. Today, you don’t need to be invited at all, and you can self-register immediately through this link.

Be Prepared to Explain Gaps in Employment

If you’ve taken extensive time off in your professional life, this is something you’ll need to explain on your application when you apply. Be prepared with a legitimate reason why you stepped away from the field.

Have Supporting Documentation On Hand

Once you’re done with the meat and potatoes of your application, you’ll need to upload documentation to support your application. Here’s exactly what you’ll need:

• Liability insurance
• W9 form
• BCBA certificate
• Certificates for any other licenses or certifications you possess

Getting these documents ready before you apply will help you save time later.

Consult the User Guide

The user guide is full of indispensable information that can help shine a light on the harder to understand parts of the process. Keeping it handy will make applying much easier and less time-consuming.

Carefully Consider Your CAQH Point of Contact

Should issues arise or more information be required, the primary contact you list on your profile is who carriers or the CAQH will attempt to get in touch with.
If the contact isn’t you, consider using a role-based email address and a phone line within your office as the main contact. That way, even if the point of contact for CAQH leaves your practice, you won’t have to worry about updating your contacts within the system.

When in Doubt, Get Help

If you’re feeling over your head about the whole process, don’t be afraid to reach out to a consultant. CAQH consultants have built their entire business around the ins and outs of applying for credentialization, and they can also answer any outstanding questions you have about the platform.

Authorize All Carriers to Access Information

You can save time in the future by allowing all carriers to access your information within CAQH. Of course, you also have the option to restrict the information to only certain carriers.
But, in the future, if you wish to participate with other carriers which you have not provided authorization to, you’ll need to manually allow them to view your information. By authorizing all carriers from the beginning, you won’t have to worry about providing additional permissions later.

Stay up to Date

If there’s one thing that’s truly important to the success of the CAQH system, it’s maintaining up to date data. You’ll regularly need to certify that all of the information on your profile is correct and true through the DirectAssure program within ProView. But, that doesn’t mean you should wait to add or edit information to your profile until you’re prompted to do so.
Keeping up to date information will ensure that there are no unnecessary errors with regards to billing or credentialization due to incorrect information in your profile. Request a Demo of WebABA to learn how we can help you manage your ABA practice and stay on top of your insurance billing needs.