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Analysis

Humana Participating in Provider Directory Improvement

By Alexandra Wilson Pecci  
   March 05, 2020

"Humana is joining an alliance of health plans that are participating with the CAQH DirectAssure solution," Ron Urwongse, director of strategy and innovation for CAQH, tells HealthLeaders.

Humana is now participating in DirectAssure, a program from the nonprofit industry alliance CAQH, which offers a single portal where physician practices can enter, update, and verify directory information and share it with all contracted health plans at once.

Humana is one of several other participants, including Aetna, Centene, and UnitedHealthcare.

According to CAQH research, the average physician practice updates directory information for 20 health plan contracts, in varying formats and on different schedules for each plan. DirectAssure aims to reduce that administrative burden.

HealthLeaders asked Ron Urwongse, director of strategy and innovation for CAQH, to fill us in on why this news is important for revenue cycle executives.

HealthLeaders: What is this news all about?

Ron Urwongse: Humana is joining an alliance of health plans that are participating with the CAQH DirectAssure solution.

The big news is that DirectAssure is built on top of an industry platform used by 1.6 million healthcare providers to submit data to over 1000 different organizations within the industry, so Humana is able to leverage adoption on the provider side to make it easier for providers to submit directory information to not only Humana, but also to other health plans.

HL: What kinds of information will they be submitting?

Urwongse: Some of the most important information within the directory data set is the practice locations, so with the DirectAssure solution the providers can indicate where they're practicing, how often they're practicing, their hours of operation, whether they're accepting new patients. 

And It makes it really easy for these providers to clean up old practice information that the health plans might not have had a chance to clean up in past years.

HL: Can you tell us some of the reasons revenue cycle executives should be interested in this?

Urwongse: Revenue executives and other leadership within in provider organizations should care about this because in past years there's been a fragmentation of channels by which they could submit this this of information to health plans.

This isn't specific commentary on Humana, this was kind of an aggregate industry health plan problem. They should care about it because now there exists a rationalized way to get this specific dataset into some of the leading health plans within the industry. It's a one-stop shop for them to submit this data.

HL: Can you connect the dots between the accuracy of this information and revenue cycle tasks like submitting claims, denials, working with payers?

Urwongse: I'll answer it in a couple of ways. The first way is that for participation in a health plan's network, of course the plan needs to have all this demographic info so that they can publish within their directories.

Often that's a contractual requirement that the plans have with providers so it's one of the gates that they have to get through in order to get in-network and then to submit claims.

The other thing that I'll comment on this that…the DirectAssure solution qualifies the information that the providers are submitting. [For instance] let's say there's a provider group with for instance, 10 different location and 100 providers. CMS in their audits of health plan directories, often found that those types of groups may submit all 10 locations on behalf of all the 100 providers.

Now, are all 100 providers actually practicing at all 10 locations? Probably not, but the provider organizations understandably were a little bit fearful that if they didn’t submit all that information claims would get denied.

This new channel [DirectAssure] allows the provider organizations to indicate even if there's an affiliation between a practitioner and a location; they're able to indicate whether or not they're actually taking appointments or seeing patients at a location.

That's incredibly important because it gives both the provider organizations and the health plans exactly what they need. Health plans have really good information on what locations to publish for a particular provider in the directory, and the provider organizations can be confident that claims are not going to get denied because they haven’t submitted all the right information.

HL: Can this help with surprise billing at all?

Urwongse: I think it's a step in the right direction in terms of surprise billing, especially around the in-network versus out of network [issue] and whether providers are accepting new patients or not.

When providers submit that type of information to health plans like Humana, if there's any discrepancy between what the provider thinks and what they health plan actually has within [the] contract with the provider, they're able to reach out to the provider and clarify any confusion.

That contract information within provider organizations sometimes is not at the tip of their fingertips, and not readily available to them, so trying to align that information and make it more clear—who's in network and who's not in-network, and whether they're accepting new patients or not—can be step in right direction in terms of reducing surprise billing instances.

HL: What else should revenue cycle executives know?

Urwongse: I think the other challenge, at least within the actual healthcare provider organizations is finding the right data within their systems to be able to submit the right directory information to health plans.

There's always a really great partnership between the provider organizations and the health plans when the provider organizations are able to look at their own internal processes and see what needs to be improved there to improve data quality, just as the plans are doing as well.

[In addition], most providers already participate in CAQH's ProView for credentialing purposes, so the vast majority of providers are already coming in every 120 to look at, review, and attest to their information.

We're just piggybacking off of that process and we're asking them to review their directory information alongside their credentialing information. And we're making it easy for them to really focus on the right data. We ask them very direct questions, like, 'Are you still practicing at this location?' We make it super easy for them to do that.

Alexandra Wilson Pecci is an editor for HealthLeaders.


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