CAQH and Provider Data Management

What is CAQH?

The Council for Affordable Quality Healthcare (CAQH) is a non-profit alliance of health plans and trade associations, developing and leading initiatives that positively impact the business of healthcare. Through collaboration and innovation, CAQH accelerates the transformation of business processes, delivering value to providers, patients and health plans.

CAQH realizes that the availability and sharing of electronic data is driving a revolution in our nation’s healthcare system, and access to accurate, timely provider data is critical for its success. Without timely access to provider data, today’s healthcare organizations will suffer.

The Cost of Poor Provider Data Management

There are many cost implications associated with poor provider data management. Two areas where limited access to accurate, timely provider data are driving up costs are credentialing and directory maintenance.

CAQH Credentialing


Credentialing is the process of obtaining, verifying, and assessing the qualifications of a practitioner/provider to provide care or services in or for a healthcare organization. CAQH research indicates that many organizations use multiple methods for credentialing and that moving to a single credentialing platform could reduce annual credentialing costs by 40%. On a national level, CAQH estimates that streamlining the exchange of credentialing information on one platform could save as much as $2.26 billion annually.

Directory Maintenance

Provider data collection requirements are becoming increasingly more complex and require updating and confirming with greater frequency. To improve accuracy, regulators have set minimum requirements for how frequently plans must contact practices to verify and update their information.

  • CMS requires Medicare Advantage plans to contact providers quarterly.
  • States require commercial and government funded plans to conduct outreach on a variety of schedules, including some that exceed federal requirements. Berkeley Research Group reports:
    • 19 states require provider directory updates at least on a monthly basis.
    • 12 states require updates between quarterly and annually.
    • 7 states require directories to be “up to date” or updated in a timely manner.

CAQH estimates providers incur annual cost of $2.65B to maintain directory records.

Directory Maintenance
Standardizing Provider Data Collection

Standardizing Provider Data Collection

There's a lot of overlap between the data sets required for credentialing and directory maintenance. That is why streamlining provider data collection is critical to healthcare organizations’ success. According to CAQH and VerityStream shared best practices, your credentialing software should:

  • Standardize the requested content such as licenses, education, and demographic information
  • Streamline the number of requests to update or submit information
  • Simplify the data submission and reconciliation requirements
  • Maintain a comprehensive database of validated data

Simplified Ongoing Data Maintenance for Rosters and Directories:

Provider Directory Management is often a highly manual process that creates numerous opportunities for human error. Your directory should connect to your credentialing solution to:

  • Consolidate multiple health plan outreaches into a single outreach for each provider
  • Create and maintain standard roster files that can be electronically shared with Health Plans as updated or required
Simplified Ongoing Data Maintenance for Rosters and Directories
Improved Provider Satisfaction

Improved Provider Satisfaction:

A 2019 AMA survey found that 67% of physicians are interested in one interface to update payers. Providers want to spend more times with patients and less time on paperwork. With a Standardized Data Collection process in place they can:

  • Avoid having to manually update their information with individual payers
  • Help their patients avoid coverage issues by ensuring they are accurately represented in all payer directories

Managing provider data has major financial implications on your organization. If you’re looking to seamlessly standardize the process, VerityStream can help. We currently serve over 2,400 hospitals and 1,300 outpatient facilities in the U.S.