Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Private Payers News

Provider-Owned Health Plans Adopt Interoperability Standards

Three provider-owned health plans have completed CAQH CORE certification for data interoperability.

Provider-owned plans certify interoperability

Source: Thinkstock

By Jesse Migneault

- Three provider-owned health plans have recently completed multiple phases and been awarded CAQH CORE certification.  This achievement places the provider-owned health plans at a level that supersedes present regulatory requirements for interoperability and electronic information sharing.

Boston Medical Center Health Plan, Providence Health Plan and UPMC Health Plan have completed testing and have been awarded the CAQH Committee on Operating Rules for Information Exchange (CORE) certification.

The CAQH CORE model provides a technical framework for the exchange of medical claims and EHR data, allowing organizations such as Boston Medical Center Health Plan to achieve “economies of scale, manage risk and improve population health.”

"As a provider-owned health plan, we have a unique understanding of how critical it is for data to flow seamlessly and securely between payers, hospitals and other partners," said Kim Sinclair, Chief Information Officer of Boston Medical Center Health Plan.  

"The CORE seal demonstrates to all of our partners our commitment to efficient data exchange and it enables us to identify partners that we can count on to do business efficiently, so we can focus on coordinating the care of our members."

According to CORE, their mission is to “drive the creation and adoption of healthcare operating rules that support standards, accelerate interoperability, and align administrative and clinical activities among providers, payers and consumers.”

Founded in 2005, CAQH CORE, is a nonprofit affiliation of payers, plans, networks and industry associations who work together to simplify health information exchange and data interoperability in an effort to reduce costs and streamline the delivery of care.

CORE’s onboarding process for new participants involves extensive training of users and a systems analysis of the IT infrastructure of prospective affiliates.  CORE has a four-phase system of integration before an organization is awarded a CAQH CORE certification.

Organizations such as the VA and Mayo Clinic are listed as current phase I participants in the CAQH CORE program.  Over 70 public and private payers are currently engaged in various phases of involvement with the program as well.

The CORE affiliation currently draws participation from over 130 healthcare organizations, including public and private payers, vendors, and provider organizations.  The collaboration represents 75 percent of insured Americans.

The adoption of CORE by provider-owned health plans can be seen as the convergence of two trends: the move towards a value-based healthcare model and the integration of technology to increase interoperability between disparate networks.

Provider-owned health plans are seen by some as being the future of the healthcare economy.  Their rapid growth in recent years has been due in part to a concerted transition from a fee-for-service based system to a value-based care approach.   This new system is especially suited to healthcare providers, such as hospitals.

A McKinsey & Company report from April 2016 indicates that provider-owned health plans have expanded in recent years, thanks in part to their involvement in the ACA marketplace.  Recent data shows 15 million people are insured by provider-owned insurance plans in 39 states. 

“The CORE seal gives trading partners confidence that all parties are adhering to the rules when conducting these transactions—an important sign that sharing information will be secure and efficient,” the organization said.

As of 2017 over 300 CORE Certifications have been awarded to public and private entities, including health plans, hospital systems, clearinghouses, and vendors.


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