Solutions

The Mass Collaborative is dedicated to improving the quality of health care through increased transparency, efficiency, and innovation for both providers and health plans. Our initial focus is on credentialing, eligibility, prior authorizations, and communications. The Collaborative continues to work with the health care community to identify and resolve ongoing administrative issues.


This section describes the solutions that the Mass Collaborative has implemented to advance administrative simplification in the health care industry.

Credentialing:

The Challenge:

Before 2004, credentialing was extremely time-consuming and cumbersome for providers, requiring separate processes and forms for each health plan. In 2004, health plans and providers developed a uniform process for health plan credentialing. Credentialing simplification efforts within the broader health care community have evolved since then, yet challenges remain.

The Solution:

The Mass Collaborative's Credentialing Workgroup has created a streamlined process for health plan credentialing by mapping the credentialing process to identify pain points and implementing process improvements. Currently, participation in the uniform health plan credentialing process is voluntary; however, under Chapter 288 of the Acts of 2010 the Bureau of Managed Care is required to develop regulation that carriers use uniform credentialing standards and methodologies. In addition to this the credentialing workgroup has:

  • Created a distribution list so that health plans can email credentialed providers
  • Established a standardized, dedicated process, for health plans to use when responding to application status inquiries
  • Developed a standardized process for notifying health plans and other providers of updates to hospital rosters

Eligibility:

The Challenge:

Insurance eligibility verification is a critical, challenging part of the overall health care process. Millions of eligibility checks are performed monthly, with the vast majority performed electronically. When the transaction goes smoothly, it ensures a seamless process for the patient, provider, and the health plan.

The Solution:

The Mass Collaborative has been working to ensure a smooth eligibility process. In 2012, it implemented a first-in-the-nation 'alpha search name normalization' standard to reduce the number of incorrect ‘Not Found’ responses. Now the Mass Collaborative is working to identify gaps in the electronic eligibility process and is partnering with NEHEN to identify solutions to further increase the efficiency of the process.

Denied Claims Appeals:

The Challenge:

Historically, providers needed to use plan-specific forms to submit denied claim appeals to health plans causing confusion and rework both for the provider and the health plan. In addition, reference materials and guidelines were not standard.

The Solution:

The Massachusetts Collaborative created the Request for Claim Review Form, which may be used to submit a claim to a health plan or MassHealth for additional review. An accompanying reference guide provides valuable information on how to submit the form.

Prior Authorizations:

The Challenge:

Currently, the prior authorization process varies widely from one payer to another in the state of Massachusetts. One of the key challenges is that the process is largely manual, relying heavily on faxes and numerous phone calls. Most providers and payers agree that there is room for improvement in this area.
MA Chapter 224 of the Acts of 2012 directs the Division of Insurance (DOI) to develop standardized and electronic prior-authorization forms.

 Medication and Imaging Services
 Behavioral Health Services

The Solution:

The Mass Collaborative's Prior Authorization Work Group is developing standardized prior authorization forms for behavioral health, medical/surgical procedures, prescription drug benefits, imaging, diagnostic testing, laboratory testing, provider office visits, and other services (including DME and home health).

Payer-Provider Communications:

The Challenge:

Improving the communication between health plans and providers is an important goal, especially as national and state regulations around payment for services continue to shift. Varied interpretations of new policies and procedures are often the result when there is a lack of communication

The Solution:

The Mass Collaborative’s Payer-Provider Work Group has been working since 2013 to simplify the administrative processes associated with communicating information between payers and providers. In 2013, the work group created a Standardized Information Change Form as the new single form to communicate name, address, and other office changes to payers in Massachusetts.
The work group is also working closely with payers and providers to:
  • Support the Massachusetts price transparency laws by creating a standardized patient-information form that can be used by health plans, hospitals, and physician practices to help patients get accurate and timely cost estimates.