Delegated Roster Management: Best Practices for Payers

by Jake Tunney, Business Development Manager, Leap Orbit

Provider Network Development and Management Executive, Loretta Haythorn, joined us on Interoperability Roundtable for a conversation on Delegated Roster Management: Best Practices. Below is a recording and written recap of our conversation.

1. Delegated Roster Overview
   1. What are they – Delegated rosters are mass listings of provider demographic information received directly from health systems to be used for credentialing as well as PDM, Network Development, and Directories.
   2. Why are they important – they are a primary source of demographic updates.  They come directly from the health system, providing data in a mutually agreed-upon format to increase the efficiency of contracting, credentialing, and loading provider data into multiple platforms from one source document. Health plans can upload/ingest from one source vs. manually entering data.
   3. Why have they been growing in importance
      1. In expansion, delegation can free up staff to manage the influx of providers joining the network as well as improve the credentialing process.
      2. An increasingly significant portion of provider data is coming in through delegation as a result of Acquisition/M&A within the provider space. 
      3. Health systems are improving their internal credentialing process to be more aligned with NCQA guidelines.
2. Roster Challenges
   1. Need to intake updates consistently from health systems/provider groups
   2. Need to validate format conformance
      1. Could be receiving a massive number of rosters on a monthly or quarterly basis in varying formats
      2. May need to manually reconfigure data
   3. Multiple departments may need to be involved in the process.
   4. Validate that the information is correct
      1. Claim Denials – We have seen trends of claims paid incorrectly because the provider data didn’t match up with the services/bill/benefit design (group NPI vs Individual NPI, mismatched address, incorrect provider role in the system: Specialist vs PCP)
      2. CMS has, in recent years, put pressure on health plans to achieve certain levels of provider data accuracy. Now, with interoperability, it has become mission-critical that the information made available is accurate. 
   5. Ingestion & Matching – use data within internal systems for the claims system, provider directories, etc.
      1. Upon upload of rosters into the payer’s systems you need to be able to quickly identify and resolve duplicates
   6. Electronic feed vs. manual feed
      1. Fairly common to still see a manual feed at smaller plans
3. Impact on Networks and Contracting
   1. Rosters are useful to evaluate the value of a potential new contract, at times within the scope of a network expansion. 
   2. They can help answer:
      1. How many of these providers are already in my network?
      2. Determine if they’ll resolve adequacy gaps
   3. This can help with negotiations around fee schedules. 
4. Lessons Learned/Best Practices
   1. Invest in data cleansing software – this will help clear out variations in address, phone, basic items and help in the deduping process – some will even use mined data from external resources (data scraping from Google, CMS, NPPES, etc) to provide data validation.  (Check out our product Convergent for an example: https://getconvergent.io)
   2. When possible, add mutually agreed upon format and frequency requirements to the delegated agreement or the master contract  – in some cases you can try to tie quality metrics or penalties to delegated roster requirements in the contract
   3. Enforce a standard format as much as possible and as soon as possible in the contracting process
      1. Request rosters in your standard format
      2. Leverage open data standards whenever applicable (eg, FHIR, SNOMED, NUCC, USPS, etc.)
      3. Use dropdown fields in your format where possible (MD, DO, PA, etc) 
   4. Provide feedback ASAP to submitters – keep lines of communication open and work with the health system on an ongoing basis.
   5. CAQH – can be a good source of data but not a silver bullet.
      1. Only ⅓ of U.S. providers use CAQH so you need another way to capture roster updates (try our roster upload tool here)
      2. In an ideal world, this would solve all your problems – providers are to self-attest quarterly
      3. A lot of payers have had to turn off the auto-feed because doctors have not updated there and corrections were already made in the payer’s provider data management system.