How IAMHP Created a Universal Standardized Roster

Background

Drilling down to the core of Medicaid health plans, the accuracy of provider directories plays a crucial role in ensuring that patients can find and access the care they need. However, maintaining accurate and up-to-date provider information poses significant challenges, exacerbated by data silos, varying roster formats, and differing regulations at both federal and state levels. In the face of all of these challenges, a universal standardized roster is something that many states and healthcare organizations consider a pipe dream.

Under the leadership of Samantha Olds Frey, the Illinois Association of Medicaid Health Plans (IAMHP) was successful in creating a universal standardized roster for all Illinois Medicaid managed care organizations (MCOs). Leap Orbit’s Convergent entered as a data partner, bolting on automation capabilities following the roster’s implementation. In this case study, we’ve summarized some of the key takeaways from their collaborative, multi-stakeholder approach in achieving healthcare interoperability.

Compliance Challenges

The Medicaid health plans in Illinois faced a multifaceted problem. Lawsuits related to ADA information accuracy in provider directories highlighted significant gaps in the existing processes. At the same time, new CMS regulations and changes in Illinois state law, prior to the No Surprises Act, required health plans to make substantial improvements to their provider directories. These challenges underscored the need for a systematic approach to enhance the accuracy and reliability of provider information.

In Illinois, the need for accurate provider directories became particularly pressing due to lawsuits challenging the accuracy of Americans with Disabilities Act (ADA) information, the first iteration of Centers for Medicare & Medicaid Services (CMS) Mega Rule, and changes in Illinois state law affecting Medicaid provider directories.

IAMHP’s Objectives

The overarching goal was to improve the quality of Medicaid provider directories through a series of targeted objectives:

• Enhance ADA information gathering and accuracy.
• Achieve compliance with CMS regulations and Illinois state laws.
• Standardize provider rosters across Medicaid health plans to ensure consistency and reduce administrative burdens.

Solution Development

The journey to a universal standardized provider roster began with a clear recognition of the existing challenges and the need for a cohesive strategy. Health plans decided to collaborate on creating a standardized roster rather than making isolated changes. This involved extensive meetings, discussions, and the joint analysis of existing rosters. Key focus areas included ADA compliance, the adoption of military time for consistency, and the introduction of color coding to simplify data entry.

The process is not for the faint of heart. I had several six- to eight-hour meetings where we were just going through data spreadsheet by spreadsheet, and white-boarding.

Samantha Olds Frey, CEO, IAMHP

Universal Roster Implementation

Implementing the standardized roster required a comprehensive and coordinated effort. Existing rosters were collected and meticulously analyzed, leading to the standardization of data fields and the addition of crucial ADA information previously overlooked. This phase marked the practical application of Convergent’s capabilities to realize the standardized provider roster:

• Roster Collection and Analysis: Existing rosters from all participating health plans were gathered and analyzed. The team had to decide on how to undergo a seamless aggregation of diverse data formats, enabling a comprehensive analysis that informed the standardization process.
• Standardization and Feedback Loop: As the team worked on standardizing data fields and incorporating essential ADA information, they facilitated an iterative feedback loop with stakeholders. The process allowed for real-time adjustments and stakeholder input, ensuring the roster met both regulatory and practical needs.
• Testing and Adjustments: Before the final rollout, they performed extensive testing with hospitals and health plans. This phase was critical in fine-tuning the roster for widespread adoption.
• Provider Community Adoption: The launch of the standardized roster was supported by an underlying goal that the provider community could easily adopt the new roster format, leading to a smooth transition and broad acceptance.
• Legislative Support and Compliance: Throughout the implementation phase, compliance monitoring played a vital role in ensuring that the standardized roster adhered to evolving legal and regulatory requirements. Adaptability was crucial in securing legislative support and fostering an environment of compliance.

Feedback was sought from the Department of Healthcare and Family Services, hospital associations, and a select group of hospitals, culminating in a refined roster that received broad acceptance from the provider community. Supportive public policy and legislation further bolstered the adoption process.

Enhanced Accuracy with Automated Validation Services

After IAMHP created the universal roster, Leap Orbit’s Convergent was added to elevate the process with its robust automation services. A key feature introduced by Convergent was automated data validation. This scheduled process meticulously checks for errors or suspicious data entries and promptly sends alerts if any discrepancies are found. Automated data validation ensures that data is error-free and ready for use by verifying its accuracy, completeness, and conformity to predefined standards. This process significantly reduces the need for manual reviews and mitigates the risk of human error. Convergent’s validation tools cross-reference data against multiple sources, ensuring a high degree of accuracy and reliability.

Looking to the future, Convergent plans to implement further automation services, including automated data transformation to ensure data is in the required format, automated data submission for seamless integration into various systems, and automated data enrichment/verification to enhance the quality and completeness of the data. These advancements will continue to streamline processes, improve data integrity, and support the ongoing efforts to maintain accurate and reliable provider directories.

Overcoming Compliance Challenges and Improving Data Quality in Medicaid Health Plans: Lessons Learned

Take a Multi-Stakeholder Approach

The journey towards establishing a universal standardized provider roster in Illinois involved a collaborative effort among various stakeholders. It began with internal discussions within the health plans to identify the need for a common, standardized roster. Subsequently, the plans collected and analyzed existing rosters to identify common fields and streamline the process.

A critical step in the process was engaging external stakeholders, such as hospitals and physician practices, to gain valuable insights and ensure their needs were met. This multi-stakeholder approach allowed for effective communication and problem-solving, even though it involved challenging discussions. Including large healthcare systems and atypical providers early in the process proved beneficial in fine-tuning the roster and making it more comprehensive.

Embrace an Iterative Process

Throughout the process, it became evident that the roster required continuous refinement. Stakeholders held several meetings, discussed various aspects, and made iterative changes to the roster and its instructions. By incorporating feedback and refining the roster through testing and further discussions, a robust and user-friendly solution emerged.

We collected every plan’s existing roster at the time. We then went through every field and identified what we wanted to retain and why we thought it was needed. As we worked with stakeholders, some were won and some were lost.

Samantha Olds Frey, CEO, IAMHP

The roster’s continued evolution was expected, with periodic updates and improvements to align with changing provider data needs. As provider data quality improves and becomes more accurate, certain fields on the roster might become optional or redundant, leading to a leaner and more efficient solution.

Look to Legislation and Policy in Standardization

Legislation played a significant role in promoting the adoption of the standardized roster. However, the success of the policy was dependent on the groundwork laid by collaborative discussions and stakeholder buy-in. The legislation mandated all Illinois providers participating with the MCOs use the roster, ensuring nearly 100% participation.

Results of the Universal Standardized Roster

The introduction of the standardized provider roster marked a significant milestone in improving Medicaid health plans in Illinois, including data quality, claims processing, and provider directories. Providers benefited from the standardization, as they no longer needed to fill out multiple, disparate rosters for different health plans. The roster provided a single, streamlined format, simplifying the process and reducing administrative burdens.

We finalized the version and put it out into the world, and then slowly found adoption from the provider community.

Samantha Olds Frey, CEO, IAMHP

Notable outcomes included:

• Enhanced ADA information accuracy and compliance with regulatory requirements.
• Improved quality of provider directories, significantly reducing risks associated with inaccuracies.
• Reduced administrative burdens by eliminating the need for multiple, inconsistent rosters.
• Improved claims processing and data quality, benefiting both health plans and providers.

A Future of Standardized Provider Data

The success story of the universal standardized roster in Illinois demonstrates the power of a collaborative, multi-stakeholder approach in achieving healthcare interoperability. By fostering open dialogue, addressing challenges, and embracing feedback, the implementation process became more efficient and effective. As other states consider similar initiatives, Illinois’ experience serves as a valuable blueprint for driving positive change in the healthcare industry.

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