How to Improve Provider Data Accuracy in Healthcare?

Accurate provider data is the foundation of a well-functioning healthcare system. It ensures that patients can find the right providers, health plans can process claims efficiently, and regulatory requirements are met. However, maintaining up-to-date provider information is a persistent challenge, leading to administrative inefficiencies and potential care gaps. In this blog, we explore provider data accuracy, its importance, key challenges, and strategies for improvement.

Atlas Systems also asked health plan members which specific pieces of directory information had been wrong – and the clear winner was: Whether a doctor or practice is accepting new patients, which was found to be inaccurate 50% of the time.

Other sources of incorrect information include:

• 28% called or sent an email to the wrong practitioner
• 26% discovered that the provider had retired or passed away
• 25% learned the health professional’s specialties were not as described
• 24% received an unexpectedly high medical bill

This blog explores the importance of provider data accuracy, common issues affecting data quality, and strategies to improve provider directory management.

What is Provider Data Accuracy?

Provider directory accuracy refers to the precision, completeness, and timeliness of data that appears in a health plan’s provider directory and reflects the provider’s actual, current status. This includes details such as provider names, credentials, specialties, locations, contact information, and network participation status. Accuracy, in this context, is not static; it depends on the data reflecting a provider’s current status at any given time.

Regulatory agencies, including CMS and state departments of insurance, set specific expectations for health plans to maintain this accuracy. CMS, for example, requires health plans to review and validate their directories at least every 90 days and document each outreach attempt. Many state-level mandates go further, enforcing stricter update cycles and requiring health plans to demonstrate provider attestation.

Responsibility does not shift based on who submits the data. Whether the source is a delegated entity, a credentialing vendor, or the provider group itself, the compliance burden remains with the health plan. Ensuring provider directory data accuracy is both a regulatory obligation and a patient safety issue, and increasingly, it is a reputational risk factor as well.

Why Accurate Provider Directories Matter

Maintaining provider directory accuracy directly influences how members navigate care, how plans avoid penalties, and how provider relationships are managed.

When directory data is accurate, it improves the entire ecosystem, from smoother claims processing to better access and fewer complaints.

Here are the core reasons accuracy matters:

• Improves member experience and trust: Patients can confidently schedule appointments without worrying about surprise billing or outdated information.
• Ensures compliance with CMS and state-level requirements: Health plans avoid fines and audit findings by meeting update frequency mandates.
• Reduces administrative waste: Accurate data leads to fewer denied claims, rework, and customer service escalations.
• Supports provider satisfaction: Clean directories mean fewer member misdirects, call center inquiries, or out-of-network confusion.

Strengthens operational resilience: Accurate directories reduce friction across credentialing, contracting, and customer support teams.

The Real-World Impact of Inaccurate Provider Directories

When provider directories fail, the consequences ripple across every layer of healthcare, from member access and care continuity to regulatory compliance and member trust.

And the numbers tell a troubling story.

In our latest 2025 Member Experience Monitor, we surveyed over 1,500 insured adults across the U.S. to understand how directory errors affect real people. The findings are hard to ignore:

• Members are encountering multiple directory errors per year
• Many have experienced surprise billing and care delays
• A growing percentage say they no longer trust their plan's directory as a reliable source

The report reveals how these experiences directly impact Star Ratings, grievance volume, and member retention.

These breakdowns are not isolated; they are systemic:

Trust declines: Members blame the plan when they cannot access care as expected

Compliance risks grow: CMS and state regulators continue to flag directory inaccuracies in audit findings

Operational costs increase: Each error leads to more calls, more escalations, and more appeals

Reputation suffers: Members share poor experiences publicly, influencing plan perception and renewal choices

Factors Contributing to Inaccurate Provider Directories

Even with the best intentions, maintaining provider directory accuracy is difficult, and most of the issues stem from how fragmented and reactive the process tends to be.

Let’s break down the common contributors:

• Stale or incomplete rosters from provider groups: Many plans rely on external rosters submitted by delegated entities or MSOs. These files are often outdated before they are even received.
• Manual data entry and inconsistent formats: When data is rekeyed or manually imported from different formats (Excel, PDFs, web forms), the chances of error increases dramatically.
• Lack of integration with core systems: Directories that are not connected to credentialing, contracting, or claims systems cannot automatically reflect real-time changes like terminations, address updates, or participation status.
• Multiple data sources with no reconciliation logic: A single provider may appear in multiple feeds with conflicting data points. Without a normalization and validation process, those conflicts go unresolved.
• Irregular audits and limited accountability: If compliance checks only happen once a quarter or are limited to surface-level reviews, inaccuracies can persist for weeks or months before being caught.

In most cases, it is not one big failure. It is a series of small gaps: uncoordinated, manual, and poorly tracked, that gradually erode the reliability of the data.

Strategies for Improving Provider Directory Accuracy

Compliance checks alone can’t fix directory accuracy. Health plans need to rethink provider data management from the ground up. The following strategies are grounded in current best practices and regulatory expectations, and designed to help payer organizations build sustainable, audit-ready, and patient-centric data ecosystems.

1. Establish a unified Source of Truth (SOR)

One of the most effective ways to reduce data conflicts is to move away from fragmented silos and toward a single, validated source of truth for provider data. This means:

• Creating "gold records" for each provider that consolidate verified inputs from NPPES, CAQH, state licensing boards, and internal systems.
• Prioritizing data sources by confidence levels and assigning weights accordingly.
• Using a rules engine to automate which attributes can be reused across plans, product lines, or states without repeated verification.

This centralized approach not only reduces redundancy but also limits opportunities for human error and data drift.

2. Automate roster validation and ingestion

Many inaccuracies stem from outdated, manually submitted rosters. Automating the ingestion and reconciliation of these files can eliminate delays and spot inconsistencies early:

• Set up structured intake processes via secure provider portals, APIs, or integration with delegated entities.
• Cross-check incoming data against your gold records and public registries in near real time.
• Flag mismatches instantly for remediation before they reach downstream systems like claims or directories.

3. Segment data by impact, not just frequency

Not all provider attributes carry equal operational risk. Instead of treating every update the same way, segment and prioritize data cleansing based on business impact:

• Prioritize attributes that directly affect member access, location, network status, contact details, and accepting new patients.
• Use impact analysis models (e.g., Six Sigma DMAIC) to trace errors back to root causes and fix workflows, not just fields.

4. Apply real-time integration with credentialing and claims systems

Inaccurate provider data often arises from delays in updating critical fields across internal systems. This can be mitigated by enabling:

• Real-time sync between credentialing, contracting, and directory systems.
• API-first architecture to allow bi-directional data flow across business units.
• Role-based data access and tokenization to ensure PHI and PII stay secure during updates.

5. Embed data governance at the workflow level

Governance cannot be an afterthought. It needs to be baked into the provider lifecycle management process:

• Use governance frameworks that assign confidence scores to data elements.
• Flag expired credentials, duplicate entries, or out-of-network affiliations before they reach the member.
• Maintain a dashboard for real-time visibility into data hygiene metrics and remediation status.

6. Audit at the right cadence, not just to check a box

While CMS mandates updates every 90 days, relying solely on this cadence may expose gaps. Progressive health plans are now:

• Implementing continuous auditing models with dynamic thresholds based on usage, accuracy trends, and member complaints.
• Leveraging external benchmarks like CAQH, LexisNexis, and Symphony for validation and calibration.
• Running predictive audits using historical patterns to forecast which records are most likely to degrade next.

7. Empower providers with transparent, digital tools

Providers are more likely to submit timely, accurate data when they see how that data is used and when the process is simple:

• Offer intuitive self-service portals that include feedback loops, submission tracking, and real-time verification status.
• Use digital nudges and automated reminders when credentials are about to expire or addresses appear outdated.
• Standardize onboarding documentation and allow providers to correct or verify data before it reaches the member-facing directory.

8. Make AI and predictive analytics do the heavy lifting

As data complexity grows, manual validation will not scale. AI-driven approaches can reduce false positives and speed up decision-making:

• Use machine learning algorithms to detect patterns in prior data corrections and apply auto-healing.
• Deploy analytics engines to monitor for signs of degradation (e.g., spikes in complaints or claim denials tied to specific provider attributes).
• Tap into GenAI tools to extract structured data from unstructured inputs like faxed rosters, emails, and paper forms.

These strategies are about building trust with your members, strengthening provider relationships, and avoiding costly fallout from compliance violations. Investing in this level of precision now will put your organization in a far better position to adapt to national directories, stricter audits, and rising member expectations in the years ahead.

The Future of Provider Directories in Healthcare

Provider directories are becoming critical infrastructure for digital health access, care coordination, and payer transparency. As the industry moves toward more integrated ecosystems and consumer-driven expectations, directory accuracy will take on even greater strategic relevance.

Here is where the landscape is heading:

• National directories and centralized registries: Federal efforts to build national directory frameworks, including CMS’s proposed mandate for a unified provider directory infrastructure, will place new expectations on how data is shared, verified, and governed.
• Real-time access over static listings: Patients expect immediate, accurate answers across websites, mobile apps, and call centers. Static PDFs and quarterly updates will no longer be sufficient.
• Tighter integration with digital front doors: Accurate provider data will power scheduling tools, virtual care platforms, and AI assistants, making directories a core part of the patient experience, not just an administrative tool.
• AI-driven validation and auto-correction: As directories scale across platforms and product lines, manual QA processes will not keep up. Expect automation to play a greater role in identifying mismatches, predicting data decay, and triggering real-time remediations.
• Stricter audits and interoperability mandates: CMS and state regulators are already pushing for deeper data accountability, and new mandates may soon require real-time interoperability with credentialing, contracting, and provider portals.

The takeaway is simple: future-ready directories are proactive, not reactive. They are a living interface between health plans, members, and care delivery.

How Atlas Systems Helps Health Plans Safeguard Directories, Members, and Trust

Inaccurate provider directories erode trust, expose health plans to regulatory penalties, and delay care when patients need it most. Each missed update or mismatched record represents a breakdown in the system meant to protect both providers and patients.

At Atlas Systems, we treat provider directory accuracy as a mission-critical function, not a check-the-box task.

Why? Because we have seen the downstream impact of errors firsthand, from CMS audit failures to grievance spikes, to provider abrasion that slows onboarding and disrupts member care.

Here’s how we help solve it:

• Over 70% reduction in roster processing time with automated ingestion and normalization
• 40+ data validation checkpoints across demographic, credentialing, and participation fields
• Support for real-time sync with delegated entities, credentialing systems, and claims
• Proactive alignment with CMS 90-day update rules, Section 508, and ADA accessibility requirements
• Fully managed support for provider-payer connectivity through the Atlas PRIME® platform
• Fully ADA-compliant provider directories built for screen readers, keyboard navigation, and visual accessibility

Our clients choose PRIME® because we go beyond remediation; we build systems that prevent errors in the first place. Whether it is improving first-touch data accuracy, reducing provider outreach burden, or building audit-ready logs, our approach is built for long-term sustainability.

If your organization is still relying on spreadsheets, quarterly audits, or manual reconciliation, now is the time to rethink that strategy. Talk to our experts to see how our provider data and compliance solutions can safeguard your directory, your members, and your reputation.

Frequently Asked Questions (FAQs)

1. How often should provider directories be updated?

According to CMS guidelines, Medicare Advantage plans must review and update their provider directories at least once every 90 days.

2. What should I do if I find incorrect information in my insurance plan’s provider directory?

If you notice incorrect provider information, such as outdated addresses, unavailable providers, or wrong network status, you should contact your health plan immediately. Health plans are required to investigate and correct the error, and failure to do so could result in regulatory action or member grievance escalation.

3. Can I be billed for out-of-network services if the provider directory said they were in-network?

It depends. Federal and state regulations (including the No Surprises Act) offer some protections for patients when inaccurate directories cause out-of-network billing. However, plans may still be held accountable for directory errors that mislead members, especially if they affect network adequacy or access to care.

4. Are there regulations that enforce provider directory accuracy?

Yes. CMS enforces provider directory accuracy under Medicare Advantage rules, and several state insurance departments have specific mandates for timeliness, accessibility, and accuracy. Plans that fail to comply may face corrective action plans, star rating reductions, or financial penalties.