Accurate healthcare provider data matters to all of us.

Today, anybody with a smartphone can find a book, song, restaurant, car ride, or job lead in seconds. So why does it still take phone calls, interpreting policyholder cards, and hours to find the right doctor? Shouldn’t we be able to open an insurer’s directory, specify the type of doctor we need, how far we’re willing to travel, and then see an accurate list of available healthcare providers?

Many consumers are finding that the directory listing for a doctor is not correct: the office location has changed, the phone number to schedule an appointment is wrong, or the doctor no longer accepts the insurance. According to one recent audit, on average, over 50% of data in directories has errors.

The simple task of scheduling an appointment has become a game of hit or miss.

While it is tempting to point fingers, bad provider data is the result of systemic problems that have emerged over time. The problem has gotten so bad that legislators and regulators, with the best of intentions, are jumping in to solve it. Unfortunately, this is likely to produce a patchwork solution to a nationwide problem. It might, in fact, make matters worse. Physician practices, hospital systems and insurance plans cross state lines, and having to meet different regulatory requirements from one location to the next could add yet another layer of complexity. In addition, there are unintended consequences: health plans regularly contact entire provider networks with phone calls, postcards, and faxes to request directory updates — which incurs cost on both plans and providers and yields little to no benefit in accuracy improvement.

The problem can be boiled down to two fundamental issues:

  1. Providers and health plans need to align on criteria for high quality directory data, and
  2. Providers and their staff need an easy way to keep their directory information updated.

Healthcare providers view health plans primarily as “payers”. Since claims payments are top-of-mind, providers are submitting data to plans assuming their information will be loaded into claims systems. Patient-facing directories are a distant thought. It’s only been in the past two years, and mostly as a result of regulatory motivation, that plans began to emphasize that data will be used in directories.

All good provider data originates from the provider, so there needs to be a shared understanding of what good data looks like. Long-term campaigns to educate providers on how their information is used and how to keep it updated are conducive to both claims and directory purposes — and critical to solving this problem. Aggressive outreach campaigns that focus on regulatory risk that plans face don’t land well with the provider audience. The focus should be on improving the experience of plans’ and providers’ shared customer: the patient. Doctors and other healthcare providers entered the field to help people, so appealing to this mission is important.

Just as important, it needs to be as easy as possible for providers to do the right thing. Different health plans are asking for different information in a variety of methods (phone, fax, portal, and even paper forms) from their providers. The myth is that providers desire choice in how they interact and submit data to plans. Choice complicates and paralyzes, creating burden and cost for both plans and providers. Providers overwhelmingly prefer that plans select and stick with a single, simple way of collecting data.

It will take an industry effort to gradually evolve perspectives and processes on the provider side to submit the best data to update provider directories. Doing so will be a significant step in maximizing patient access to care. Individual and customized approaches to provider data collection have exacerbated the current problem, and proprietary, one-company solutions won’t solve it.

Health plans need to collaborate in how they gather information from the same providers, so they can reduce the time practices must spend entering information into multiple portals and forms. There are existing opportunities to leverage third party sources, data pre-population, and artificial intelligence to support this effort. The easier it is for doctors to share information, the more likely they are to keep it complete and up-to-date.

So, let’s do it better now. Let’s reduce the administrative workload on doctors so they can focus on their priority — patient care. Let’s reduce the need for individualized health plan provider data collection so they can focus more resources on aligning with a value-based world. And let’s get accurate provider directories to consumers so they can easily find a doctor.

The healthcare industry is growing and now is the time to finally solve the provider data problem. If you think you may ever need a doctor, the reality is healthcare provider data matters to you.


Ron Urwongse is a Senior Product Manager for CAQH, which started solving problems with provider data management more than a decade ago. The organization convenes key healthcare players to develop industry-wide solutions that simplify business processes. CAQH Solutions are designed to create efficiencies and reduce administrative burden for both healthcare providers and health plans.