5 Challenges in Provider Data Management

Dr. Hernandez* is an orthopedist who practices in a small town. She just opened up a small clinic where she works with a nurse and a nurse practitioner to serve the town’s population.

When she started her clinic, she imagined her days would be spent setting broken bones, performing X-rays, and helping people feel better. But instead, she’s recently found herself mired in paperwork, spending as much as a day a week on administrative duties rather than seeing patients.

Last week, Dr. Hernandez had bumped into a friend who told her she had wanted to make an appointment to see her but hadn’t been able to find her information in her health plan’s provider directory. Dr. Hernandez was perplexed, as she knew her clinic was in-network with the plan, but after several phone calls, she learned that her new clinic’s address, phone number, and location data hadn’t yet been updated. The frustration of losing patients, coupled with the hours of administration work, led Dr. Hernandez to wonder if starting the new clinic had been a good idea.

Accurate, up-to-date provider data underpins everything from network adequacy and directory accuracy to care navigation, claims processing, and regulatory compliance. Yet, despite its critical role, providers like Dr. Hernandez are mired in paperwork and lose out on patient opportunities. Hospital systems struggle to manage provider data from thousands of employees, and patients often struggle to find in-network providers to help them find care. Provider data management (PDM) systems face challenges that lead to data degradation, higher administrative burden, and ongoing frustration.

In a recent webinar held in partnership with Candor Health, we discussed the obstacles payers and hospital systems face with PDM. The speakers highlighted that these issues stem from outdated infrastructure, rigid processes, and disconnected data flows. The result is predictable: frustrated providers, rising administrative costs, and members unable to reliably find the care they need.

So, how can these challenges be avoided?

While the problems are widespread, they are driven by a combination of root causes. Individually, each driver may not pose a significant issue, but together they compound to create myriad problems.

In this article, we’ll explore five of the most common drivers behind the challenges facing PDM systems and show how tech-forward solutions, like CertifyOS, can proactively address each issue before it becomes a problem.

Problem Driver #1: Updates Made at the Wrong Hierarchical Level

Historically, all provider data updates were done manually, creating a massive administrative burden. Administrators would spend hours updating the same information hundreds, if not thousands, of times. While PDM technology has streamlined this process through tech-enabled updates, it has also introduced new challenges.

One major issue involves hierarchical information. Dr. Hernandez, for example, works at multiple sites. She works at her new clinic four days a week, but still has hospital rights at a local hospital once a week, where she can perform surgeries and treat patients. If the PDM systems universally updated the provider’s address to her new clinic and failed to recognize that she also worked at a hospital, it would result in an inaccurate record.

Every record tied to a given provider must reflect the correct data, or it will appear in network directories as though Dr. Hernandez no longer practices in that area. If this happened, Dr. Hernandez would struggle to file claims and patients would be unable to find her.

While this may seem like a rare occurrence, it is actually systemic. It happens frequently because many PDM databases aren’t designed to handle updates at the correct hierarchical (or, as we refer to it, atomic) level.

The Solution: CertifyOS addresses this problem with survivorship logic that establishes the organizationally agreed-upon “version of truth” for each data point. Instead of letting a simple update, such as an address change, cascade into widespread errors, CertifyOS’s PDM system ensures that all updates are linked to the correct records, at the right level, accounting for hierarchical nuances and preventing downstream issues.

Problem Driver #2: Inconsistency Between Data Sources

While the incentives for clean, accurate data are obvious, keeping information in sync is incredibly difficult in a system reliant on multiple, inconsistent data sources. Take a simple example: When Dr. Hernandez moved to her new clinic location, she followed protocol and updated her information directly with the health plan. Even with that update, the delegate group or provider group in the physician’s network took weeks (or longer) to update their roster, so when Dr. Hernandez’s friend looked for her, the data was incorrect.

The reality is that provider data is seldom clean or straightforward. Many clinicians work across multiple groups or practice sites, and most participate in several health plans. This creates a fundamental question: Which source should be trusted? The information submitted by the provider? The roster? The most recent timestamp? Each decision introduces complexity, and none consistently solves the problem.

As these inconsistencies compound, they create downstream issues across the entire ecosystem. What appears to be a minor timing discrepancy can disrupt referrals, delay claims, stall credentialing, and impact patient experience. It also contributes to “over-affiliation” in directories, where providers appear tied to 10, 15, or more locations (many of which are outdated or inaccurate), leading to claim denials and frustrated patients.

The Solution: CertifyOS was built to synchronize provider data across systems in real time, creating a single source of truth. Our AI-enabled platform compares data across sources (primary source data, CAQH databases, and more), flags discrepancies instantly, and resolves inconsistencies before they cause downstream issues. The result: cleaner data, faster claims processing, accurate directories, and a smoother experience for both providers and patients.

Problem Driver #3: Directory Accuracy Updates Do Not Reference Contracted Status

A key component of network compliance law is the requirement that payers make provider data (such as contracted status) available to members in a way that is accurate, current, and transparent. This means maintaining precise directory information for locations, specialties, credentials, and more.

While this sounds straightforward, the reality is anything but. Large, dynamic datasets naturally degrade over time. As networks expand, providers relocate, and clinicians earn new credentials, inaccuracies multiply quickly if updates aren’t captured and reconciled across systems. Even when accuracy is a top priority (and it is), errors are inevitable.

One of the most significant contributors to these inaccuracies is the frequency of status changes. When a provider stops practicing at a listed location, leaves a network, or shifts their specialty, payers must update that information immediately so members can find appropriate alternatives. But each update also creates a coverage gap that must be filled just as quickly. As described in the webinar, it becomes a “game of whack-a-mole”—fixing a directory listing on one side while racing to close the gap it creates on the other.

The Solution: A holistic infrastructure that supports provider data management at both the macro and micro levels. CertifyOS’s single-API platform updates directories in real time, ensuring changes are reflected instantly and allowing payers to identify and respond to care gaps as they emerge.

Problem #4: Locations Impact Network Adequacy

New and changing locations are a persistent source of data accuracy problems. When a provider moves to practice in a new location—even if it’s part-time—their directory information changes. When this is a one-off, it’s one thing, but sometimes entire hospitals or hospital systems change, creating a situation where hundreds, if not thousands, of providers have new locations.

For example, in early 2025, Mt. Sinai Beth Israel Hospital closed its doors after serving Manhattan residents for over 135 years. They employed thousands of employees, and cared for tens of thousands of New Yorkers, and the closure impacted the entire community. It also made a mess of provider data. Payers had to not only update each provider’s data with new practice information across different hospitals, but also ensure that Manhattan residents near Beth Israel had in-network access to care in that area.

Any time there is a location change—either a closure or the construction of a new hospital or clinic—there is an increased PDM burden. In our complex system, where most providers practice in more than one location, this is even more complex as location changes introduce more inconsistencies.

The Solution: In a modern world where many practitioners practice in a variety of locations and even virtually, PDM can get really complex. AI-enabled technology like CertifyOS can process data quickly, helping payers and systems manage complexity.

Problem Driver #5: Provider Roster Data Doesn’t Map to Payer Systems

This challenge actually emerged from an earlier solution: payers recognized the need to clean up their provider data, so each built internal systems tailored to its own priorities. Some adopted external PDM tools, others developed proprietary platforms, but over time, every payer’s system evolved into a unique structure and set of requirements. And while these efforts were meaningful and necessary, they also introduced a new problem driver.

Because every payer system operates differently, data fields and hierarchies don’t align. The structure, its required fields, and data formats vary from payer to payer. This creates a significant administrative burden—some providers and groups must complete upward of 18 forms for a single status change—and leads to inaccuracies when roster data can’t be cleanly mapped to payer systems.

A simple example illustrates the issue: one payer may require an address in a single line (e.g., “123 Main Street, New York, NY”), while another splits it into four fields (street number, street name, city, state). When systems like these attempt to sync data, details can be dropped or mismatched, causing errors that ripple across directories, claims, and credentialing workflows.

The Solution: PDM requires a “smart” infrastructure capable of detecting nuances across payer systems and harmonizing data across varying field structures. CertifyOS’s platform is designed with this logic built in, enabling accurate, consistent data alignment across systems—without adding administrative burden.

Addressing These Challenges

The industry recognizes that meaningful change is long overdue. Health plans need flexible, configurable, rules-driven infrastructure that can adapt to the nuances of each network, keep pace with evolving standards, and automate the validation work that downstream processes depend on. Moreso, a solution that addresses these issues holistically also offers the key benefit of delivering impactful results rendered across one health plan's entire partnership ecosystem—network effects that have real, meaningful impact industry-wide.

Tech-forward platforms like CertifyOS are designed to confront these challenges head-on, helping payers streamline operations and reduce complexity. PDM will never be entirely without challenges. But with the right infrastructure in place, we can move toward a system where accurate data is consistently matched to the right providers and networks remain current for the patients who rely on them.

*Names and identifying details changed for privacy