Provider Data: The Glue Between Network Operations, Access, and Experience

In the healthcare ecosystem, a single resource sits at the intersection of multiple business-critical functions: provider data.

Provider data management may not be the most crucial function (after all, taking care of patients always comes first), but without accurate provider data systems in place, the many players in the healthcare system struggle to deliver care effectively and operate efficiently.

Unfortunately, our current provider data management system is broken, leading to cascading effects. A 2023 JAMA study found that 81% of entries across 5 large national health insurers contained inconsistencies, and misaligned incentives have made it difficult to find and manage solutions. What’s more, siloes between payers, providers, and members have led to increasing levels of data degradation and an ever-growing administrative burden.

As a result, health plans are struggling to maintain efficient networks that meet patient needs, payers face regulatory fines, providers suffer from delayed payments and a loss of patients, and members simply don’t have access to the healthcare providers they need when they need them.

There is an emerging solution: A Provider Data Management (PDM) system built to ensure accurate, up-to-date provider data, holding together operations, access, and member experience. As we work to usher in the future of healthcare, a future where a tech-forward infrastructure ensures seamless integration between various stakeholders, it’s vital that we recognize the role that provider data plays. 

Provider Data Fortifies Network Operations

Behind every health plan, hospital system, and healthcare clinic lies a web of administrative processes that keep the system running, ensuring patients receive care, providers get paid, and plans remain compliant. Accurate, up-to-date provider data supports each of these fundamental processes, creating the backbone for network operations.

When provider data management systems are in place:

• Members can trust that the providers in their health plan networks hold the appropriate licensing and credentialing.
• Provider directories reflect real-time information, reducing member abrasion and ensuring regulatory compliance.
• Plans avoid financial penalties and reputational damage from incorrect provider data.
• Administrative teams aren’t burdened with costly data clean-up, and avoid expanding administrative work and rising costs.
• Providers and members avoid costly claim denials caused by mismatched information.
• Patients can get the care they need when they need it.

Well-managed provider data streamlines network operations, reduces administrative burdens for providers and payers, and ensures timely access to care for members. What’s more, efficiencies created by streamlined provider data processes could save the healthcare system tens of millions of dollars each year.

Provider Data Provides Healthcare Access

Administrative infrastructure churns behind the scenes, making network operations invisible to most, but patient access is overtly exposed to nearly everyone. Members turn to provider directories to find in-network physicians, specialists, and facilities. When they can’t find what they need, they can’t get the care they need.

At a fundamental level, if a member searches for a provider and finds incorrect information (such as a wrong address or unavailable specialist), their care is delayed, and their trust and experience with their plan erodes. These problems become even more evident in underserved communities, where inaccurate directories can mean delays in accessing critical care.

Accurate provider data is not only about compliance or relieving the administrative burden for plans and payers; it’s also about connecting members to the care they need, when and where they need it.

A 2024 J.D. Power & Associates study found that the most significant factor in how a member rates their plan is access to care. Plans are assessed based on member scores on CMS Star ratings, which have a direct impact on the financial health of plans. Accurate provider data ensures care access, supporting a key priority for most health plans.

Provider Data Leads to a Better Experience for All Players

The value of an accurate provider data system doesn’t just stop at network operations and healthcare access; it also directly impacts the experience of nearly every player in the entire healthcare system. Accurate provider data strengthens the healthcare system as a whole, improving the experience for everyone involved.

Essentially, when provider data is accurate, everyone experiences healthcare more positively:

• Member experience. Having accurate provider directories means that members can confidently choose in-network providers, building trust and satisfaction. Trust and satisfaction often equate to higher member satisfaction scores, better retention, and higher CMS Star ratings.
• Provider experience. Health plans aren’t just beholden to members. Outdated or inconsistent provider directories can lead to loss of business for providers and delays in payment, leading to expenses and administrative burdens.
• Payer experience. Payers are also responsible for the experience of their internal teams. Better data translates into a reduced administrative burden, stronger relationships with providers, and improved employee retention.

Ultimately, accurate provider data enhances trust across all stakeholders—making it a cornerstone of payer experience strategy.

Connecting Data Silos

Even with clear incentives to have effective provider data management systems, most payers struggle with provider data accuracy. Provider data often lives in separate systems, and without a single source of truth, the data degrades. Without a unified provider data strategy, silos form, leading to disconnection.

At CertifyOS, we think that the best way to reduce this disconnection isn’t by breaking down the silos, but by connecting them. Strong provider data management can act as the ‘glue’ that holds these critical functions together, enabling data to flow seamlessly and ensuring everyone has access.

CertifyOS is building the connective tissue (or glue, if you will) to hold the next generation of healthcare operations together. We want to connect the siloes between payers, providers, and members with an unseen, but essential infrastructure that quietly and seamlessly delivers a real-time, verified provider data layer. 

By embracing high-tech, proactive provider data management systems, payers can shift away from siloed data and clunky systems to a proactive, reliable, and scalable system that strengthens provider relationships, reduces administrative costs, and gives members confidence in their care.

Ultimately, it’s simple: better provider data equates to better healthcare outcomes for all. Instead of a liability, we want to help make provider data a strategic asset, driving streamlined operations, more access to care, and higher member, provider and employee experience for all.