Why the Provider Data System Is Broken and What We’re Doing About It

At first glance, provider data management appears to be a relatively straightforward endeavor: Health plans regularly collect and update provider information, aligning with regulatory requirements, ensuring that patients have access to high-quality care, and that providers are paid on time.

It seems simple, but in reality, it’s a complex and messy process that has become exceedingly burdensome and expensive for all parties.

Which leads us to ask the question: Why is provider data management so hard?

• Why are payers struggling to aggregate accurate data and keep it up-to-date to ensure their members have access to correct information and comply with regulations?
• Why do providers struggle to input their information and keep it up to date with the most current information?
• Why are regulators struggling to ensure that the entire provider data system reflects the most accurate information so that patients can find the right doctors to meet their needs?
• And why is the entire healthcare industry spending millions of dollars and thousands of hours each year in an attempt to streamline the provider data system?

The answers are complex, and the solutions in place aren’t solving the problem. Things are getting worse and worse every year, and players across the industry are wondering why a single, centralized solution hasn’t taken hold.

While we don’t have all of the answers, we are working on it. At Certify, we’ve been pondering this exact question for years, and we hope to initiate the conversation that leads to a solution that works. We have a vision of what the provider data system could be and how it can drive the future of the healthcare system.

The Root Causes of the Provider Data Problem

At one of the sessions at our Blueprint Summit, Jamila Sykes, VP of Provider Data Operations and Reimbursement at Highmark Health, described our current provider data as a big pot of soup. She asked us to imagine a big pot on the stove with a variety of chefs tossing in ingredients as they see fit. One chef adds a potato, another a carrot, and another a piece of chicken. Before long, you aren’t sure what’s in the pot, and if you realize the recipe didn’t call for carrots, it’s impossible to strain them out.

There are significant issues with a large pot of provider data:

• Inaccurate data: There’s so much data that’s been tossed into the pot that it’s impossible to know what data is accurate and what is outdated.
• Infrastructure challenges: Just like all of the different chefs throwing ingredients into the soup, there are multiple data sources all pouring into various platforms, making it challenging to keep up with what is being added.
• Ambiguous standards: The data is often behind layers of administration, so stakeholders' visibility into the timeliness or frequency of data updates.
• An increasing administrative burden: Providers are forced to juggle multiple platforms to perform updates, while payers must sort through data coming in from a variety of sources, and regularly clean up the data pool. Even when providers comply and provide information, the data quickly goes stale.
• Unclear accountability: Payers are responsible for ensuring their provider data is accurate, but providers aren't regulated for their inputs, nor are they notified when specific changes are necessary across various platforms.
• Limitations on incentives: Individual health plans are only incentivized to address data problems within their networks, and providers are only incentivized to participate to the extent that they need to receive payment.
• Legacy technology. The current infrastructure is unable to keep pace with the system's demands, and outdated tech platforms contribute to the administrative burden.
• Flawed solutions. Many have attempted to devise solutions, but most have flaws that exacerbate the problem.

The provider data system is flawed because every stakeholder operates from a different playbook, and each has distinct obligations and incentives. This siloed complexity has driven the entire system into a state of disarray—an aptly described pot of soup full of insufficient and outdated data, which feels impossible to clean up.

Why Existing Solutions Fail

The problems with provider data are well-known, and several entities across the healthcare system have tried to find solutions. These solutions have helped to push progress, but have ultimately failed due to the scope of the problem.

The most common solution involves data-driven vendors utilizing secondary sources to purchase or scrape provider data and run analytics, then providing health plans with a confidence score on the accuracy of this data. This has helped, but the problem is that the data that’s input into the systems is only as accurate as the source it’s scraped from. Provider data systems are still full of inaccurate or outdated information.

Other vendors have developed tools that assist health plans in collecting provider information. For example, some products offer a “front door” where providers can enter and add data, and then health plans subscribe to the resulting data. The problem with these solutions is that no one has a significant market share, meaning that providers still end up having to enter information in multiple sources, leaving health plans with numerous murky pools of data instead of a single, comprehensive one.

Another solution that has emerged is homegrown patchwork systems, which support provider data management by physically calling healthcare systems to obtain up-to-date data. The problem is that this data is only valid for a short period, so continuous updates are necessary to ensure accurate data. Additionally, many systems only access a portion of the data, resulting in an incorrect representation of the data.

Each of these systems has helped stakeholders take incremental steps toward a solution, but none has successfully addressed the overarching problem. The truth is that the entire system needs an overhaul – we need a single source of truth, a modern infrastructure, and AI-driven data that is continuously updated and verified for accuracy. We need to power the next generation of provider data intelligence.

The "One Source of Truth" Dilemma

It’s increasingly apparent to all parties that a centralized provider data system would be beneficial; however, with numerous stakeholders who have each invested in their systems and processes, it’s challenging to bring everyone to the table.

One of the biggest hindrances to a single source of truth is the proliferation of “single solutions,” often leading to further fragmentation. Most payers have invested millions of dollars (and not to mention years) in their provider data systems. Many have made significant progress in cleaning up their data and developing frameworks to ensure data integrity. Their teams have been trained on their systems and administrative processes. Although these are burdensome, they serve a functional purpose. Additionally, while much of the provider data is plan-agnostic, some data, such as specific specialties under contract with a particular plan, is not.

With this in mind, it’s challenging for many payers to envision adopting a new system or utilizing someone else’s tools. Instead, payers are expected to develop and maintain their own systems to manage their provider data, resulting in higher administrative burdens and more complex processes.

Why the Incentives Don’t Align

While a single source of truth would be beneficial to all players, the incentives for a single source of truth don’t always align.

Health plans must remain compliant and efficient, so they need systems in place to ensure their data is up-to-date and accurate. They also want their members to be able to access provider information quickly to obtain the care they need.

Providers want to focus on caring for patients, rather than being buried in administrative tasks. They want their provider information to be consistent and accurate, with minimal administrative effort.

Meanwhile, members want accurate, plan-specific data so that they can quickly and easily find the right in-network provider. Regulators aim to influence outcomes but lack direct levers, while hospital systems seek to ensure they receive payments promptly and accurately.

Essentially, everyone wants better data, but nobody is willing to take on the burden of maintaining it.

Certify’s Approach to Data Infrastructure

As we mentioned earlier, Certify has spent the last several years contemplating a solution to the issue of provider data integrity. We know that the problem is complex—and we know the solution will take time and innovation.

Rather than adding another tool or intermediary solution, Certify is focused on building the foundational infrastructure that will enable the entire system to manage provider data at scale. We aim to create interoperability, ensuring the correct data is in the right place at the right time.

This new, modern infrastructure can solve all of the problems with our current provider data system at once. It can be a single source of truth that leverages the foundational elements to create robust solutions that specifically meet the needs of all players. It can clean up the data sources and address the problems that led to the system failure in the first place.

To Put It Simply: Provider Data Doesn’t Have to Be This Hard

We are working to develop a new vision for managing provider data. We acknowledge the complexity, but we are ready to stand alongside our partners and do the work. Piece by piece, step by step, we are prepared to architect the future of provider data. One day, one step, and one piece of data at a time.

Together, we can architect a future where network effects drive incremental benefits for all parties, and where provider data is simple, efficient, and helps every stakeholder to get what they need.

Want to learn more? Book a demo.