Real-World Implications

Consider a patient using a health plan directory to find an in-network specialist. They schedule an appointment successfully, take the day off work, and arrange for a ride to the office, only to arrive at a location where the provider no longer practices. This scenario can lead to:

• Patient dissatisfaction: Wasted time and money; frustration with the provider and the health plan.
• Administrative burden: Health plans and providers spend resources correcting errors.
• Delayed care: Treatment is postponed, potentially worsening outcomes.

Revenue loss: Providers lose income and risk losing patients permanently.

These issues are avoidable with proactive provider data management, including regular updates and accuracy checks.

The Hidden Cost of Poor Provider Data Management

Beyond missed revenue opportunities, poor consumer experiences, unexpected billing/claims denials issues, and regulatory risks, the hidden costs of poor provider data management are staggering.

Here’s why investing in accurate data is essential for a healthier, more efficient healthcare system.

1. Financial Impact: Inaccuracies Drive Up Costs, Bring down Revenue and Profitability

Errors in provider data can create a domino effect of financial consequences. The most common problems that arise from inaccurate data are evidenced in these two areas:

A lack of consumer awareness of available care options “near them” resulting in missed customer acquisition opportunities and ensuing revenue opportunities.

Post-service billing/claims errors and claims denials that lead to increased administrative burdens and delays in reimbursements.

A report on the directories of the nation’s five largest health plans revealed that four out of five entries were inaccurate.⁵ These inaccuracies aren’t minor inconveniences. They represent a financial black hole impacting revenue growth, profitability, and operational efficiency.

Health plans and providers must dedicate additional resources to reconcile and correct these errors, which ultimately drives up costs:

• Directory maintenance: CAQH estimates the cost of directory maintenance to US health systems is $2.76B annually, while siphoning resources away from patient care. Streamlining directory maintenance could save health systems $1.1B annually.⁶
• Manual management: For health plans, the expenses associated with handling these errors add up quickly. Manual directory management for a small payer with just 10,000 providers can cost over $300,000 annually in verification processes alone. For larger payers, these costs can balloon to over $22 million annually.⁷

Enhancing the quality and accuracy of information provided by health plans can significantly improve member experiences, foster trust, lead to better healthcare outcomes, and increase member retention and acquisition. This improvement in service and information quality can also substantially boost:

• Financial performance of health plans: Potential gross margins range from $753 to $1,982 per enrollee across Group, Individual, Managed Medicaid, and Medicare Advantage markets.⁸
• Revenue protection for health systems: Delays in credentialing can cost hospitals and provider groups $1,000–$5,000 per provider per day, with some organizations reporting over $1 million in annual lost revenue.⁹
• Physician-driven patient retention and referral efficiency: Accurate provider data helps guide referrals, keep patients in-network, and reduce referral leakage, which can average 55%–65% and negatively affect a hospital’s financial health.¹⁰

2. Patient Experience: Smooth Access to Care Begins with Accurate Data

Provider data accuracy is also essential for ensuring a seamless patient experience. When patients use health plan directories to find physicians, incorrect phone numbers, outdated addresses, or missing information can disrupt their ability to access timely care. In fact, according to a recent study by KyruusHealth:

• Over 70% of consumers went online the last time they searched for care.
• Over 55% rely on their health insurer’s provider directories to choose their healthcare providers.
• 34% encountered inaccurate provider information within their health insurer transparency tools.
• 30% of consumers skipped or delayed seeking care as a result of finding inaccurate provider information (rising to 44% among Gen Z).

Interestingly, health systems continue to be seen as the most trustworthy resource for gathering information, closely followed by health plans. Consumers rate “Accepts my insurance,” “Clinical expertise on my condition,” and Appointment availability,” as the top 3 factors when selecting a new healthcare provider, service or location, but 63% of those who skipped or delayed care last year say they could not find an appointment.¹¹

Incomplete or inaccurate provider data leads to care gaps, as many consumers will delay or skip seeking care altogether. Further, value-based care models prioritize patient well-being and satisfaction, but inaccurate provider data undermines these goals.

Patients who encounter errors in the directory at health systems and insurers alike may face unexpected medical bills or delays in care, and they may even forgo seeking treatment due to frustration or confusion. Consequently, inaccurate data jeopardizes both patient satisfaction and health outcomes from a patient/member perspective, and both experience and loyalty scores for both health systems and health plans.

3. Compliance and Risk: Avoiding Legal and Regulatory Pitfalls

Outdated provider data also creates compliance risks. Regulations like the No Surprises Act and the 2026 REAL Health Providers Act require accurate and accessible provider information. Non-compliance can lead to fines, legal consequences, and reputational damage.

Under the CMS regulations, Medicare Advantage plans must review and update their provider directories every 90 days, promptly remove non-participating providers in the network within 5 business days, and report the accuracy of their provider directory to CMS, which would be published on the CMS website.

Under the No Surprises Act, health plans may face fines up to $100 per day per affected individual. Providers could be fined up to $10,000 per violation. Additionally, providers may be removed from the health plan directory if they fail to verify their information.

Further, if a patient receives out-of-network care due to an inaccurate provider directory and is billed more than in-network cost-sharing amounts, the health plan or provider may be required to refund the excess amount with interest.