Why Provider Data Cannot Drift—Ever
Verification is no longer a quarterly task or post-audit clean-up. It is now a continuous operational requirement driven by the convergence of regulatory mandates, consumer expectations, and network adequacy scrutiny.
Why Continuous Verification Matters
Regulatory pressure is accelerating
Under the No Surprises Act, payers must verify provider information every 90 days and process updates within 2 business days. Failure to maintain accuracy can result in “hold harmless” obligations—forcing payers to absorb out-of-network costs when members rely on incorrect directory data. (CMS No Surprises Guidance)
Directory errors remain pervasive
A CMS Report found error rates ranging from 5% to 93% across five major health plan directories—even for plans with significant resources.
The AMA warns of member harm
The American Medical Association states that inaccurate directories “make it easier for plans to fail to build networks that are adequate and responsive to enrollees’ needs,” creating direct consumer-access risks.
Provider data changes rapidly
Within a 90-day window, providers frequently:
- Move locations
- Change affiliations
- Modify availability
- Update contact information
- Close practices or retire
Static or periodic verification cannot keep pace with this natural rate of change.
Verification Projects vs. Continuous Verification
Legacy Model: Periodic Verification
Most plans still operate in a batch-driven model:
- Quarterly or annual outreach
- Manual reconciliation
- Roster files and spreadsheets
- Point-in-time accuracy that degrades immediately
The CAQH Index estimates that provider-data and directory-related maintenance costs the U.S. healthcare system over $5 billion annually, much of it tied to outdated manual processes.
Modern Model: Continuous Verification
Continuous verification transforms verification into an operating discipline:
- Automated ingestion of all internal and external sources
- Identity-level reconciliation and conflict detection
- Attribute validation (location, status, specialty, availability)
- Event-triggered verification and continuous monitoring
- Real-time updates to downstream systems
- Live accuracy and completeness metrics
This aligns with the direction regulators are moving—and what members expect.
How Payers Operationalize Continuous Verification
1. Establish a unified provider identity
Eliminates conflicting NPIs, mismatched addresses, duplicate entities, and fragmented updates.
2. Continuously monitor for provider changes
Licensure updates, affiliation changes, relocations, sanctions, schedule changes—these events require immediate detection, not quarterly review.
3. Automate verification across multiple channels
Phone, email, portal, API, and authoritative-source checks must operate at scale to stay compliant with 90-day verification windows.
4. Reconcile changes across all downstream systems
Directories, claims, credentialing, contracting, and MCO operations must reflect verified updates in near real-time.
5. Maintain audit-grade evidence
Regulators increasingly expect timestamped verification logs, lineage evidence, and documentation showing governance and oversight.
6. Monitor accuracy and timeliness as KPIs
Metrics such as verified-within-90-days, unreachable rates, discrepancy rates, and drift indicators become part of the operating fabric.
Continuous Verification = Compliance, Consumer Protection & Risk Reduction
Continuous verification provides measurable value:
- Protects members – CMS Medicare Advantage audits continue to reveal ~49% directory location inaccuracies, underscoring systemic access and safety risks.
- Reduces compliance exposure – NSA rules, CMS interoperability mandates, and emerging centralized directory pilots all require payers to maintain accurate, evidence-backed data. (CMS Interoperability and Prior Authorization Final Rule – CMS-0057-F)
- Reduces financial leakage – Out-of-network reimbursements, misrouted claims, and call-center escalations are directly tied to inaccurate provider data.
- Cuts operational waste – CAQH estimates that automation could eliminate up to $20 billion in annual directory- and credentialing-related administrative waste.
Polus HCP: Infrastructure for Continuous Verification
Polus HCP gives payers the operational backbone required for continuous verification:
- Automated multi-source ingestion
- Identity resolution & deduplication
- Attribute-level validation
- Change detection & verification workflows
- Continuous accuracy monitoring
- Audit-ready event logs
- Real-time publishing across enterprise systems
It transforms verification from a periodic project into a continuous, compliant, controlled enterprise capability—aligned to the regulatory environment payers face today.
Polus HCP is an automated solution for maintaining provider data accuracy efficiently.