For U.S. health plans, provider data is no longer a routine operational task. The historical approach–periodic spreadsheets, quarterly refresh cycles, and static directories–cannot withstand today’s regulatory scrutiny or member expectations. Inaccurate or stale provider information now represents a material enterprise risk, driving regulatory penalties, member abrasion, cost leakage, and reputational exposure.
The Risk Landscape
Third-party research continues to confirm the depth and persistence of provider data inaccuracy:
- 33% of directory users report encountering outdated or incorrect information. (LexisNexis Risk Solutions, 2025)
- Independent research found 5% to 93% error rates across five national insurer directories depending on the category. (JAMA Network)
- The American Medical Association warns that inaccurate directories shift financial risk to patients, forcing them to pay out-of-network costs or delay care.
These failures create measurable liability: ghost networks, member dissatisfaction, surprise-billing exposure, forced in-network reimbursements, and a continuous drain on administrative budgets.
Why It Happens
Despite regulatory acceleration, most payer organizations still face structural barriers:
- Manual, time-lagged processes (spreadsheets, vendor refreshes, email loops) introduce drift and inconsistency.
- Fragmented provider identity—one clinician may appear under conflicting NPIs, locations, or specialties.
- Siloed source systems (credentialing, contracting, provider relations, claims, directories) generate mismatched records.
- Tightening mandates—CMS requires 90-day verification, 2-day updates in some cases, and FHIR-based exchange readiness. Operational teams are not equipped for continuous verification at scale.
The result is predictable: elevated compliance exposure and mounting operational costs.
Consequences for Payers
When provider data drifts, even slightly, the downstream impacts compound:
- Member churn and abrasion stemming from inaccurate care-access points.
- Out-of-network claims and NSA “hold harmless” exposure when members rely on incorrect directory data.
- Audit and regulatory vulnerability, particularly as CMS expands interoperability requirements and launches centralized directory pilots.
- Stars rating and CAHPS performance degradation driven by misroutes, delays, and poor directory transparency.
Provider data is no longer administrative metadata, it is a regulated, auditable asset that must be continuously governed.
What “Controlled Provider Data” Means
Achieving control requires shifting from a directory-centric mindset to an identity-centric infrastructure model:
- A unified provider identity resolving NPI, location, specialty, and plan participation across systems.
- Automated, multi-source ingestion—not quarterly refreshes—supported by continuous verification.
- Real-time updates to network status, availability, contact information, and compliance fields.
- Defensible audit trails to satisfy NSA, CMS, and state-level oversight.
The goal is not to update the directory, but rather to eliminate the root causes that break it.
Polus™ HCP: Turning Risk Into Controlled Infrastructure
Polus HCP is now live and available to payer organizations nationwide.
Built specifically for health plans, Polus HCP transforms fragmented provider data into a unified, validated, and compliant source of truth. Leveraging automation, enrichment, identity resolution, and a patent-pending consensus engine, Polus provides:
- Automated Multi-Source Ingestion
- Standardization and Normalization
- Validation Against Trusted Sources
- Enrichment and Contextual Mapping
- Identity Resolution and Deduplication
- Compliance Automation and Logging
- FHIR-Ready Publishing and API Delivery
Polus HCP operationalizes compliance (NSA, CMS, FHIR Directory APIs), eliminates manual cleanup, and materially reduces administrative burden, turning provider data from a liability into governed infrastructure.
We invite you to learn more about Datagence Provider Data Solutions – Polus HCP.