How Robust Provider Data Helps Avoid Noncompliance and Regulation Penalties

Provider networks are proliferating, with growth fueled by passage of the Affordable Care Act, the rise of value-based care, and other factors. These networks vary in type from broad preferred provider organizations (PPOs) to narrow systems that cater to unique populations. 

As the number of networks grows, so does concern over their ability to serve their member populations with correct data. The results have affected all participants in healthcare in that there's increasing scrutiny and specificity regarding federal and state level regulations for provider directories 

Regulations constantly evolve and differ among states, adding another layer of complexity to an already rigorous process. The topic of such change, dissonance, and its effects (e.g., litigation, operational challenges, and regulatory compliance) is addressed in depth in a white paper that sheds light on the subject.  

How are network directories evaluated?  

The National Committee for Quality Assurance (NCQA), the nation’s most prominent accreditation body for payer organizations, guides on physician directory requirements and recently published an update that contained changes related to directories. 

The NCQA scores directories based on multiple elements including: 

  • The provision of an online provider directory that displays name, specialty, location, affiliations, certifications, whether or not they are accepting new patients  
  • Whether the provider data is updated within 30 days maximum of the receipt of new or changed information 
  • Whether search functionality is offered within the directory   

In addition, the Centers for Medicare and Medicaid Service (CMS) federally regulates that healthcare organizations follow its guidance on directories: 

  • All provider information must be “easily accessible” and publicly available on websites 
  • Provider information in the directory should be updated frequently, and at least monthly 
  • The provider directory must list provider location(s) 
  • The listing must cite whether the provider is accepting new patients  
  • The provider directory must list the provider’s specialty/specialties  

Healthcare provider organizations and payers can face fines of up to $5,000 per day per incident for noncompliance with CMS or state-level regulations. The reasoning behind such stiff penalties is that CMS, NCQA, and other regulatory and accreditation bodies realize: 

  • Consumers rely on accurate provider information to receive appropriate care 
  • By publishing inaccurate data, healthcare organizations are underserving their patients, community, and member population(s) 
  • Hospitals, systems, and health plans can’t fulfill their role in reining in healthcare costs in general if they cannot maintain accurate data on those providing care   

As a result, the consequences of failing to follow the regulations can be costly for the organization and the broader healthcare industry. Even with stringent regulations in place and the stakes of maintaining accurate provider directories climbing, the health systems and insurers that manage them are struggling to keep up with changes. 

Integrate provider data and keep it accurate  

To tackle ongoing provider directory challenges—and to solve other problems that stem from inaccurate data—healthcare organizations must automate workflows, integrate data, and reduce reliance on IT by taking a digital house approach. Use these tips as a guide: 

Use a central hub to create one source of truth    symplr_Iconography_GroupA_60

Maintain a single, rich data profile for every credentialed and referring provider and continuously share updates enterprise wide.   

Deliver a better customer experience

osition your organization to give patients/members and teams best-in-class provider search and scheduling capabilities. 


Optimize network and revenue cycle performance symplr_Iconography_GroupA_79

Drive up registration, scheduling, billing, and electronic health records performance with better data quality to improve service for referring providers and to reduce claims delays.   


symplr Directory is an innovative provider data management solution that fulfills these needs for payers and health systems. It optimizes provider data (i.e., people, places, and services) for use across the EHR and in marketing and claims systems using platform tools that offer provider enrollment, management, search, and outreach across the enterprise.  

Networks, both broad and narrow, benefit from symplr’s platform, which continuously curates and feeds updated provider information into the provider directory for use on public-facing sites and for internal use. This enables users to accurately track and report out provider health plan and network participation and share that data for provider search.   

Meet compliance while enhancing consumer experience with symplr Directory, real-time integrated provider data. 

 Learn more about symplr Directory today. 

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