By Andy Aroditis

It’s open enrollment and millions of consumers are shopping for a health plan that best meets their clinical and financial needs. The stakes are high. Inadvertently choosing an out-of-network provider can result in catastrophic medical bills.

Reliance on provider directories to help individuals identify which care providers are covered under their plan is important than ever. Especially as the pandemic has left 22 million Americans out of work and many will be purchasing insurance through federal and state marketplaces for the first time.

As a critical resource, provider directories—which contain such demographic data as a physician’s name, address, phone number, hours of operation, services, and whether or not they are accepting new patients—are essential to the provision of healthcare. Directories help consumers find in-network, often conveniently located, providers that offer a specialized service or perhaps speak a specific language. Therefore it’s essential that provider directories reflect the most accurate and up-to-date physician demographics so patients and consumers can maximize the value of their coverage.

Payers and care providers depend on provider data for referrals, claims payment, hospital privileging, provider credentialing, payor contracting and network management. Further, the shift to value-based payment models creates a need for better coordination between payers and their provider networks, particularly around the areas of risk sharing and quality measures.

Unfortunately, provider data is rife with errors and inaccuracies. A 2018 CMS report found 52% of Medicare Advantage provider directories were inaccurate. Errors included providers not at the location listed, providers not accepting the insurance plan at that location, and providers not accepting new patients when the directory indicated they were. Another 2018 survey, from the American Medical Association, found that over half of US physicians say they encounter patients every month with health insurance coverage issues due to inaccurate directories of in-network physicians.

Provider data is constantly changing and as a result, demands around the clock attention to ensure information is accurate and up to date. Each year, doctors retire, lose their license, pass away or are sanctioned. Research shows that 2 – 2.5 percent of provider demographic data changes each month, and an estimated 20 to 30 percent of physicians change their affiliations each year.

Consolidation, lack of widely shared standards for data capture, and the growing number of disparate sources contribute to poor and outdated information, leading to considerable frustrations for physicians and consumers alike.

Take for example in 2019, when insurance giant Anthem mistakenly advertised that WellStar, Georgia’s largest healthcare provider, was in-network. The incident left hundreds of thousands of consumers with out-of-network costs and delayed medical procedures. It also resulted in a $5 million federal class-action lawsuit that is still pending.

A Single Source of Truth for Provider Demographics

Inaccurate provider data spread across multiple clinical and administrative systems has serious consequences for patients, payers, and providers industry wide. Old phone numbers and outdated address information hinder access to care. It’s also costly. The Council for Affordable Quality Healthcare, Inc. (CAHQ) estimates that it costs the U.S. healthcare industry more than $2 billion a year to maintain provider data.

A robust, enterprise solution can streamline this process by unifying disparate provider data from various sources to create a golden provider record so consumers can make informed decisions about their care plans. Further, it can help payers avoid fines and penalties.

Employing an enterprise-grade digital registry that can automate the process of aggregating, cleansing, updating and sharing information network-wide is one of the best ways to ensure a single source of truth of provider data. Health plans, hospitals, and other health organizations can leverage a provider registry as a tool to facilitate the most accurate and up-to-date physician demographic data for reduced costs, administrative inefficiencies, and improved member and patient satisfaction.

NextGate’s Provider Registry automates the process of continuously reconciling provider information across an organization’s enterprise. The registry collects, cleanses and updates provider demographics including a physician’s specialties, office locations, hospital affiliations, languages spoken, practice hours, and accountable care organization (ACO) participation. Data is pulled from credentialing databases, financial systems and CMS’ NPPES NPI Registry, as well as an organization’s internal sources of physician data, including admitting, attending, referring and residents.

With the added benefit of Loqate’s address verification technology embedded into the NextGate Provider Registry, the solution is able to identify precisely where physicians offer their services and leverage the address of the patient to pinpoint which providers within a specific radius are covered under their plan. Using address verification and geocoding to standardize and authenticate address information in real-time, the Provider Registry delivers extraordinary value to providers, the organizations managing those providers, health plans, and the patients enrolled in those plans.

To learn more about how NextGate’s Provider Registry can help your institution gain access to accurate and current provider data to reduce inefficiencies, improve member and patient satisfaction, and empower consumers to make informed decisions, click here.

Stay up-to-date on the latest innovations in enterprise identification, subscribe to the NextGate blog today.

Andy Aroditis is CEO of NextGatethe global leader in healthcare enterprise identification. You can reach him at