4 Ways Provider Data Quality Impacts Healthcare Operations

by | Nov 7, 2022 | Healthcare

Provider data quality concept on a laptop.

Maintaining high provider data quality has been a long-standing challenge in the healthcare industry. Although organizations have access to more powerful data management platforms than ever before, the scope of provider data has broadened significantly in recent years and continues to become more complex as more states move to carve in dental, pharmacy, and long-term care services into managed care organizations. 

On top of heightened complexity, healthcare organizations now also face enhanced regulatory control as Congress passed in January this year the No Surprises Act – an addendum to the Consolidated Appropriations Act of 2021 – which stipulates that all U.S. health plans must update their provider data directories within 48 hours of notification from a provider or third-party vendor. As patients still regularly receive unexpectedly high medical bills due to unknown out-of-network services as often as 20% of the time in ER visits and 16% of non-emergency hospital visits, lawmakers intend to use the risk of absorbing those costs as an incentive to improve provider data directories. 

While avoiding regulatory penalties is a sufficient reason for organizations to evaluate their provider data quality going forward, there’s carrot and stick in this equation. Investing in the tools and practices to ensure high-quality data for provider directories also delivers many valuable, operational benefits. In this guide, you’ll learn what provider data is and how maintaining it to a high standard of reliability can improve operations in your organization.

Key Takeaways:
  • Recent legislation has made provider data quality a high priority for healthcare organizations in the U.S.
  • While improving provider data quality is a complex challenge, it offers many operational benefits beyond avoiding penalties. 
  • High-quality provider data can help organizations improve patient care and satisfaction while reducing costs. 


What Is Provider Data?

Provider data refers to the contact and service data healthcare organizations keep putting patients in contact with the healthcare service providers they need. When one organization sends a patient to another for any service treatment, they select a provider from their database of provider data. Providers, in this case, would include specialists or clinics by referral, lab and imaging services, license providers, and other healthcare service providers patients may need. 

Who Is a Provider?

In recent years, the definition of a provider in the healthcare industry has expanded beyond hospitals and private practices to include a more holistic roster of organizations that play a role in healthcare. These include:

  • Social Workers
  • Behavioral Science Organizations
  • Nurse Practitioners
  • Substance Abuse Counselors
  • Community Health Centers

Broadening the scope of who is a provider reflects the ongoing healthcare industry shift towards value-based care, an approach to healthcare delivery that considers patient circumstances outside the clinical setting, such as quality of housing and transportation, employment, and access to a healthy diet. 

What Is Provider Data?

Every provider listing in an organization’s provider network must contain current data about the provider, including:

  • The names of individual care providers or organizations
  • Current physical address
  • Current phone numbers, email addresses, and websites
  • Participating health plans and networks

With most organizations and practices maintaining dozens of managed care contracts with different health plans –which on average, contain more than 140 different provider data form fields – ensuring provider data quality has become increasingly challenging for healthcare operations. 

As it’s not only patients who rely on provider data quality – but also health plans, providers, government regulators, and marketplace vendors – the reliability of provider databases is important to operations throughout the healthcare ecosystem. 

As organizations collect provider data from various external sources such as national databases, health plans, third-party data providers, and medical associations, provider databases are rife with possible duplicates and variants that result in patients receiving unreliable information. However, with the right data management tools, healthcare organizations can automate the merging and reconciling incongruent datasets. Using data management tools to ensure high provider data quality requires working through three stages. 


Stages creating a high-quality internal provider data source.
Image Source: https://www.caqh.org/sites/default/files/explorations/defining-provider-data-white-paper.pdf
  • Reconciling an organization’s internal data, such as claims, credentials, and licensing
  • Integrating internal data with external data sources such as the American Medical Association (AMA) Masterfile and Medicare Provider Enrollment, Chain and Ownership System (PECOS)
  • Applying quality assurance through verifications with third-party vendor

How Provider Data Quality Affects Healthcare Operations

An organization’s provider data quality has far-reaching effects throughout operations downstream. High provider data quality can deliver many operational benefits while reducing bottlenecks and inefficiencies.

1. Better Provider Selection Choices

Connecting patient with the care providers they need is the first purpose of provider data directories. The more accurate and inclusive that data is, the more likely patients will receive referrals to the optimal provider based on considerations of services, location, availability, and plan association. 

2. Accelerated Patient Appointment Scheduling

According to recent data, as many as 70% of patients are routinely unable to successfully schedule an appointment with their first referred provider due to inaccurate or outdated provider data. For every bad data point passed on to patients, wasted time accrues as they contact the referring organization again and then attempt to schedule another appointment. 

3. Reduced Costs

Cost of bad provider data.
Image Source: https://risk.lexisnexis.com/insights-resources/infographic/cost-of-poor-provider-data-quality-infographic

Unnecessary costs associated with bad provider data total roughly $24 million annually in the U.S. Investing in the tools and practices necessary to create and maintain high-quality provider data pays off in the long run and mitigates the risks of violating the No Surprises Act. 

4. Improved Patient Satisfaction and Patient-Physician Relations

Naturally, patients on the receiving end of unnecessarily high medical bills or who can’t schedule timely appointments because of bad provider data become frustrated and angry with their healthcare providers. Over time these emotions erode trust and can result in patients postponing or putting off appointments for the care they need. Conversely, consistently delivering accurate, minimal medical bills and helping them accomplish smooth referral transitions will build trust and raise overall patient engagement with your organization. 


Healthcare Data Management with Coperor by Gaine

While new data management solutions abound in the market, the healthcare industry has long awaited a comprehensive master data management platform designed specifically for the industry’s unique challenges. Coperor by Gaine fills this gap in data management solutions with ecosystem-wide capabilities to integrate data sources across your organization and your contracted partners.

To learn more and schedule a live demo, contact Gaine today. 


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