What is Provider Data Validation – Are You in Compliance?

Curious what all the news is about? Here are the basics of Provider Data Validation: What it is and why it’s important.

Healthcare consumers rely on their insurers to provide comprehensive, current, and accurate information about in-network practitioners. It is critical that this information is accurate the first time a practitioner is added to the network, and that it is regularly validated to ensure continued accuracy.

Provider data validation is a crucial component of compliance. Over the past few years, we have seen the Centers for Medicare & Medicaid Services (CMS) and state regulators shift their review process to require accurate information to be maintained in a health plan’s public directory. As someone who oversees the network, you want to have a strong process in place to easily maintain and monitor your provider data to ensure continued compliance. Let’s take a deeper dive to better understand the importance of provider data validation for compliance and your members.

What is Provider Data Validation?

Provider data validation – also known as provider data verification or attestation – is a process where health plans confirm that information listed for healthcare providers is current, correct, and complete.

Provider data validation helps ensure key information about the practitioner is accurate. This information can include:

Digital Contact Information (Phone Number, Email, Website)
Office Location
License Status and Board Certifications
Hospital or Practice Group Affiliation

The goal is to update and maintain their provider data to prevent incorrect provider information from having negative downstream effects for patients, providers, and plans. Whether it’s an address that’s no longer valid or a provider who is no longer in-network, even small errors can lead to delayed care, billing issues, or compliance violations.

While Federal and State healthcare programs may differ in their specific requirements, they share a common goal: Ensuring members have access to the care they need while promoting timely delivery of that care. By aligning with these objectives, you can enhance member satisfaction and maintain compliance, all while strengthening the overall effectiveness of your provider network.

To protect consumers, CMS requires Medicare Advantage plans to routinely contact providers in their networks to validate or update the information for the public-facing directory. By maintaining an accurate database, you’re able to provide your members with an honest picture of which practitioners they can schedule an appointment with.

In addition to requesting health plans to get in touch with practitioners on a quarterly basis, network adequacy reviews are another way CMS monitors the compliance of a Medicare Advantage Organization (MAO). Health plans can submit their network for an annual review.

Otherwise, every plan will, at some point, go through the Triennial Network Adequacy Review. This review happens every three years or when a triggering event occurs such as when a new application is created, a compliant about network access is filled or the health plan is expanding into a new service area.

Those in violation face potential compliance or enforcement actions and financial risks. But beyond these reasons, provider data accuracy directly impacts member trust, access to care, and operational efficiency.

See how we helped a plan stay review-ready and compliant-confident with smart provider network management.

Why is Provider Data Validation Important?

Actively managing the accuracy of provider data is critical to ensuring your members can access medical care. The directories that you provide are often the only source of information members rely on to locate providers that are within their network. Incorrect information within provider directories can lead to confusion and frustration for patients and providers.

Without consistently checking the information through provider data validation, inaccuracies can grow, and this can become a significant barrier to accessing care.

For example, a member searches the network for a podiatry specialist and contacts the office only to find that they are not accepting new patients or may travel to an inaccurate address. In a worst-case scenario, an outdated listing may show an out-of-network provider as an in-network, leading to a surprise billing charge for the member, which you or the practitioner must now fit the bill for.

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Learn more about why inaccurate data is a barrier to care.

How Do You Validate Provider Data?

Here Are Our Recommendations

Manual validation is labor-intensive and error-prone. Leading plans are turning to automated provider data management solutions that streamline validation, track outreach, and flag discrepancies in real time.

Best practices for successful provider data verification:

Use a centralized platform like Quest Enterprise Services® (QES®) Accuracy
Automate outreach to providers for quarterly attestations
Monitor data freshness and flag outdated or inconsistent records
Integrate external data sources for enhanced verification (for example, licensing boards, hospital affiliations, etc.)
Implement standardized data entry practices.

With the right tools, provider data accuracy becomes a strength — not a stressor.

Proven Solutions for Your Provider Network Management

Looking to simplify your workload? Let Quest Analytics take on the heavy lifting! Our solutions and dedicated team specialize in provider data accuracy and provider network adequacy for various lines of businesses, including Medicare Advantage, Medicaid and Commercial. Schedule a strategy session today and see how we can help you every step of the way.