The REAL Health Providers Act Makes Clean Provider Data a Must-Have for Payers

The REAL Health Providers Act (RHP Act) is poised to reshape how payers manage provider data. While the industry has long understood the value of accurate provider directories, this legislation raises the stakes considerably. For payers navigating the shifting regulatory landscape, the message is clear: accurate, timely, and transparent provider data isn’t just a best practice anymore, it’s a legal imperative.

Payers that embrace robust provider data management (PDM) solutions are better positioned to meet regulatory demands, enhance member satisfaction, and improve relationships with providers. The real competitive advantage lies not just in checking regulatory boxes, but in building a more trusted, transparent healthcare experience.

What Is the REAL Health Providers Act?
Introduced in October 2023, the REAL Health Providers Act (S.3059) directly targets the widespread issue of “ghost networks”. These are the provider directories that list clinicians who are either unavailable or no longer in-network.

Set to take effect in 2027 for Medicare Advantage (MA) plans, the RHP Act includes strict requirements for how payers verify, update, and display provider data. While it currently focuses on MA plans, the implications are far-reaching. The industry is watching closely, and commercial payers may face similar expectations soon.

The RHP Act outlines several mandates aimed at improving provider directory accuracy and boosting transparency for members:

• Real-Time Updates: Provider directories must reflect changes in availability, location, and network participation within 48 hours.
• Enhanced Accuracy Requirements: Errors in directories may result in fines and sanctions, increasing the financial risks of bad data.
• Credentialing Standards: Standardized credentialing processes aim to eliminate redundancies and improve member trust.
• Member-Centric Information: Directories must include user-friendly features like languages spoken, telehealth capabilities, and disability accommodations.
• Verification Cadence: MA organizations must verify provider data every 90 days, with unverified providers flagged clearly.
• Annual Reporting and Public Accuracy Scores: Plans must analyze and report directory accuracy each year. These scores will be publicly posted starting in 2028.
• Together, these provisions represent a major shift in how provider data is maintained and monitored, and they underscore why outdated tools, and manual workflows can no longer keep up.
  
  

The Real Challenge for Payers: Clean Data at Scale
Implementing these new standards is easier said than done. Payers face a complex provider data ecosystem, one that often includes disparate systems, manual workflows, and inconsistent data sources. The RHP Act shines a spotlight on the inefficiencies many plans have tolerated for too long.

Here are three of the biggest hurdles payers face:

1. Data Fragmentation: Most payer organizations manage provider data across multiple systems, including claims, credentialing, contracting, directories, and more. This fragmentation leads to discrepancies and inconsistencies that are tough to spot and even harder to fix.
2. Manual Workflows: Many payers still rely on spreadsheets, PDFs, or outdated software to verify and update provider data. These manual processes are time-consuming and error-prone, making it virtually impossible to meet the 48-hour update rule or 90-day verification requirement.
3. Compliance Pressure: The penalties outlined in the RHP Act add new urgency to these challenges. Failure to comply can lead to financial penalties, public accuracy scores that hurt your brand, and, in some cases, loss of member trust when patients can’t find the care they need.
   
   

If the RHP Act is the challenge, advanced provider data management software is the solution. A robust PDM platform helps payers shift from reactive to proactive, streamlining compliance while improving data accuracy, operational efficiency, and member experience.
Here are four ways the right technology can make a big difference:

1. Automate Real-Time Data Accuracy: Sync and validate provider data automatically across systems and directories, replacing manual, error-prone processes.
2. Strengthen Data Integrity and Compliance: Use AI and primary source verification to cleanse, validate, and reconcile records — keeping directories audit-ready and penalty-free.
3. Unify and Cleanse Credentialing Data: Centralize credentialing workflows to eliminate outdated, duplicate, and inconsistent data, ensuring clean, connected records.
4. Improve Member Trust: Deliver accurate, user-friendly directories with rich, reliable provider details that help members find the right care with confidence.

Provider directories are often the first-place members go when seeking care. If that experience is frustrating or inaccurate, the ripple effects are significant. Members may delay treatment, churn to other plans, or file complaints with regulators.

Get Ahead of the Curve
The RHP Act may not go into full effect until 2027, but the time to act is now. Building a compliant, scalable provider data management strategy takes time and delaying until the last minute could be a costly mistake.

Here’s what payers should be doing today:

• Conduct a data health audit to identify gaps and inconsistencies in current systems.
• Engage providers in proactive outreach and verification workflows.
• Invest in a streamlined PDM solution that integrates credentialing, directory management, and real-time updates.
• Prepare for transparency by improving directory accuracy ahead of public score releases.

Clean Provider Data is a Strategic Imperative
The REAL Health Providers Act marks a turning point for provider data in healthcare. For payers, it’s a wake-up call to ditch legacy systems, rethink outdated processes, and invest in modern solutions that deliver compliance, efficiency, and member satisfaction.

But more than a compliance hurdle, this is an opportunity. By modernizing your provider data infrastructure, you’re not just avoiding fines, you’re building a foundation for a better, more member-centric healthcare system.

Because in a world where accuracy is law, clean data isn’t just smart. It’s essential.

 

Learn more about Perspecta's Provider Data Management Solution 

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