New CMS Mandate Puts Provider Directories on Display: Is Your Data a Liability?

The latest CMS rule introduces risk to enrollment due to provider data errors

Can your plan share provider data updates within 30 days of learning of a change as required by CMS? Is compliance a concern given the tight window of opportunity to meet the new CMS standards against the list of existing priorities?

Let’s face it, accurate provider data is and has been an industry-wide problem. Only one-third of provider listings contacted by Senate subcommittee staffers in 2023 were accurate.

CMS Turns Up the Heat on Provider Data Accuracy

In response to these ongoing concerns, the Centers for Medicare & Medicaid Services (CMS) has updated its rules under 42 CFR Part 422, (CMS-4208-F2) to make provider directory accuracy a front-and-center priority. With these changes, inaccuracy is now a direct threat to your compliance, performance, and bottom line.

Here's what you need to know about the phased rollout:

Starting with 2026 Open Enrollment:
CMS will integrate provider directory information into the Medicare Plan Finder. For the first time, beneficiaries will be able to compare provider networks side-by-side in the platform they rely on for shopping. If a beneficiary enrolls in a plan using information from the Plan Finder and later discovers that the provider directory was inaccurate, they will have a 90-day Special Enrollment Period to switch to another Medicare Advantage plan or return to Original Medicare. This means any errors in your data could immediately influence both plan selection and member retention.

Beginning in 2027:
Medicare Advantage plans must directly submit their provider directory data to CMS, update it within 30 days of any changes, and attest at least annually that the information is accurate. With the provider directory now public-facing, non-compliance or lingering errors can result in penalties, reduced enrollment, and further regulatory scrutiny.

The shift makes sense. Beneficiaries deserve reliable info, but it also raises the stakes for health plans. A practical example illustrates the point. How quickly can your systems handle updates when a provider moves practices or stops accepting new patients?

The Hidden Risks of Inaccurate Data

Beyond compliance, think about the broader impact. Errors won't stay buried in internal audit reports anymore; they'll be visible to every shopper on the Plan Finder. That visibility could erode trust, leading to lower enrollment rates or higher churn. Members might file complaints if they arrive at an appointment only to find the provider isn't available, damaging your plan's reputation. They may even decide to cancel your plan under the new 90-Day Special Enrollment Period.

And it's not just about members. Providers get frustrated too when directories list them incorrectly, potentially straining your network relationships. In a competitive market, where plans vie for beneficiaries, clean data becomes a key differentiator that helps your plan stand out as reliable and member-focused.

Market and Operational Realities

This heightened visibility shines a light on longstanding market challenges.

• Data is dynamic. Every day, provider data is changing both outside and inside the four walls of a health plan.
• Health plans have not had a system of record for all data changes across their network function.
• The goal historically was to strive for “accurate at a point in time” data which was uploaded into disparate systems without regard for data quality or data survivorship. Often, updates are overwritten and replaced with inaccurate information from other systems.
• Payers are often built on an ancient technology stack that lacks interoperability and scalability, often forcing IT Leaders to pursue tactical solutions to remediate technology debt at a cost of strategic infrastructure and functionality investments.
• Data accuracy often complicated by system migrations that cause data context shifts between systems.
• Previous efforts to modernize the data model—whether through Data Lakes, Data Fabrics, or legacy master data management systems—have fallen short of solving the underlying inaccuracies and consistently delivering clean, timely data to every application.

Given this reality, plans now face a narrow window to proactively address data quality before it goes public on the Medicare Plan Finder. Failure to act risks not only CMS penalties but also lowered Star Ratings and missed enrollment goals.

Why Quick Fixes Fall Short

You might be tempted to patch this with manual updates or basic onboarding tools, but these approaches generally create even more problems. Siloed systems lead to inconsistencies, where changes in one database don't sync everywhere. It's a reactive scramble that drains resources and still risks errors slipping through.

Our experience suggests the weakest link in the Provider Data Value Chain is an equal combination of –

1. the level of resources a provider has on hand to track and provide updates
2. the variety of update formats required across the 200+ payers.

The natural “bootstrap” response is to turn to “par” providers for more updates sooner. It is worth highlighting, all MA Carriers will be running at the same narrow doorway, yet nothing (i.e. added resources, IT automation) has changed. Logic suggests running the same broken process faster and more often will not lead to improvement. In fact, adopting this approach will likely create more errors and accuracy will drop in time. When this occurs, the plans are the ones left with a CMS compliance risk and potentially missing annual enrollment targets as beneficiaries select carriers based on inaccurate provider information.

Building a Foundation of Trust with Accurate Data

It’s clear that hiring a third-party data broker alone isn’t enough to overcome these complexities. Providers’ agreements with plans vary across lines of business, resulting in nuance that generic data services can’t capture. What’s necessary is a comprehensive System of Record that Gaine Health Data Management Platform provides.

Gaine continuously captures, integrates, cleanses, validates, enriches, and publishes changes from every part of your network function, this span contracting, credentialing, roster intake, claims, and member directory. This not only meets CMS's 30-day rule but also builds a foundation of trust—reducing complaints, improving member satisfaction, and even boosting your Star Ratings through better access metrics.

Gaine Health Data Management Platform provides a real-time and accurate bi-directional source of provider data truth across your disparate systems.

At Gaine, we have helped plans like yours cut error rates significantly, turning data management from a chore into a strength. For instance, our platform handles complex matching and merging, so you always have a single, accurate view of providers. Gaine goes beyond surface fixes with automation, workflow orchestration, and collaboration tools designed to tackle these challenges head-on. With unified data governance and real-time updates, you can transform provider data from a liability into a competitive advantage.

Ready to make your provider data a competitive edge? Contact us to schedule a demo and see how Gaine can get you compliant and confident before the 2026 deadline.