Ready or Not, Provider Directory Data Is Going Public: Why It’s Time to Ditch Old Fixes and Build for Trust, Compliance, and Growth

Executive Summary

• Accurate provider data has long been an industry-wide challenge. In 2023, a Senate Subcommittee investigation revealed that only one-third of provider listings contacted were accurate—highlighting the systemic nature of the problem.
• CMS Final Rule CMS-4208-F2 mandates that Medicare Advantage (MA) provider directories be publicly displayed on the Medicare Plan Finder starting in 2026, with direct data submission and annual attestation required by 2027.The window of opportunity to address CMS’ change is tight for most plans and providers.
• Inaccurate provider data now represents a public liability—errors can lead to member disenrollment through a 90-day Special Enrollment Period, directly impacting plan growth and retention.
• With industry-wide provider data accuracy hovering around 60%, MA plans face increasing reputational risk, regulatory scrutiny, and competitive disadvantage.
• In Wisconsin, almost all of the state’s twelve MA carriers face unique challenges in both urban and rural settings, where inaccurate listings can mislead beneficiaries and disrupt access to care.
• Supporting Payer data requests, Providers are overwhelmed by fragmented data requests from multiple MA plans—often in incompatible formats—leading to reduced data quality and increased operational strain.
• Legacy systems and siloed data practices hinder real-time updates and survivorship logic, exacerbating inaccuracies across applications.
• A technology-driven, collaborative approach between payers and providers offers a scalable solution—streamlining updates, reducing provider fatigue, and ensuring compliance.
• In today’s regulatory and consumer landscape, accurate provider data is a strategic imperative—essential for member trust, strong provider relationships, and competitive differentiation.
• CMS’ changes require a new approach to an old problem — and Gaine is uniquely positioned to help MA plans meet this moment with confidence.
• Gaine offers a purpose-built solution with a proven track record, leveraging an innovative data model that enables real-time updates to each host system in the IT ecosystems.

Introduction: A New Era of Transparency

The CMS Final Rule CMS-4208-F2 marks a pivotal shift in Medicare Advantage oversight. By integrating provider directories into the Medicare Plan Finder, CMS is making provider data a public-facing asset—or liability. For MA plans, this means that inaccuracies are no longer hidden—they’re visible to regulators, competitors, and most importantly consumers.

What’s Changing and Why It Matters

Beginning in 2026:

1. Provider directories will be displayed on Medicare Plan Finder.
2. Beneficiaries can compare networks during plan selection.
3. Errors can trigger a 90-day Special Enrollment Period (SEP), allowing members to switch plans.

By 2027:

1. Plans must submit provider data directly to CMS.
2. Updates must occur within 30 days of any change.
3. Annual attestation of accuracy is required.

This shift transforms provider data from a back-office function into a strategic differentiator—or a public liability.

The Risk Landscape: Accuracy at 60%

Despite years of investment, provider data accuracy remains alarmingly low. Studies show only ~60% of listings are correct. This exposes MA plans to:

1. Enrollment loss via SEP-triggered disenrollment.
2. Regulatory penalties for noncompliance.
3. Reputational damage from public-facing errors.
4. Competitive disadvantage in a more transparent marketplace.

Wisconsin Spotlight: A Case Study in Complexity

Wisconsin’s twelve MA carriers serve diverse populations across urban and rural settings. The CMS mandate applies equally—but rural dynamics introduce unique challenges:

1. Limited provider availability means inaccuracies can mislead beneficiaries.
2. Rural members may travel long distances based on incorrect listings.
3. Operational strain on providers increases as health plans request more frequent updates.

Without change, Wisconsin Providers will face a flood of fragmented data requests—often in incompatible formats, on different schedules, and through siloed systems as each of the 12 MA Carriers seek compliance by asking for more frequent data updates. Based on experience in California, this “boot strap” approach will lead to fatigue, confusion, and a discernable reduction in directory data quality.

Root Causes of Inaccuracy

Several systemic issues contribute to persistent data problems:

1. Constant Change: Affiliations, addresses, credentialing, and availability shift daily.
2. No Unified Source of Truth: Data is fragmented across health plan departments and systems.
3. Point-in-Time Practices: Snapshot uploads lack survivorship logic, overwriting clean data in some instances.
4. Legacy Technology: Aging infrastructure limits interoperability and scalability.
5. Migration Drift: System transitions disrupt data integrity.
6. Failed Modernization: Data Lakes and legacy MDM systems often fall short of delivering improved provider data.

The Path Forward: Strategic Collaboration

Compliance alone isn’t enough. MA plans must transform their approach to provider data:

1. Invest in an operational data layer that enables real-time updates.
2. Work within existing payer application formats and standards to improve consistency (minimizing the need to affect change within existing applications).
3. Collaborate with providers to align incentives and reduce friction.

Gaine’s data model enables this transformation—striving to eliminate the ineffective and resource-intensive roster process and empowering plans to provide beneficiaries with accurate, compelling networks at the point of purchase.

Conclusion: Accuracy as a Strategic Imperative

Provider data is no longer a back-office concern—it’s a public-facing asset that drives member trust, regulatory alignment, and competitive advantage. With CMS-4208-F2, the stakes are higher than ever.

MA plans must act now to:

1. Examine current data practices.
2. Engage providers in collaborative workflows.
3. Modernize infrastructure for real-time updates across their IT ecosystem to achieve directory accuracy.

Is your provider data ready for public display? Gaine helps MA plans and providers achieve scalable, compliant, and accurate directory data.Our most recent success includes moving a health plan from 62% provider data accuracy to over 95% while achieving more than a 7:1 Return on Investment in IT and Operational overhead cost savings.

Contact Gaine to discuss your plan’s unique needs and learn how we can help you prepare for CMS-4208-F2.