How Modern Provider Data Management Positions Health Plans for Success
The healthcare industry is at an intersection of technology, artificial intelligence (AI), and operational efficiency. For payers, ensuring provider data integrity is fundamental to scaling business operations and thriving in a competitive environment.
In a recent speaking session at the America’s Health Insurance Plans (AHIP) 2025 event, leaders from HealthEdge® and the Public Employees Health Program (PEHP) discussed the ways modern provider data management solutions can eliminate operational inefficiencies and drive measurable results for other health plans. They also shared unique insights on how PEHP leveraged the HealthEdge Provider Data Management solution to help reduce friction, save costs, and increase automation.
The Hidden Costs of Fragmented Provider Data
Provider data serves as the foundation for nearly every health plan operation, yet many organizations struggle with disparate systems. Gathering data from multiple sources, verifying, and uploading to a single database can create costly inefficiencies.
PEHP’s experience with managing provider information illustrates the magnitude of these challenges can reach: before implementing a comprehensive provider data management solution, the payer managed 65,000 practitioners across multiple disparate systems and contended with significant data quality issues.
“We had 7,000 data issues with our practitioners, 1,500 duplicate locations, and practitioners listed multiple times for each location they practiced at,” said Lance Toms, Operations Management Director at PEHP. “We were exponentially increasing our claims backlog.”
These data quality problems created a cascade of operational issues, requiring five full-time employees dedicated solely to manual data entry and processing. The organization relied on paper applications and multiple fillable PDFs, with manual data entry processes taking up to two weeks to complete. These practices led to payment delays, provider abrasion, and increased administrative costs.
Address Critical Data Management Pain Points with an Integrated Solution
With ongoing advancements in digital technologies, AI, and machine learning, payers have access to a modern, comprehensive approach to provider data management. Traditional systems and processes often lack the continuity and sophistication needed to handle the dynamic nature of provider information, which includes frequent changes in credentialing status, network affiliations, and practice locations.
“Provider data is no longer a back-office data set,” said Parvathy Sashidhar, Senior Director of Product Management at HealthEdge. “It’s front and center when it comes to your AI transformation, technology shifts, or any major initiatives within your organization.”
Modern provider data management platforms address these challenges through key capabilities like:
Automated Data Integration and Cleansing
AI-powered provider data management platforms can process both structured and unstructured data formats, utilizing generative AI frameworks to transform disparate data sources into standardized formats. This eliminates the manual processing that previously consumed significant staff resources.
Real-Time Validation and Enrichment
Modern systems can perform over 300 built-in quality checks, including real-time NPPES validations and address standardizations. This proactive approach prevents inaccuracies from impacting downstream systems.
Intelligent Duplicate Prevention
Advanced trust hierarchies and validation logic address duplicate records at their source, eliminating one of the most persistent challenges in provider data management.
Quantifiable Results Drive Operational Excellence
PEHP’s implementation of HealthEdge Provider Data Management delivered measurable improvements across multiple operational areas. The data migration process achieved a 99.96% success rate and was completed in just 3.5 hours, addressing years of accumulated data quality issues and delivering immediate efficiency gains in less than one full business day.
The automation capabilities allowed PEHP to reallocate resources previously dedicated to manual data processing.
“We’ve been able to reduce between two and five FTEs just for data exchange alone and allocate their time differently,” Toms noted. This resource optimization enabled staff to focus on higher-value activities that directly support business objectives.
At the same time, PEHP enhanced claims processing efficiency, achieving a 13% to 15% increase in auto-adjudication rates immediately following implementation. This improvement reduced claims backlogs and accelerated payment processing for providers.
Finally, the solution’s dashboard capabilities provide comprehensive visibility into critical data like provider networks, organizations, and practitioner roles. This enhanced visibility enables data analytics teams to focus on performance analysis rather than data reconciliation, supporting more strategic decision-making.
3 Strategic Advantages of a Modern Provider Data Management Solution
Beyond immediate operational improvements, modern provider data management platforms can position health plans for future growth and innovation. The foundation of accurate, accessible provider data enables advanced analytics, AI-driven insights, and automated workflows that drive competitive advantage.
1. Compliance Support and Risk Management
Regulatory requirements, including the No Surprises Act and various state mandates, demand accurate, up-to-date provider directory information. Automated compliance support ensures timely updates and reduces the risk of penalties associated with inaccurate provider data.
2. Member Experience Enhancement
Accurate provider directories directly impact member satisfaction by ensuring members can locate in-network providers and access care without unexpected costs. This reduces member service calls and improves the overall member experience.
3. Future-Ready Architecture
Cloud-native platforms built on modern architectures support scalability and integration with emerging technologies. This flexibility enables health plans to adapt to changing regulatory requirements and market conditions without significant system overhauls.
Implementation Considerations for Provider Data Management Solutions
As with any new technology adoption, successful provider data management implementation requires careful planning and execution. Key change management considerations include factors like integration capabilities, custom configurations, and the availability of staff adoption training.
An effective provider data management tool should offer both native integration with existing core administrative processing systems (CAPS) and the flexibility to connect with external systems through configurable APIs. This ensures seamless data flow across the entire technology ecosystem.
Business rules and validation processes should also be configurable to accommodate a health plan’s unique organizational requirements. Low-code, no-code frameworks, like the ones HealthEdge Provider Data Management uses, enable rapid customization without extensive technical expertise.
But to get full value from advanced provider data management solutions, staff need to know how to use them. Offering staff training, sharing regular implementation updates, and embracing feedback about process adaptation are critical for success.
Positioning Your Health Plan for Future Success
The healthcare industry continues to evolve, with increasing emphasis on value-based care, population health management, and regulatory compliance. Provider data management serves as a critical foundation for these initiatives, enabling health plans to operate efficiently while delivering superior member and provider experiences.
“We’re really excited about putting this platform in place that allows us to do the things we’ve been trying to do for so many years,” said Toms. “We now have the tools to do so.”
Organizations that invest in modern provider data management capabilities today position themselves for success in an increasingly complex healthcare environment. The combination of operational efficiency, regulatory compliance, and enhanced member satisfaction creates a sustainable competitive advantage that drives long-term organizational success.
Learn more about how the HealthEdge Provider Data Management solution can help your health plan ensure provider data accuracy to stay ahead of the shifting regulatory landscape. Read the data sheet.
