NEW REPORT: INSIDE THE DATA

DEFICIT UNDERMINING PAYERS’ NETWORK STRATEGIES

As U.S. healthcare spending approaches $5 trillion annually, payers are under unprecedented pressure to rein in costs while simultaneously enhancing member satisfaction and care quality. Provider network design is being recognized now, more than ever, as a powerful lever for meeting these goals — yet operationalizing smarter, value-driven networks remains elusive.

A new survey of 100 health plan executives, conducted by Becker’s Healthcare in partnership with Quest Analytics®, exposes a pressing dilemma: While payers increasingly view network performance as central to their strategic priorities, many face significant challenges with data quality, analytical capabilities and execution. These limitations hinder their ability to act decisively in a quickly evolving regulatory and competitive environment.

To better understand the path forward, Becker’s Healthcare spoke with Bob Tavernier, Solutions Executive at Quest Analytics. He outlined key opportunities in data-driven design — from ghost provider detection to understanding competitor network composition — and how more precise, actionable insights can help payers create networks that deliver measurable and sustainable value.

EVOLVING PRIORITIES: THE PROVIDER NETWORK AT THE CENTER

The Becker’s-Quest Analytics survey respondents — executives from regional health plans serving commercial and Medicare Advantage populations — identified these top priorities for 2025:

• Improving member satisfaction
• Enhancing clinical quality
• Total cost of care
• Lowering administrative costs

For many, provider networks are foundational to achieving these goals. Sixty-five percent of respondents indicated network design is very important or essential to boosting member satisfaction, and 53% linked it to lowering administrative costs. While responses were more mixed regarding clinical quality, more than a third still view network design as a critical contributor.

“Within network designs, it’s really important to understand the market and the membership population being served — not only from a cost perspective, but from an access perspective,” Mr. Tavernier said. “Payers’ desire is to ultimately provide the right level of access to care at the right time and in the right place.”

Smart networks go beyond network adequacy standards, he added — they prioritize high-performing providers and optimize cost-effectiveness through tools like network tiering. “Designing network tiers based on high-quality, low-cost providers is important to achieving better clinical outcomes such as reducing ER visits, readmission and the number of days in acute care settings,” Mr. Tavernier said.

DATA: THE CRUX OF NETWORK EXECUTION

Survey respondents highlighted the importance of a range of data-driven insights for network optimization, particularly:

• Competitor network composition (71%)
• Provider cost/utilization efficiency (65%)
• Member access to care (53%)
• Negotiated competitor rates (37%)
• Value-based care readiness (37%)

Yet despite the strategic value of this information, confidence in the underlying data is shaky. Nearly half of respondents rated their provider cost and utilization data as poor quality. Forty-seven percent cited moderate quality in access to care metrics (value-based care readiness metrics were rated similarly). No respondents felt that they had access to high quality competitive data.

This data quality gap impairs payers’ ability to respond with precision to market demands and regulatory scrutiny. Mr. Tavernier attributes much of the disconnect to the nature of available datasets. For one, paid datasets — healthcare data sources that health plans can purchase to inform network design decisions — often lack the granularity and clarity organizations need for decision-making, making it harder to extract relevant insights. If the data isn’t consolidated in a usable way, it takes longer to refine and apply, delaying network design improvements.

“Payers ultimately need a holistic view of the market, which involves data submitted from all payers that is comprehensive,” Mr. Tavernier said, underscoring the tendency for provider directory data to be stale or inaccurate.

Another complicating factor: interoperability. Payers often stitch together multiple data sources with inconsistent methodologies and structures, limiting their ability to generate true, cross-cutting insights.

‘GHOST PROVIDER’ DETECTION AND THE CONFIDENCE PARADOX

One of the most surprising survey findings for Mr. Tavernier was the disconnect between perception and reality regarding ghost providers — those listed in directories who are not actually seeing patients. Despite 100% of the Becker’s-Quest Analytics survey respondents expressing confidence in detecting ghost providers, Quest Analytics’ own research has shown that 67% of networks in public use files report ghost provider rates above 9%. This disparity raises a critical question — why are so many ghost providers still being kept in the network?

These inaccuracies can trigger a cascade of financial costs: elevated administrative costs, increased exposure to regulatory risk, member dissatisfaction and churn, missed growth opportunities, and inefficient resource allocation.

Mr. Tavernier pointed to the industry’s overreliance on outdated provider data verification processes and the use of web-sourced data, both of which can create a false sense of confidence in data accuracy. As a result, health plans may not recognize the extent of their ghost provider issues. Legacy verification methods often fail to account for critical changes — such as provider retirements, contract updates, or changes in practice locations. Similarly, data gathered through web scraping is frequently unvalidated, leading to errors or incomplete records. These gaps in oversight allow ghost providers to remain undetected and persist in the system.

To address these challenges, health plans need actionable insights into the data elements that truly matter — confirming whether providers are actively seeing patients, correctly listed in directories, participating in the appropriate networks, and accurately tied to practice locations. The goal isn’t to gather more data, but to ensure that the data is trustworthy, complete, and genuinely reflective of current reality.

ADDING CLAIMS-BASED CHECKS TO STRENGTHEN DIRECTORY ACCURACY

To close these gaps, regulators are introducing additional data validation requirements to ensure that the providers listed in the directory are truly active members of an insurer’s network before consumers purchase coverage. Increasingly, this means incorporating claims data to verify provider activity, in addition to existing provider directory accuracy requirements. Mr. Tavernier explained, “We’ve seen federal and state regulatory changes mandating health plans to have a process to verify and update provider directory information more frequently. Now, they’re adding another layer of verification by requiring claims data to confirm providers are actively seeing patients. For example, some state departments of insurance now require plans to flag and reach out to providers who haven’t submitted claims in the past 6 to 12 months. This ensures that listed providers are not only contracted, but also actively delivering services — improving transparency and protecting consumers,” Mr. Tavernier said.

Mr. Tavernier also noted how several states, along with the federal government, are adopting or exploring network adequacy standards beyond geography, incorporating factors like appointment wait times, provider-to-enrollee ratios, access to telehealth and behavioral health services, language and cultural competency, and claims data to identify active providers and patterns of care delivery.

“These policies reflect a larger shift toward outcome-driven network oversight, where health plans are expected to demonstrate not only theoretical access, but actual functional access supported by utilization data.”

Incorporating claims-based validation adds rigor to network design and can close long-standing gaps in provider directory accuracy. It also reduces the risk of ghost networks and improves oversight of provider performance, especially in critical areas like behavioral health and rural healthcare.

TOOLS FOR A DATA-DRIVEN FUTURE

Payers need easy access to reliable, timely data when evaluating their networks against competitors. While they can purchase competitive intelligence — including insights into which providers are in rival networks, the services they offer, pricing, and patient sentiment — the data is often derived from web-scraped online directories. As Mr. Tavernier noted, this approach frequently results in low-quality data that lacks the detail, accuracy, and completeness necessary for informed decision-making. It’s typically not immediately consumable or actionable, limiting its value for timely network evaluation and design.

“Finding tools to assist payers that can package the analysis in a way that’s actionable in multiple business use cases is absolutely critical,” he said.

For payers aiming to design high-performing networks, integrating multiple layers of intelligence is key. Tools like Quest Analytics’ Provider Claims Insights (PCI) offer a strategic advantage by combining authentic, sourced network data with claims intelligence layered with insights on cost, quality, and utilization. PCI enables payers to better assess provider performance and suitability, and to build smarter networks that reflect real-world care delivery.

Competitive composition plays an essential role in provider network design, especially as payer organizations seek to stand out in a competitive market. While payers typically possess quality and cost information for their own networks, they often struggle to compare these metrics against competitors, Mr. Tavernier said. Quest Analytics’ QES® Competitive Insights tool provides a clear view of how a plan’s network stacks up against the competition — including which providers are in other networks and how they compare across performance metrics.

When used together, PCI and Competitive Insights deliver the contextual intelligence payers need for sustainable, performance-driven design — turning data into action and strategy into execution.

THE ROAD AHEAD: FROM COMPLIANCE TO ACCOUNTABILITY

The stakes for smart network design are rising. Payers are expected to move beyond directory listings to show meaningful provider availability and actual service delivery. They must anticipate and meet evolving consumer expectations, stay ahead of regulatory mandates and compete in an increasingly outcomes-driven landscape.

“Ultimately, this policy-driven evolution is transforming how provider networks are evaluated and built,” Mr. Tavernier said. “It pushes the industry to prioritize not just compliance, but accountability, ensuring that networks truly meet the needs of member populations they serve.”

As healthcare continues to evolve, health plans that invest in precision analytics and intelligent design will be best positioned to lead — with networks that are not only compliant, but competitive, consumer-centric and cost-effective.

“This is a critical space that requires a lot of time and focus, not only in the ‘here and now’ but into the near future,” Mr. Tavernier said.