Network Operations

What Is Network Operations?

Network operations is the health plan function responsible for building, maintaining, and managing the provider network members rely on to find in-network care. This includes provider data management, which keeps provider records accurate, credentialing, which verifies a provider meets the plan's and regulator's requirements before joining, and provider directory accuracy, which is the member-facing output most people interact with. 1

Network operations sits at the intersection of compliance, data quality, and member experience. A network can be strong on paper while still failing members if the directory listing a provider's address, phone number, or acceptance status is wrong. This function has come under increasing regulatory scrutiny, as federal and state rules have tightened accuracy requirements and added real consequences for plans that fall short. 2

Why It Matters

Provider directory accuracy directly affects whether members can access the care their plan promises, and inaccuracies are a well-documented, persistent problem across the industry, not an isolated failure at any one plan. A member who calls a disconnected number, or shows up to a provider who no longer accepts new patients, hits a real access barrier, regardless of how comprehensive the network technically is. 3

Regulators have responded accordingly. CMS and state insurance departments increasingly treat directory accuracy as a compliance metric with real consequences, not just a customer service nicety, which has raised the operational stakes for network operations teams considerably. 4

Nearly 49 percent of provider locations listed in Medicare Advantage online directories contained at least one inaccuracy, such as a wrong address, phone number, or acceptance status, according to a CMS national review. 5

How Network Operations Works

• Provider contracting: The plan negotiates and finalizes contracts with providers and facilities, establishing the reimbursement rates and terms that define network participation.
• Credentialing verification: Before a provider joins the network, the plan verifies licensure, malpractice history, and other qualifications required by regulators and accreditation bodies.
• Data maintenance: Provider data, address, specialty, and accepting-new-patients status, is continuously updated as providers move, retire, or change practice details.
• Directory publication and validation: The plan publishes provider data in its directory and periodically validates it against outreach or third-party sources to catch drift. 6
• Compliance monitoring: The plan tracks directory accuracy against regulatory thresholds and responds to corrective action requests from CMS or state regulators when issues are found. 7

Regulatory and Compliance Considerations

CMS requires Medicare Advantage and ACA marketplace plans to maintain a minimum directory accuracy rate, generally around 85 percent, measured across practice locations, phone numbers, specialty designations, and network participation status. Plans that fall below this threshold face corrective action requests, and under recent legislation, Medicare Advantage plans will soon be required to publicly report their directory accuracy scores, adding a transparency dimension to what was previously an internal compliance metric. 8

CMS conducts periodic phone surveys of listed providers, and its national reviews have consistently found inaccuracy rates near or above 45 percent across the industry, a gap that has persisted despite more than a decade of regulatory attention. This reflects the structural difficulty of the problem. Provider data changes constantly as physicians move, retire, or update their practice details, and most plans still rely heavily on provider self-reported updates rather than continuously validated data feeds. 9

For network operations teams, the compliance response increasingly means treating directory data as a continuously monitored asset rather than a periodically refreshed one, since accuracy is measured, and increasingly reported publicly, at whatever moment a regulator happens to check. Automating outreach for data confirmation, and cross-validating listings against multiple independent sources rather than a single system of record, are becoming standard practice. Plans that treat this as a continuous data operations problem, rather than a periodic compliance exercise, close the gap faster and sustain it longer. 10

Interoperability between a health plan's internal systems and the external sources used to validate provider information adds another layer of complexity. A plan might maintain accurate internal records while still publishing an inaccurate directory if the connection between its credentialing database and its member-facing directory platform is not fully automated, since any manual step in that handoff lets data go stale. Closing this internal integration gap is often a faster, lower-cost fix than the external validation work that gets more attention in compliance conversations. For a health plan, that integration discipline is what keeps a technically strong network usable for members.