FHIR-Based Provider Directory for Compliance & Accuracy

Client Background.

A regional health insurance provider needed to comply with CMS Interoperability and Patient Access Rule by building a real-time, accurate, and FHIR-enabled provider directory. Their existing provider directory was outdated, leading to compliance risks, inaccurate network data, and poor member experience.

Business Problem.

  • Regulatory Compliance Issues – CMS mandates payors to maintain publicly accessible, FHIR-based provider directories to improve data transparency.
  • Inaccurate & Outdated Provider Information – Manual updates led to missing provider details, incorrect specialties, and duplicate records.
  • High Administrative Costs – The provider verification process was labor-intensive, requiring multiple touchpoints to validate data.
  • Interoperability Challenges – The existing system lacked API-based integration with provider systems and third-party directories.

Our Solution.

  • Developed a FHIR-Compliant Provider Directory API – Created a fully interoperable, searchable provider database that integrates with provider networks, state health registries, and external validation sources.
  • Automated Data Validation & Cleansing – Integrated AI-driven deduplication & provider credential verification to ensure accuracy.
  • Enabled Compliance with CMS Mandates – Ensured FHIR R4 compliance with mandatory resources such as Practitioner, Practitioner Role, Organization, and Location.

Implementation Process.

  • Month 1: FHIR-based provider directory schema design & CMS compliance mapping.
  • Month 2: API development for payor-provider data exchange & real-time updates.
  • Month 3: AI-powered data cleansing, deduplication & verification workflows.
  • Month 4: Security, compliance validation & public API launch.

Results & Impact.

  • 100% CMS Compliance – Successfully met regulatory mandates with an accessible & up-to-date FHIR-based provider directory.
  • 75% Reduction in Data Errors – AI-driven validation improved provider data accuracy and eliminated outdated records.
  • 40% Cost Savings in Provider Credentialing – Automated workflows reduced administrative overhead in data validation.
  • Enhanced Member Experience – Enabled real-time provider lookup with accurate locations, specialties, and network participation.

Key Takeaways.

  • FHIR-based provider directories ensure compliance while improving operational efficiency.
  • AI-driven data cleansing reduces provider network inaccuracies.
  • Real-time API integration enhances interoperability with EHRs and health exchanges.