The REAL Health Providers Act: What health plans need to know to comply | Viewpoint

Provider directory inaccuracy is a big problem for health plans that can delay care and leads to significant call center volume.

A Health Affairs study found that 53 percent of patients searching for care in health plan directories found inaccuracies. CMS audits of Medicare Advantage plans’ online directories found error rates approaching 50 percent.

The REAL Health Providers Act, signed into law on February 3, 2026, introduces new federal requirements to improve provider directory accuracy in Medicare Advantage plans, addressing “ghost networks” and protecting patients from unexpected out-of-network costs. Plans must move from maintaining directories to actively verifying, measuring, and reporting accuracy.

Compliance requirements take effect in plan year 2028, with public accuracy scores beginning in 2029. CMS will publish these scores, increasing visibility across plans.

In addition, plans must operationalize a set of new requirements, including:

• Verification of all provider records at least every 90 days with documented audit trails
• Removal of providers within 5 business days of confirmed departure
• Annual random-sample accuracy audits submitted to CMS
• Clear indicators for unverified data in directories
• Member protections when inaccurate data is used

There is a clear shift toward health plans being accountable for and measuring provider directory accuracy. What was once an internal challenge is now a visible, reportable indicator of plan performance, introducing real regulatory, financial, and reputational risk for plans that are not prepared.

Key deadlines

Aug. 2027: HHS publishes implementation guidance

2028: Compliance takes effect; 90-day verification; 5-day removal; cost-sharing protection; annual audit

2029: Scores are published: CMS publishes accuracy scores; plans must publish them on directories

What Is Changing

The REAL Health Providers Act introduces a new standard of accountability for the accuracy of provider directories. At its core, the regulation establishes five clear requirements that plans must operationalize:

1. 90-Day Verification Cycle

Plans must verify every provider record at least every 90 days, with a documented, timestamped audit trail.

This requires moving from periodic updates to continuous, trackable verification across all provider data.

2. 5-Day Removal Window

Plans must remove providers from directories within 5 business days after they are confirmed out-of-network.

This significantly compresses update timelines and increases pressure on data ingestion and coordination workflows.

3. Annual Accuracy Analysis

Plans must conduct a random-sample accuracy audit and submit results each plan year.

Accuracy becomes a reportable compliance metric, requiring defensible measurement and audit-ready documentation.

4. Member Cost-Sharing Protection

Plans are required to absorb cost-sharing when members rely on inaccurate information about in-network providers.

Directory accuracy now carries direct financial implications, increasing plan costs through reimbursement, remediation, and member cost-sharing protections.

5. Flag Unverified Records

Plans must display a visible “data unverified” indicator for any provider record not verified within 90 days.

This introduces real-time transparency into data quality, directly impacting member trust, plan experience, and how members evaluate and choose plans.

How Health Plans Should Prepare

Meeting the REAL Health Providers Act obligations requires more than incremental changes. Health plans need to modernize how provider data is managed, verified, and measured.

To prepare, plans should take four key steps:

1. Assess Your Baseline

Benchmark current directory accuracy against CMS expectations and identify gaps across specialties, geographies, and data fields.

Without a clear baseline, it is difficult to prioritize remediation or measure improvement over time.

2. Automate Verification

Manual re-verification at 90-day cycles is not scalable. Plans must move to continuous, automated validation of provider data.

This includes automating roster ingestion, making fragmented provider data consistent and usable, and implementing continuous verification, including NPI monitoring.

3. Unify Directory and Roster Data

Break down silos between provider directories and roster data to ensure directories accurately reflect current network participation.

Directories must reflect contractual reality in real time to avoid inaccuracies, unverified records, and compliance risk.

4. Prepare for Public Scoring

Accuracy will be publicly visible starting in 2029. Plans need to build the infrastructure to measure, monitor, and defend accuracy now.

This requires treating accuracy as a core KPI, with audit-ready reporting and clear accountability across teams.

Why Most Health Plans Are Not Ready

The biggest challenge is not understanding the regulation. It is operationalizing it. Most health plans today rely on:

• Fragmented provider data systems
• Manual roster ingestion and updates
• Inconsistent verification workflows
• Limited ability to measure or defend accuracy

Under the REAL Health Providers Act, these gaps become compliance, audit, and member experience risks.

To comply, health plans need to:

• Automate roster ingestion and normalization to eliminate manual workflows and create clean, structured provider data
• Continuously validate provider records against CMS-aligned standards with confidence scoring and clear remediation actions
• Enrich and maintain complete provider profiles to support accurate directories and better member search
• Evaluate directory changes before they’re implemented to maintain network adequacy, improve access, and support confident compliance decisions

The result is accurate, defensible provider data that supports compliance, improves operations, and strengthens member trust.

Chris Gardella is senior vice president of H1.