A health plan's claims kept getting denied. Everyone assumed the new claim system was the culprit, so that is where they looked. Melissa Goshorn's team found it somewhere else entirely, in the provider data feeding that system and the transformations it went through on the way in. Denials dropped 97%. As she puts it: nobody had any idea it was a provider data problem. They were not even considering that system at all.

Melissa is president of DocMe Health, the health division of digital services firm DocMe360, where the model is to sit inside a health plan's systems and files rather than hand over a three month assessment and leave. She started out in senior living, moved on to healthcare nonprofits working alongside some of the country's most prominent cardiologists, made a stop at a technology startup, and spent close to a decade supporting CAQH and its suite of provider data solutions. In this conversation with Nick Helfrich and Mitch Gorodokin, she argues that provider data is the red headed stepchild of healthcare data, and also the thing every other system is anchored on.

In this episode:

• The 97% denial reduction, and why nobody on that project suspected provider data until they were in the files

• Source of truth versus system of record, and the field level governance most organizations never put in place

• Why a phone number is never just a phone number: appointments, claims and prior auth each need a different one

• The one large plan she knows of with a genuinely clean directory, and the single rule that got it there

• Why "carrot or stick" is the wrong frame for getting providers to attest, and what she says instead

• Medicare Plan Finder, and the moment plans start treating provider data as a sales problem

• What happens when a FHIR based directory API gets transformed into a flat file on a batch job, and how many vendors a single member complaint now has to travel through

• Why most directory regulation only binds Medicare and Medicaid, leaving the commercial book as the Wild West

• How a plan that treats data as its differentiator organizes itself differently, right down to who is allowed to keep a spreadsheet

• Why the existence of an entire directory accuracy industry makes her sad, and how it connects to what health insurance costs

Subscribe to Provider Data Dorks for the people fixing healthcare's hardest data problem. New episodes weekly on YouTube, Spotify, and Apple Podcasts.

Timestamps:

00:00 Intro

01:33 Welcome to Provider Data Dorks

02:39 Meet Melissa Goshorn

04:31 Why she's allergic to the words strategy firm

06:27 How they cut claim denials by 97%

07:35 Source of truth, the most overused term in the industry

09:29 Why nobody gets down to one system

10:27 A phone number is never just a phone number

12:23 Governance at the field level

14:13 Putting your thumb on hard ROI

16:35 Which data points cause the most rejected claims

17:49 The one plan with a genuinely clean directory

20:18 What everyone else is doing instead

24:02 Walking through an engagement

26:47 Getting called in for the fire drill

28:35 If you know one health plan, you know one health plan

30:21 Paper, fax machines, and a state's largest payer

31:38 The FHIR API that became a flat file on a batch job

34:06 The Real Health Providers Act

35:20 Vendor fatigue and consolidation

41:53 Health plans are data-first organizations

45:28 The CFO conversation and the multi-year payback

49:39 Why adequacy is the wrong bar

50:36 The three million dollar filter

54:36 Is regulatory pressure actually moving the industry

1:00:35 Drawing the whole ecosystem on a whiteboard

1:04:05 Attacking the problem together

1:06:21 The unsung provider data point

1:08:31 Best or worst advice

Over 60 million Americans live with a mental health condition, and about six in ten can’t get consistent access to care. Visar Tasimi’s team gets someone into behavioral health care in an average of four days. He’ll tell you supply is only part of the problem. The bigger part is data.

Visar is Senior Vice President of Provider Success and Market Operations at Lucet, where he oversees a network of roughly 60,000 behavioral health providers. Behavioral health breaks the usual assumptions: it is not uncommon for one provider to work for three or four different companies, which multiplies the same record three or four times over and makes all of it harder to keep accurate. In this conversation with Nick Helfrich and Mitch Gorodokin, Visar walks through NavConnect, the work of finding out when a provider is actually free, and the single fix he’d want the whole industry to adopt.

In this episode:

• Why one behavioral health provider working for four companies quadruples the data problem
• What a ghost network actually is, and why it’s almost never malicious
• The four-day speed-to-care number, and what it takes to hit it
• The number one filter members search on when choosing a therapist
• Therapeutic alliance: getting someone into care versus keeping them there
• Why telehealth solved geography and not matching
• Shared credentialing, and the single source of truth he’d build with a magic wand
• The advice his grandmother still calls to check he’s following

Subscribe to Provider Data Dorks for the people fixing healthcare’s hardest data problem. New episodes weekly on YouTube, Spotify, and Apple Podcasts.

Timestamps:

00:00 Intro

03:58 The through line from finance to dental to behavioral health

07:16 What makes finding a behavioral health provider so hard

09:20 Telehealth solved geography, not matching

10:27 One provider, four companies, four times the data

13:54 NavConnect, and finding out when someone is actually free

15:24 The four-day speed-to-care number

17:18 Why licensing letters change from state to state

21:10 The magic bullet he doesn’t have yet

23:55 Therapeutic alliance, and the filter members search first

25:01 Where cash pay fits in

27:57 What a ghost network actually is

32:53 Who is really responsible for accurate data

38:53 Behavioral health and chronic disease

42:17 Closing the loop back to the PCP

45:15 Shared credentialing and a single source of truth

49:06 Nobody went to school to maintain 20 directories

52:30 His honest advice for health plans

1:02:11 Lightning round

1:03:24 His grandmother’s advice

Starting in 2028, every health plan will have to confirm that every doctor in its directory is actually there, every ninety days. Nick Bernold thinks the goal is right and the mechanics are close to impossible. Ten to fifteen payers calling the same practice, reading sixty names down the phone to an office that's booked from opening to closing. His words for what happens next: the practices hang up. He's already testing the workaround, and the week before this recording one of his AI voice agents called a doctor's office and got an AI receptionist.

Nick is chief product officer at J2 Health, where he was the first hire in January 2022 and has built the company's provider network analytics and led product ever since. He came to J2 after three years designing network analytics and strategy products at Oscar Health, and started his career in finance at Bridgewater Associates. He holds a B.A. from Dartmouth and finished law school at Yale, where he was headed for tax law before healthcare pulled him back.

In this episode:

• Why network adequacy turned out to be an ops problem before it was a data problem, and what he got wrong walking in with a "data brain"

• The gray areas: PDFs from the early 2000s that practitioners will tell you are not remotely how the rules actually work

• Why 20 to 40% of doctors listed as in-network have no appointment available inside a two to three month window

• The counterintuitive trade-off where tighter time and distance standards hand more leverage, and higher premiums, to consolidated provider groups

• What the Real Health Providers Act gets right, and the 90-day verification requirement he doesn't think anyone can operationalize

• Secret shopper calls run by AI voice agents, including the one that reached an AI receptionist on the other end

• The two directory use cases regulators keep collapsing into one: the existing patient checking coverage and the new patient trying to get in the door

• The 1997 cap on CMS-funded residency slots he believes sits upstream of the entire access problem

• His one recommendation for network leaders before 2028: consolidate to a single internal source of truth

Subscribe to Provider Data Dorks for the people fixing healthcare's hardest data problem. New episodes weekly on YouTube, Spotify, and Apple Podcasts.

Eric Galvin has run health plans as both CFO and CEO. At one of them, the directory data was bad enough that regulators raised concerns about whether consumers could actually find care. He says so plainly here, then describes what he found when he went looking: a scary place, with all kinds of scary reasons the data is the way it is, most of them things the industry did to itself.

Eric spent nine years at ConnectiCare as CFO and then CEO, served as EVP and chief growth and medical cost officer at EmblemHealth, ran PopHealthCare and Emcara Health as CEO, and was most recently CFO of Geisinger Health Plan. Across thirty years on both the payer and the provider side, his conclusion is that the provider data problem survives for human reasons more than technical ones. It comes down to trust, and to the fact that the people senior enough to fix it are often the least free to describe it out loud. In this conversation with Nick Helfrich and Mitch Gorodokin, his prescription for the whole system comes down to one word: simplify.

In this episode:

Why well-intentioned incentive design, from stars ratings to quality metrics, can degrade the patient experience it was built to improve

Why stripping out administrative waste still would not make healthcare affordable

The "bill without a price" problem: healthcare's strangest economic quirk

"Manage yourself out of a job": his advice to provider data directors seeking executive buy-in

Why he thinks a clearinghouse model, similar to credit reporting, could fix provider data industry-wide

What racing sports cars and his eye doctor reveal about the consumer data layer healthcare is missing

The colleague with a cancer diagnosis who could barely navigate the system she had worked in her entire career

Subscribe to Provider Data Dorks for the people fixing healthcare's hardest data problem. New episodes weekly on YouTube, Spotify, and Apple Podcasts.

Every health-tech company promises AI will make you healthier. Dr. Ankoor Shah says that's not what the technology is actually being built to do. A pediatrician who co-led Washington DC's COVID-19 response and now serves as VP of Clinical Excellence at Included Health, Shah delivers two on-record hot takes: that healthcare technology has historically widened disparities rather than closed them, and that today's AI is funded to optimize the revenue cycle, not patient outcomes.

From there, Nick and Mitchell get into the part that actually decides your care: how you find a doctor who's safe, and why the system makes that so hard. Shah explains why the biggest quality gains come from moving people out of the bottom quartile, how doctors with sanctions slip across state lines undetected, and why he himself has no real incentive to keep his data accurate across a dozen health plans.

It's a clear-eyed look at where provider data, quality, and AI actually intersect, from someone who has practiced, run public health, and now builds.

In this episode:

Why Shah says healthcare AI isn't built to make patients healthier

The "history of technology widening disparities" argument, from telehealth to wearables

How Included Health quantifies provider quality at the individual NPI level

Why moving patients out of the bottom quartile beats chasing top-tier docs

How sanctioned providers stay in-network across states

The credentialing burden that leaves directory data permanently stale

Why aligning the member's "mind, body, and wallet" is the real unlock

Subscribe to Provider Data Dorks on YouTube, Spotify, and Apple Podcasts.

Most health plans manage the invisible backbone of healthcare, provider data, across disconnected systems, spreadsheets, and vendors that don't talk to each other. One bad record cascades downstream into claims, payments, and patients who can't find a doctor. So why do so many plans still try to build their own fix?

Sam Deshpande spent 17 years at Capital One in risk and credit, then ran risk, technology, and information at Humana as chief risk officer and later CIO. That makes him the rare leader who has sat on both sides of every buy-vs-build, business-vs-IT fight. In this episode he gives Nick and Mitch a clear rule for what to build, what to buy, and why provider data is the textbook case for buying: complicated, universal, and ruinous to get wrong.

Highlights:

Why he calls the business-IT divide "two separate nations," and how good leaders close the border

The three questions he asks about any product before the demo matters

His rule of thumb: if it's complicated and everyone uses it, buy it

Why "transformational" is overused, and the only two things that earn the word

How he'd fix provider data from a clean slate as a health plan CEO: decide, declare, design

Where AI genuinely moves provider data, and where teams are kidding themselves

The $60 shovel story that reframed how he buys AI tools

New episodes of Provider Data Dorks every week. Subscribe on YouTube, Spotify, and Apple. Hosted by Nick Helfrich and Mitch Gorodokin.

Finding an in-network doctor shouldn't take twenty phone calls. But provider directories (the invisible backbone of healthcare) are wrong so often that the best payers in the country top out at 70% accuracy, and the worst sit at 30%.

Most people assume that gap is a mystery. Ron Urwongse proved it's measurable.

Ron is the co-founder of Defacto Health and former innovation and strategy lead at CAQH. When CMS mandated that insurers publish their provider directory data through public APIs, he did something almost nobody else did: he read them. All 150 of them. By aggregating those feeds and scoring where payers agree and disagree, Defacto turned one of healthcare's messiest problems into something you can actually put a number on.

In this conversation with hosts Nick Helfrich and Mitch Gorodokin, Ron breaks down why cleaning data upstream beats patching it downstream, why "single source of truth" might not save us, and the surprisingly human reasons good directories go bad.

Why payer directory accuracy ranges from 30% to 70% and what separates the two

How consensus scoring across 150 payers reveals which addresses are actually right

The dropdown-menu mistake quietly generating thousands of directory errors

Why health systems often hold better data than the payers publishing it

What the No Surprises Act, MA Plan Finder, and Real Health Providers Act mean for you

How Defacto audits insurers using nothing but the data those insurers publish

Ron's rule for building anything that lasts: fall in love with the problem

Subscribe to Provider Data Dorks for the people fixing healthcare's hardest data problem. New episodes weekly on YouTube, Spotify, and Apple Podcasts.

Steve Klasko was a DJ named Little Stevie Kent who got into medical school partly because an admissions officer recognized his voice from the radio. He then spent 40 years proving that listening (really listening) separates transformational leaders from the ones who just manage decline.

As CEO of Jefferson Health, he took a $1.5 billion system to $10 billion in nine years, fought the FTC, and made enemies in every insurance boardroom in Philadelphia. His method was simple: stop asking lawyers what you're allowed to do. Tell them what you're going to do, and ask them how to defend that action.

In this episode:

Why Jefferson was "a place where good ideas go to die" and how Klasko changed that by deciding the lawyers worked for him, not the other way around

The credentialing nightmare hiding inside every hospital M&A deal, and what those three months of lost revenue actually cost

Why healthcare is 15 years behind finance: "We select doctors for organic chemistry grades. Then we're amazed they aren't more empathetic."

The MRI pricing story: Klasko called six facilities, asked a simple question, and the last one hung up on him

How defragmenting a hard drive became his mental model for fixing broken provider data infrastructure

His vision for 2031: patients own their data, credentialing happens in milliseconds, and the whole apparatus is a commodity

His one wish for healthcare, told through a Jason Kidd quote about turning things around 360 degrees

Follow Provider Data Dorks on Spotify and Apple Podcasts for weekly conversations with the leaders who built the system and the ones rebuilding it. New episodes every Wednesday.

Provider data has been called the invisible backbone of healthcare. It drives directories, network adequacy, credentialing, claims… basically everything. And in most organizations, it's still managed through spreadsheets, siloed systems, and a stack of vendors that don't talk to each other. So why hasn't the industry fixed it?

Tyler Ford has spent his career at the center of that question, from the Advisory Board to UnitedHealth Group to his current role as SVP of Strategy and Operations at Union Healthcare Insight. He's one of the few people who has seen this problem from every angle: the plan side, the regulatory side, and the advisory side. And in this conversation, he doesn't pull punches.

What's covered in the first episode of Provider Data Dorks with Tyler Ford:

• Why provider data is a definitions problem, a technology problem, and an incentives problem all at once and why that intersection is what makes it so hard to solve
• The credentialing standoff: health plans need accuracy and compliance; providers need speed. Why bridging those two priorities has never worked
• The one provider data standard that actually succeeded (the CRED App), why it worked, and the lesson the industry hasn't learned from it
• Why standards without enforcement are just suggestions and what No Surprises Act implementation taught the industry about accountability
• What Tyler calls the "Gordian knot" problem: why shared credentialing isn't one solvable problem but a system of layered complexity in technology, incentives, process, and people
• The five pillars of CertifyOS's shared credentialing model and why Tyler thinks the conditions to finally make it work are actually here
• Why the shift toward consumer-driven health plans (ICHRA/ECS) is about to make clean provider data mission-critical for health plan survival

Subscribe to the show on YouTube, Spotify, and Apple Podcasts, or wherever you get your podcasts.