Defacto Health Joins H1
When we started Defacto Health, we set out to solve a single problem: the industry had no way of knowing which providers were in which payers’ networks.
At best, providers would publish an ‘Insurances Accepted’ page on their web site or tell patients ‘Yes, we accept Blue Cross’. Similarly, provider search and plan shopping platforms had insurance data at the carrier level. These answers were neither specific nor comprehensive, and left patients uncertain about whether their provider was actually in-network with their health plan.
A set of CMS interoperability rules in 2021 created an environment and infrastructure where these questions could finally be answered. We built Defacto to put those APIs and that Provider Directory data to work to solve a range of problems for patients, providers, payers, and the government that needed the answer to ‘What insurances does this provider accept?’
Built Alongside Payers, the Hard Way
Getting there wasn’t fast. Outside of a few national payers, most provider directory APIs simply didn’t work when we started testing them in 2021. They were all some combination of non-conformant, incomplete, or not built with real world use cases in mind. We spent years in the trenches with payer teams and their interop vendors filing issues, following up, testing resolutions, filing them again. Some payers moved fast and fixed their APIs in weeks. Some of the interop vendors added our tickets to their backlogs where they literally sat for years. We stuck with it, tracking hundreds of tickets to resolution, one payer at a time, until we were on a first-name basis with payer interop teams across the industry (we send holiday cookies now).
That persistence is also what built our relationship with H1. We’ve worked alongside H1 and Ribbon Health since 2022, watching each other solve complementary pieces of the same problem. We observed how Defacto’s work made H1’s platform better for health plans, digital health companies, and other health care innovators.
How the Industry Is Using Our Data Today
Today, Defacto’s data covers 150 payers and roughly 85% of covered lives across the country. Defacto’s customers use our data across a range of use cases: directory cleansing, network benchmarking, enrollment statusing, and provider search. Payers use it to assess directory accuracy, isolate error clusters, and benchmark their networks. Provider organizations use it to know when their providers are enrolled in payers’ networks. And the data now powers the #1 doctor search engine on the web, so the insurance info shows up directly in what patients see.
Along the way, we’ve published national reports on directory accuracy and payer API compliance, and stayed involved in the working groups shaping the future, including CMS’s ongoing National Provider Directory effort. We’ve been open about what we’ve learned, even when it wasn’t flattering to any one party, because that openness is what earned us a seat at the table with payers, providers, and regulators alike. That open dialogue and collaboration, more than any single feature, is what allowed a two-person company to have an impact.
Regulation played a role in getting here: new federal rules motivated payers toward faster, more standardized directory reporting than they had five years ago, and a lot of our early work was simply making sure payers could comply with the baseline interoperability requirements.
A powerful cultural shift is emerging today: payers and providers are now sitting in the same room, having direct conversations about what data is right and what needs fixing. In the past three weeks, we’ve sat in on conversations between payers and providers about Medicare Plan Finder and REAL Health Providers Act where they are beginning to a) agree on a consensus definition of directory accuracy, b) admit to their respective problems and responsibilities, and c) agree on tangible next steps to solve the directory problem. Defacto has played a small role in encouraging those conversations by observing and reporting on data issues on both sides of the aisle, and equipping both payers and providers with the right data to have empirical conversations about how to improve their directories.
What Doesn’t Change
Joining H1 doesn’t change why we built this. We still believe the way forward is to be a catalyst for collaboration across the industry, not just a vendor for a specific industry segment. That means we’re just as focused on making this data work for patients trying to find care, and providers trying to get paid correctly, as we are for the payers who are working to make their directories more accurate and usable.
H1’s scale changes what we can build; it doesn’t change who we’re building it for or the problems we’re trying to solve for them.
Why We’re Excited About H1
We didn’t have to go looking for a partner who understood this problem. The H1 team understands the problem deeply and has wrestled within it for as long as we have. Joining H1 means we finally get to finish a job we started alone: full coverage of ‘insurances accepted’ data, at a pace we couldn’t reach on our own. It means helping payers actually close out the directory accuracy problem, not just measure it. It means helping patients make the best decision they can about care and coverage, in a way that stays transparent and interoperable no matter which plan or system they’re navigating. And it means having more capacity to support CMS’s ambitious National Provider Directory work, and to help payers, providers, and the rest of the industry adapt as all of this keeps moving.
From Ron and TJ
We’re proud of what we built the hard way, one payer relationship at a time. We’re even prouder that it’s landing somewhere that can take it further than we could on our own. Thank you to every payer team, standards collaborator, and colleague who worked alongside us these past several years. This next chapter is possible because of you.
