Anytime humans are involved, we invite a margin for error. This is why regulatory bodies are so critical for public health and safety. We need unbiased oversight to uphold healthcare quality, watch out for patient safety, and ensure funds are properly managed.
Having trusted agencies that enforce and standardize care is critical, but it’s also an administrative behemoth for healthcare organizations. Monitoring provider network quality and compliance requires an active approach and real subject matter expertise.
Read on as we break down the 101 of provider network compliance for payers and providers. Once we’re up to speed, we’ll reveal the powers of ongoing provider monitoring, share the risks of falling out of compliance, and offer tips for making compliance much less painful across organizations.
We need regulatory bodies in healthcare for a host of reasons. As previously mentioned, humans are imperfect. This rings true whether or not there is any ill intent. Even if we assume that everyone is acting above board, manual processes like medical credentialing, are subject to error without the right systems in place.
With national regulatory bodies enforcing compliance standards across clinical settings, healthcare quality improves. For networks to function, we need checks in place. Largely, this is for patient safety, but regulatory compliance also exists to prevent the misuse of government funds and protect the integrity of Medicare.
The risk of errors and non-compliance diminishes when we bake in regulation, governance, and automation. Each layer of enforcement and monitoring in a medical compliance system helps to identify outliers and suspicious activity. Unfortunately, illegal activity and fraud against Medicare, Medicaid, and other payers is not uncommon.
In fact, Becker’s Hospital Review has a column dedicated to legal and regulatory issues that features a monthly round-up of top provider fraudulent billing stories.
Here’s a peek into one month’s top headlines: A New Jersey physician was convicted for submitting $5.4 million in fraudulent claims to Medicare through a telemarketing scheme. A mental health service provider from Washington was recently sentenced to three years in prison for fraud against Medicaid. An Arizona physician faces up to 10 years in prison and a $250,000 fine for $3.7M in fraud against private insurance companies.
We need provider network compliance and provider monitoring to safeguard against bad actors and mismanaged funds, but moreover, to uphold the day-to-day standards of our majority, well-meaning providers.
When it comes to measuring and enforcing quality and healthcare compliance standards on providers, we’ve got a number of organizations that provide guidance. The three most widely adopted are the National Committee for Quality Assurance (NCQA), The Joint Commission, and the Utilization Review Accreditation Commission (URAC).
The shared goal of these non-profit, regulatory bodies is to ensure high-quality patient care and safety and to uphold provider excellence. However, each of the three national agencies has a slightly different flavor of compliance.
Most regulatory standards require provider licensure, as well as dozens of potential sanctions and exclusions, to be monitored every month. But why?
Here are the top reasons why provider network monitoring is crucial for any payer or care delivery organization:
Ongoing monitoring involves a comprehensive review of various state and federal sources to validate the credentials and conduct of providers. With dozens of federal and state databases maintaining lists of excluded or debarred providers, automated network monitoring allows for continuous, daily data pulls that would not be manually possible.
To remain NCQA-compliant, provider networks must support ongoing monitoring of provider NPI numbers, license exclusions & sanctions, updates to malpractice history, disciplinary information, Medicare opt-outs, state licenses, DEA, board certifications, and Medicare/Medicaid sanctions & exclusions.
In case you’re not sold on the need for automation, take a glance at the full NCQA-required source list for providers. And then take a look at the recommended additional monitoring sources. Still team “Not-tomation”?
Automation software plays a pivotal role in enhancing the frequency and quality of provider network monitoring. Without automation, it’s next to impossible to stay on top of the required and recommended compliance and regulatory checks.
Here’s how automating network monitoring benefits care delivery organizations, payers and health plans, and pharmacy and biotech:
Verifiable’s Credentialing Automation and Provider Network Monitoring solutions enable real-time verifications for compliance checks. To do this at scale, Verifiable is always “listening” for changes from key sources and alerts teams only when action is required.
This ongoing provider monitoring allows care delivery, payer, and pharmacy organizations to maintain meticulous, up-to-date records of their provider networks, establishing comprehensive documentation. An automated paper trail streamlines the audit preparation process and promotes regulatory review confidence.
What happens when one of your providers continues to see patients when they have an expired license or are listed on an exclusion list?
Regulations exist for providers to uphold the highest possible standards of care for patients, to increase safety, and to standardize healthcare delivery processes. With so much on the line, the costs for non-compliant organizations are undoubtedly XL.
Incomplete monitoring or delays can result in penalties and unnecessary financial burdens.
If a practicing provider is found non-compliant and flagged on an exclusions list, there are 60 days to take action before it goes into effect. If the provider is unaware of the exclusion or does not remediate it, this can result in civil monetary penalties, potential bans from Medicare and Medicaid, and even revoked licenses. It’s serious business for an individual provider, but the brunt of the responsibility and risk often falls on the care delivery organization.
Automating primary source verifications and data checks with credentialing automation software is the only way to excel with provider compliance. With dozens of source lists and regulatory bodies, meeting the bare minimum is a challenge, let alone going beyond with additional sources and increased frequency.
Ongoing provider network compliance is a safeguard against exposing your organization to risk. It also makes our healthcare system and standards of care among the best in the world. While it can be a pain for care delivery networks, payers, and pharmacies, it doesn’t need to be headache-inducing. With the right automation software to enable ongoing monitoring, the heavy lifting of provider network compliance is alleviated.
Leading healthcare organizations are optimizing their provider networks with Verifiable. Book your demo to see why.