Guide to Provider Network Monitoring for Payers, Providers, and Beyond

The Importance of Provider Network Compliance

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.

Why We Need Provider Network Compliance

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.

Key Regulatory Bodies for Compliance

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. 

Let’s break down the key areas of interest for NCQA, The Joint Commission, and URAC

NCQA (National Committee for Quality Assurance):

  • Mission: “To improve the quality of American health care using transparency and accountability to drive quality improvement.”
  • Focus: Patient-centered care, care coordination, and population health management.
  • Measures: Grounded in evidence-based medicine with comprehensive benchmarks that cover clinical quality, population health, and consumer experience.

The Joint Commission:

  • Mission: “To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.”
  • Focus: Prioritize patient safety and quality enhancement initiatives, contributing to a safer and more efficient healthcare environment within hospitals, nursing homes, and various healthcare organizations.
  • Measures: Adherence to industry standards, enhancing patient safety measures, and fostering quality improvement.

URAC (Utilization Review Accreditation Commission):

  • Mission: “Advancing the quality of health care through leadership, accreditation, measurement and innovation.”
  • Focus: Consumer protection and quality improvement across diverse healthcare sectors, including telehealth.
  • Measures: Ensure compliance with industry regulations, track quality enhancement efforts, and safeguard consumer interests.

Comparative Break-down

  • Patient-Centered Care: NCQA takes the lead in emphasizing patient-centered care and coordination, while The Joint Commission focuses more on patient safety measures.
  • Evidence-Based Practices: Both NCQA and The Joint Commission prioritize evidence-based medicine, verifying healthcare organizations adhere to proven clinical guidelines.
  • Scope of Accreditation: URAC extends its reach across various healthcare sectors beyond traditional healthcare facilities with the most holistic approach to quality improvement.

Provider Network Monitoring to Identify Compliance Risk

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:

  1. Upholding Patient Safety and Care Quality: Ongoing network monitoring identifies providers who may put patients and organizations at risk. Without regular monitoring, providers who may pose risks due to malpractice, legal penalties, or disciplinary actions, can slip through the cracks.
  2. Enforcing Regulatory Compliance and Trust: Continuous monitoring ensures compliance with regulatory standards set by organizations like the NCQA, The Joint Commission, and URAC. Upholding these standards is a requirement for practice, and maintains trust with stakeholders, including patients, regulatory bodies, and providers.
  3. Mitigating Financial Risks and the Misuse of Government Funds: Network monitoring minimizes the financial risks associated with reimbursing excluded individuals or entities. By staying on top of any excluded, sanctioned, expired, suspended or revoked licensed providers, healthcare orgs can avoid penalties, legal action, and other negative financial and reputational impacts. They can also take proactive measures to maintain the integrity of the Medicare program by staying on top of fraudulent and suspicious billing activities.
  4. Fostering Accountability and Audit Readiness: Regular provider monitoring demonstrates a commitment to accountability but also aids in audit readiness. By maintaining thorough documentation of compliance monitoring activities, organizations are well-prepared to respond to regulatory audits and reviews. This proactive approach not only promotes trust and credibility but also facilitates a smoother audit process, minimizing disruptions and potential compliance issues.


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What Exactly is Ongoing Monitoring for Network Compliance?

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”?

State and Federal Source Checks

NCQA requires the following sources to be monitored at least monthly:

  • OIG (Office of Inspector General): Verifying that providers are not excluded from federal reimbursement programs due to misconduct or fraud.
  • SAM (System for Award Management): Screening for debarred or excluded individuals or entities to prevent potential fraud.
  • NPDB (National Practitioner Data Bank): Continuous query for real-time notifications of adverse actions taken against providers.
  • State Sanctions and Exclusions: Checking compliance with state regulations by excluding providers disciplined by state enforcement agencies.
  • Medicare Opt-Out: Identifying providers who choose not to receive reimbursement from Medicare to avoid billing issues.

Beyond NCQA compliance, additional sources that can strengthen your compliance:

  • DEA Registration: Preventing drug misuse and fraudulent prescriptions by checking that providers are registered and not under investigation.
  • NPI Verification: Simplifying financial transactions to review a provider’s NPI for verification to avoid unexpected billing delays (a HIPAA initiative).
  • SSA-DMF (Social Security Administration Death Master File): Checking against deceased persons to prevent fraudulent activity.
  • OFAC (Office of Foreign Assets Control): Making sure providers and partners are not associated with sanctioned or restricted entities.
  • State Licenses: Verifying over 200+ state and national license sources for any license marks such as suspension, revocation, or expiration.

Automation for Ongoing Provider Network Monitoring is Mission-Critical

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:

The Automation Advantage for Care Delivery Organizations:

  • Real-time Risk Identification: Daily, automated network monitoring enables real-time identification of risks or non-compliance with heightened vigilance. Automated alerts and notifications enable proactive issue resolution, mitigating risks promptly.
  • Efficient Resource Utilization: Automation streamlines monitoring processes, reducing the need for in-house medical credentialing specialists and monitoring teams. This frees up resources for strategic initiatives while maintaining even greater oversight.
  • Enhanced Compliance and Proactive Issue Resolution: Automated monitoring secures continuous adherence to regulatory standards, reducing the likelihood of compliance breaches and associated penalties. In addition, intelligent license monitoring can pull in greater numbers of monitoring sources for super-charged compliance (we’ll break these sources down shortly).
  • Improved Audit Preparedness: Network monitoring software facilitates thorough documentation of monitoring activities, ensuring organizations are audit-ready at all times and can easily demonstrate compliance with all regulatory bodies and requirements.

The Automation Advantage for Payers and Health Plans:

  • Reduced Monitoring Costs: Costs involved in outsourcing PSVs and performing provider network monitoring can be very high when compared to using automation software with a small internal team.
  • Provider Data Accuracy: With the right provider network monitoring software integrated into your data management, your provider information is always kept up to date.
  • Network Visibility and Insight: Simply, when automation is used to monitor providers, your insight into your network at a glance is transformed–giving you powerful visibility to see your network from any angle, and be proactive before issues arise.
  • Fast Action on Problematic Providers: Streamlined provider network monitoring means that you are notified the day a provider is flagged on any lists for sanctions/exclusions.

The Automation Advantage for Pharmacy and Biotech:

  • Timely Detection of Prescriber Non-Compliance: Automated monitoring of DEA and State licensure enables pharmacies and biotech organizations to have timely corrective actions and reduces the risk of penalties from regulatory authorities.
  • Increased Efficiency and Accuracy: With automated provider network monitoring, pharmacies can streamline their operations, reduce manual errors, and ensure consistent adherence to regulatory requirements, enhancing efficiency and accuracy in maintaining compliance.
  • Fill Prescriptions with Confidence: With automated provider license monitoring, you have the confidence to fill each and every prescription–knowing at that moment if it was sent from a valid provider in good standing.

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.


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Risks of Non-Compliant Providers

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.

Here are some of the risks of provider non-compliance:

  • Financial Penalties: Non-compliance by providers with Federal fraud and abuse laws can result in substantial financial penalties and fines for the healthcare organization, potentially costing millions of dollars in regulatory fees and legal expenses. Fines of up to $10,000 per item claimed or service provided, in addition to three times the claimed amounts for CMS reimbursement. Not to mention fraudulent billing in which CMS fully denies claim reimbursements.
  • Legal Liability and Lawsuits: Non-compliant providers leave the healthcare organization vulnerable to lawsuits and legal actions, resulting in substantial legal fees, settlements, and even criminal charges or jail time, subject to Corporate Integrity Agreements with the OIG. This can severely impact the organization's financial stability with fines under the False Claims Act reaching up to $11,000 per claim.
  • Impact on Patient Care Quality: Poor practices and procedures stemming from providers' non-compliance can compromise patient care quality, leading to an increase in patient care issues. This undermines the organization's ability to deliver high-quality healthcare services.
  • Reputational Damage and Trust Erosion: Instances of provider non-compliance can tarnish the organization's reputation and erode trust among patients, employees, stakeholders, and other providers. This can have a ripple effect that leads to fewer patients, low provider enrollment, and decreased community support.
  • Tarnish Provider Recruitment and Network Growth: Provider network growth is an important part of any organization’s long-term strategy. Provider recruitment and enrollment rely on the good standing of the organization, and compliance plays a part. Read how faster medical credentialing improves provider experience and helps to grow your network.

For our complete list and deeper dive into NCQA compliance, check out What You Should Know About NCQA Credentialing Standards.

Why Verifiable for Provider Network Monitoring?

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. 

How Verifiable Bolsters Network Compliance: 

  • Extends Your Reach: Monitor additional sources to excel at provider network compliance, and more easily obtain delegated contracts and provider trust.
  • Offers Daily Sanctions/Exclusions Monitoring: Exclusions require fast action, which is why Verifiable monitors these critical sources daily–giving you near real-time updates on non-compliant providers.
  • Provides No-Miss Alerts: Get alerted on every sanction and exclusion to stay ahead of penalties, risks, and fraudulent billing. See an easy list of communication and action required in an intuitive dashboard.
  • Delivers Audit-Ready Reporting: Be audit-ready with reports and logs of every compliance action taken (and monitoring check performed) including what, when and who from your team.
  • Goes Above and Beyond NCQA Standards: Other sources are highly valuable to monitor regularly (DEA, NPI, OFAC, SSA-DMF) to build reputational trust, attract top provider talent, and build delegated credentialing relationships.


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TL; DR: Provider Network Compliance 101

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.

  • Provider Network Monitoring Significance: Ongoing monitoring establishes patient safety and regulatory compliance, which prevents the misuse of funds, fosters accountability, and kickstarts audit readiness.
  • Why Network Monitoring Automation?: Automation streamlines monitoring processes, enabling real-time risk identification, efficient resource utilization, and enhanced compliance which facilitates smoother regulatory reviews.
  • State and Federal Checks: Automated network monitoring reviews state and federal sources, ensuring compliance with exclusion lists and regulations.
  • Risks of Non-Compliance: Non-compliance leads to financial penalties, legal liability, compromised care quality, and reputational damage for healthcare organizations (which can all be avoided).
  • NCQA Standards: NCQA mandates medical credentialing and primary source verification, requiring regular monitoring of Medicare and Medicaid sanctions, licensure limitations, and patient complaints. Going above and beyond just monitoring NCQA requirements builds an enhanced culture of patient and provider safety and quality.
  • Why Verifiable for Compliance Automation?: Verifiable automates verifications, offers daily monitoring, real-time alerts, audit-ready reporting, and exceeds NCQA standards for comprehensive network compliance. Did we mention it automates?

See the Verifiable Difference

Leading healthcare organizations are optimizing their provider networks with Verifiable. Book your demo to see why.