The complete guide to provider network monitoring
What health plans, providers, and other healthcare organizations need to know in 2025 and beyond
Provider network monitoring is essential for maintaining high standards in healthcare delivery. As compliance standards evolve, organizations aiming to improve patient safety and operational efficiency must advance their network monitoring standards in tandem, adopting practices and integrating technology that meet all requirements in a constantly evolving healthcare landscape.
Our guide breaks down what health plans and provider organizations need to know about network monitoring, including why it matters, what’s at stake, and how your organization can achieve future-state performance. Let’s dive in.
Our guide breaks down what health plans and provider organizations need to know about network monitoring, including why it matters, what’s at stake, and how your organization can achieve future-state performance. Let’s dive in.
01
Why provider network monitoring matters
Thorough, regular, and proactive network monitoring not only helps organizations avoid risk, but offers several far-reaching benefits that can help your organization achieve future-state performance.
Uphold patient safety and care quality
Ongoing provider network monitoring identifies providers that can put patients and organizations at risk. Without regular monitoring, providers who may pose risks due to malpractice, legal penalties, or disciplinary actions, can remain undetected within your network.
Mitigate financial risks
Reimbursing excluded, sanctioned, and suspended individuals or entities can lead to significant fines. Monitoring can help healthcare organizations avoid legal action, penalties, and other negative financial and reputational consequences.
Enforce regulatory compliance and trust
Continuous monitoring ensures compliance with regulatory standards set by key regulatory bodies. Upholding these standards is a requirement and builds trust with different stakeholders, including patients and providers.
Build accountability and audit readiness
Maintaining a thorough documentation process can help organizations prepare for regulatory audits and reviews. Deploying a proactive approach not only promotes trust and credibility but also facilitates a smoother audit process, minimizing disruptions and potential compliance issues.
02
The risks and challenges of network monitoring
Ongoing monitoring involves a comprehensive review of various state and federal sources to validate the credentials and conduct of providers and identify providers that need further attention.
When executed correctly, provider network monitoring identifies providers with:
When executed correctly, provider network monitoring identifies providers with:
- Federal and state sanctions and exclusions
- Expired licensure
- Malpractice complaints
- Non-participation in government programs
- Healthcare-related criminal convictions and civil judgments
- Suspended DEA registration
- History of patient abuse or neglect
Simply put: diligent proactive monitoring sets your organization up for success. But even small missteps and oversights can have major consequences.
Neglecting to monitor your provider network and failing to keep up with regulatory changes can lead to significant financial penalties and fines, legal issues, compromised patient care quality, reputational damage, recruiting issues, and halted network growth.
Below are some common challenges organizations face when relying on outdated network monitoring methods.
Neglecting to monitor your provider network and failing to keep up with regulatory changes can lead to significant financial penalties and fines, legal issues, compromised patient care quality, reputational damage, recruiting issues, and halted network growth.
Below are some common challenges organizations face when relying on outdated network monitoring methods.
Challenge 1
Scaling smoothly as your network expands
As organizations expand their networks, monitoring delegated and non-delegated provider compliance statuses becomes more difficult — especially so for telehealth organizations or large health plans, both of which often have providers in all 50 states.
Challenge 2
Keeping pace with frequent data changes
Provider information, licenses, and credentials are subject to change, with potentially lengthy delays between when the change takes place and when the information becomes available in your system if sources are checked manually.
Challenge 3
Monitoring multiple & disparate data sources
Monitoring different sources for sanctions, exclusions, and license verifications ensures compliance and quality. But without a singular location for storing such information, monitoring (especially when completed manually) can be complex and time-consuming — and potentially lead to significant fines if flags are missed.
Challenge 4
Avoiding compliance penalties and setbacks
Not meeting compliance requirements can lead to state or federal regulation penalties, while missed license renewals can cause operational setbacks and disrupt care access for patients.
03
Achieving NCQA compliance
National regulatory bodies provide necessary oversight, with each layer of governance designed to identify outliers and suspicious activity. The three most widely adopted regulatory bodies are the NCQA (National Committee for Quality Assurance), The Joint Commission, and the URAC (Utilization Review Accreditation Commission). Verifiable focuses on helping organizations meet NCQA credentialing requirements.
04
How are NCQA guidelines changing in 2025?
While all monitoring requirements are listed in the chart below, it’s important to track NCQA requirements as they evolve over time. Let’s dive a little deeper into future updates to prepare your organization for what’s next.
Current Guidelines
2025 Updates
(effective 1 July 2025)
Monitor Medicare & Medicaid sanctions; exclusion monitoring recommended
Monitor sanctions and limitations on licensure
Monitor Medicare & Medicaid sanctions and exclusions; exclusion monitoring now required monthly
Monitor sanctions, limitations, and expirations on licensure; licenses must be re-verified upon expiration
SAM monitoring recommended
SAM monitoring now required monthly
NCQA compliance cheatsheet
To remain compliant, provider networks must be monitored against the “required” sources listed below; monitoring additional “recommended” sources may be necessary if your organization partners with certain health plans for delegation.
Organizations relying on more traditional, typically manual methods for network monitoring may struggle to keep pace with NCQA-recommended monitoring frequency. Explore the chart below and see how Verifiable’s more frequent monitoring can help your organization stay ahead of all NCQA requirements.
Source | Purpose | Required | NCQA required monitoring frequency | Verifiable monitoring frequency |
|---|---|---|---|---|
NPDB | Continuous query for real-time notifications of adverse actions taken against providers. | Yes | Daily | Continuous |
Sanctions & Exclusions: State | Checks compliance with state regulations by excluding providers disciplined by state enforcement agencies. | Yes | Monthly | Daily |
Sanctions & Exclusions: OIG | Verifies that providers are not excluded from federal reimbursement programs due to misconduct or fraud. | Yes | Monthly | Daily |
Sanctions & Exclusions: SAM | Screens for debarred or excluded individuals or entities to prevent potential fraud. | Yes | Monthly | Monthly |
Medicare Opt-Out | Identifies providers who choose not to receive reimbursement from Medicare to avoid billing issues. | Yes | Monthly | Daily |
NPI | Simplifies financial transactions to review a provider’s NPI for verification and avoid unexpected billing delays (a HIPAA initiative). | Recommended | Monthly | Monthly |
State Licenses | Verifies healthcare providers’ educational background, professional qualifications, and passing of necessary examinations so they can practice legally with their state. | Recommended | Monthly | Monthly |
DEA | Prevents drug misuse and fraudulent prescriptions by checking that providers are registered and not under investigation. | Recommended | Monthly | Monthly |
SSA-DMF | Checks against deceased persons to prevent fraudulent activity. | Recommended | Monthly | Monthly |
OFAC | Ensures providers and partners are not associated with sanctioned or restricted entities. | Recommended | Monthly | Daily |
CMS Preclusion | Identifies healthcare providers and prescribers who are precluded from receiving payment for Medicare Advantage (MA) items and services, as well as Medicare Part D drugs. | Recommended | Monthly | Daily |
05
Building future-state network monitoring with automation
Integrating automation enhances the frequency and quality of provider network monitoring, eliminating inefficiencies stemming from manual processes and removing the potential for human error.
Here’s how automating network monitoring benefits health plans, care delivery organizations, and pharmacy and biotech:
Here’s how automating network monitoring benefits health plans, care delivery organizations, and pharmacy and biotech:
Health plans
Reduced monitoring costs
Improved provider data accuracy
Enhanced network visibility and insight
Instant notifications for sanctioned/excluded providers
Care delivery organizations
Real-time risk identification
More efficient internal resource utilization
Enhanced compliance and proactive issue resolution
Improved audit preparedness
Pharmacy and biotech
Timely detection of prescriber non-compliance
Increased efficiency and accuracy
Fill prescriptions with confidence
With dozens of source lists and regulatory bodies, even meeting the bare minimum is a challenge – especially when you monitor your network manually.
Verifiable’s automated platform enables real-time verifications for compliance checks, allowing organizations across the healthcare continuum to maintain accurate, up-to-date records of their provider networks – and establish a clear, accessible paper trail to prepare for future audits and reviews. Key features of our platform include:
Verifiable’s automated platform enables real-time verifications for compliance checks, allowing organizations across the healthcare continuum to maintain accurate, up-to-date records of their provider networks – and establish a clear, accessible paper trail to prepare for future audits and reviews. Key features of our platform include:
The Verifiable difference
Self-serve reporting & insights
Real-time integrated verifications
Proactive provider expiration notifications
Match review & intervention management
Fast credentialing. Proactive monitoring. All done at scale.
Provider network compliance can be a massive burden on your team. It’s time to change that.
Verifiable’s leading network monitoring solution automates, centralizes, and simplifies monitoring at scale for up to millions of providers across different specialties and states. Book a demo now and discover the joy of total compliance confidence.
Verifiable’s leading network monitoring solution automates, centralizes, and simplifies monitoring at scale for up to millions of providers across different specialties and states. Book a demo now and discover the joy of total compliance confidence.