The No Surprises Act requirements affect compliance with provider directories.

How Do the No Surprises Act Requirements Affect Compliance with Provider Directories?

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CredentialingOne Blog

How Do the No Surprises Act Requirements Affect Compliance with Provider Directories?

Posted on Saturday, November 13, 2021

The No Surprises Act requirements go into effect in 2022.


Section 116 of the No Surprises Act, “Protecting patients and improving the accuracy of provider directory information,” seeks to safeguard patients from relying on incorrect provider data that can lead to surprise medical bills.

The No Surprises Act will directly affect all payers and providers who will need to assess their compliance procedures related to provider directories and information verification.

Here is what you need to know about how the No Surprises Act requirements affect compliance with provider directories:
  • Every 90 days, payers must verify providers’ information and providers must assist with this process by submitting regular updates.
  • When providers make changes to their information, online provider directories must be updated within 48 hours.
  • Providers whose information is unverified will be removed from online provider directories.

Essentially, providers will need to maintain their information with payers on about a quarterly basis beginning in 2022 or risk removal from online provider directories and lose the marketing presence that these directories provide when patients search for in-network providers online.

The No Surprises Act requirements affect compliance with provider directories.

Contact us to start preparing for the No Surprises Act requirements.


The No Surprises Act requirements will help keep provider information current and improve the accuracy of provider directories. However, if you’re doing credentialing work yourself, these changes will require you and your staff to commit even more time and attention to credentialing and compliance.

CredentialingOne can handle these time-consuming tasks for you. We offer credentialing and compliance services, including:

We can even build a custom maintenance and monitoring program that works best for your providers and practice.

Providers and payers need to prepare now for the new rules that begin in 2022.

Contact us today to put a plan in place that will ensure you and your providers comply with the No Surprises Act requirements, avoid removal from provider directories, and set the foundation for a successful new year!


By Stephanie Salmich

A provider looks stressed out while she stares at paperwork and is on the phone; the blog title appears: What Happens When Provider Credentials Expire?

What Happens When Provider Credentials Expire?

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CredentialingOne Blog

What Happens When Provider Credentials Expire?

Posted on Monday, April 5, 2021

When provider credentials expire, there can be serious legal and financial consequences for clinicians and their practices. Below we outline the effects of expired provider credentials and explain how you can avoid these negative outcomes.

Expired Provider Credentials Can Result In:


A provider looks stressed out while she stares at paperwork and is on the phone; the blog title appears: What Happens When Provider Credentials Expire?

Don’t let provider credentials expire – Contact CredentialingOne to create your custom credentialing maintenance and monitoring program.

Claim Denials/Lost RevenueWhen provider credentials expire or are not updated, providers are deactivated by payers, their claims are denied, and the practice misses out on reimbursement for services rendered. This could end up costing the practice months of lost revenue since the re-credentialing process can take up to 180 days (or longer due to delays related to the pandemic).

Loss of Privileges If providers’ credentials are not current, they will lose their hospital privileges. This also affects provider enrollment as providers must have hospital privileges at a participating network hospital in order to join and remain compliant with health plans.

Lawsuits/Liability ConcernsA provider may not even be aware at first that a credential has accidentally expired or might realize they have missed a deadline after it’s too late. However, practicing medicine without a valid license (including an expired one) or providing services that require certification which the provider has not renewed can open the door to lawsuits and legal ramifications for not only the provider, but the provider’s employer/facility as well.

Fines and/or SanctionsIf a provider continues to practice medicine as usual even though they have allowed credentials to expire (e.g., writing prescriptions with an expired DEA license), they and their facility may also face significant fines and/or sanctions. Likewise, failure to keep up with state continuing education requirements affects a provider’s medical license status and can cause the provider to be sanctioned by the state medical board. Additionally, the provider’s malpractice insurance rates may increase after receiving a sanction.

Higher Insurance PremiumsAllowing malpractice coverage to lapse may also cause the provider’s premiums to rise, and some insurance companies may decline the provider another policy if there is a previous gap in coverage. The provider will be required to report any lapse in coverage throughout their career.

Refusal of Future Contracts by PayersProviders who have a history of lawsuits, legal penalties, fines, sanctions, lapsed malpractice insurance, and/or expired CAQH attestation may be rejected by some payers for future contracts.

Patient Retention Issues Patients are extremely unlikely to choose an out-of-network provider. Providers who do not remain active with payers will fail to attract new patients and risk losing their existing clientele if they become out-of-network and/or must stop providing care until they are re-credentialed.

Extra Time and Work for Providers/Staff It is much more inconvenient for everyone when provider credentials expire than if the provider had maintained their credentials by the appropriate deadlines. Extra effort and time will be necessary to reactivate the provider with health plans and obtain hospital privileges again.

How to Prevent Expired Provider Credentials & Their Consequences


Keeping track of provider credentials is time-consuming and complicated. It’s easy to miss critical deadlines and expiration dates when providers and practices try to manage this work themselves (for example, with filing cabinets, manual spreadsheets, and handwritten calendar memos that leave far too much room for human error and delays in information delivery).

CredentialingOne can build a custom credentialing maintenance and monitoring program that works with your credentialing policies. We offer a robust software solution for credentialing management and a team of experienced credentialing professionals to handle the work for you.

Our credentialing maintenance and monitoring services include:

  • Our real-time messaging alert system, which sends email and text reminders to the provider when documents are nearing expiration (starting at 120 days prior to expiring).
  • A master report for the practice indicating providers with expiring documents at 120, 90, 60, and 30 days out.
  • CAQH quarterly attestations (we re-attest the provider every 120 days and upload new documents as they are set to expire).
  • Re-credentialing for commercial payers and re-validation for government payers (e.g., Medicare, Medicaid, TriCare).
  • Demographic updates, such as address/phone/name change.
  • Directory updates; Medicare payers in particular request providers to verify their demographic information every 6 to 12 months.
  • NPDB (National Practitioner Data Bank) queries
  • SAM and OIG queries
  • Primary source verification
  • Tracking of malpractice insurance coverage, CE credits, and practice services (e.g., Radiology and CLIA certifications)

We also offer a health plan audit service for larger facilities to ensure providers are participating in the correct plans and the provider roster is current. An annual health plan audit is essential for protecting a practice both legally and financially.

Prevent Expired Provider Credentials with CredentialingOne


CredentialingOne’s expert staff and technology are dedicated to keeping providers compliant and making sure they do not miss credentialing deadlines that are vital to the health of their practice and careers. Contact us to learn more about our credentialing maintenance and monitoring services, health plan audits, and how we can help you avoid the dire consequences that can occur when provider credentials expire.


By Stephanie Salmich

Blocks with healthcare icons are stacked in a pyramid and the blog title appears: New Year’s Resolutions for Providers & Practices

New Year’s Resolutions for Providers and Practices

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CredentialingOne Blog

New Year’s Resolutions for Providers and Practices

Posted on Friday, December 11, 2020

The year is coming to an end and it’s time to plan for a successful year ahead! Have you set any New Year’s resolutions for your practice?

These New Year’s resolutions for providers and practices can help you accomplish your goals in 2021 and beyond:

Blocks with healthcare icons are stacked in a pyramid and the blog title appears: New Year’s Resolutions for Providers & Practices

Set yourself up for credentialing, provider enrollment, and revenue cycle success with these New Year’s resolutions for providers and practices.

Conduct a Health Plan Audit


An annual health plan audit is critical to the success of your practice as it protects it from liability issues, boosts front desk collections, and helps keep providers from being deactivated by payers and having claims denied.

CredentialingOne offers a health plan audit service that determines whether your practice and providers are compliant with all your payers’ contracts and the insurance plans in which you’ve enrolled. For example:

  • Have you notified payers of a provider’s termination, resignation, or retirement within the timeframe required by the contract?
  • Have your providers opted in to any new plans added by a payer?
  • Have your providers opted out of any new plans added by a payer in which they do not wish to participate?

Start the year off right with a health plan audit to ensure your provider roster is current and all providers are participating in the correct plans.

Reduce Reimbursement Denials


In addition to an annual health plan audit, it’s essential to monitor your providers’ credentials throughout the year. Credentialing errors, such as expired certificates or missing CE credits, lead to reimbursement delays, denials, and underpayments.

Any time a provider or practice fails to accurately complete/update their credentialing, provider enrollment, or hospital privileging applications and documentation in a timely manner, they risk a significant loss in revenue. Unfortunately, this is all too common as the credentialing process is complex and it is very easy for items to fall through the cracks or to overlook important tasks like following up on applications.

Allowing a team of experts to handle all provider credentialing and provider enrollment work for you can help prevent claim denials and save you a lot of time and money down the road. CredentialingOne completes this work quickly and correctly, so that providers are credentialed and recredentialed with payers as soon as possible to avoid any breaks to the revenue stream.

Furthermore, we keep track of providers’ and practices’ expirables and our real-time, automated messaging alert system notifies you of any upcoming expiration dates so that you don’t miss a credentialing deadline that would result in denied claims.

A clock and stethoscope are shown and the following statistic appears: 8-10 hours per application is the average time it takes to credential one provider with one payer.

Outsource credentialing to improve work/life balance and prevent clinician burnout.

Improve Work/Life Balance


Clinician burnout is a major concern for providers and practices alike and is often the result of too much paperwork, administrative burdens, and working long hours.

Providers spend an alarming amount of time on EHR and desk work. On top of this, credentialing and provider enrollment are complicated, ongoing, and time-consuming processes that usually take longer and are more involved than the clinician expects. Completing just one application to credential a single provider with one payer takes about 8-10 hours; and most providers enroll in at least a dozen different health plans (each with its own unique application process).

Make preventing clinician burnout a top goal for your practice this year – outsource credentialing and give your providers more time to care for patients and their own well-being!


Keep Your New Year’s Resolutions with CredentialingOne


CredentialingOne can help you reach these goals and more. Contact us to learn more about our services, and start the credentialing process with us before the new year!


By Stephanie Salmich

Profile pictures of Medicare patients appear along with the blog title: Prevent Medicare Fraud! Information for Providers & Their Patients

Prevent Medicare Fraud: Information for Providers & Their Patients

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CredentialingOne Blog

Prevent Medicare Fraud: Information for Providers & Their Patients

Posted on Wednesday, October 28, 2020

Many con artists and scammers see the COVID-19 pandemic as an opportunity to commit healthcare fraud. Providers can help prevent Medicare fraud and protect their patients from identity theft with the information below.

Prevent Medicare Fraud: Information to Share with Patients


The negative effects of Medicare fraud include higher deductibles and co-pays for Medicare beneficiaries, cuts to services covered by the program, and increased healthcare costs and taxes for all. You can help prevent Medicare fraud by making your patients aware of this crime and providing them with resources regarding how to avoid Medicare scams.

Here are some tips and reminders to share with your patients:
  • Never give your Medicare Number or Medicare card to anyone other than participating Medicare doctors/pharmacists or a person you trust who may work with Medicare on your behalf. Protect it like you would your Social Security card and SSN.
  • Never accept offers for free medical care in exchange for your Medicare Number or other personal data. For example, scammers might claim they will send you a coronavirus test or masks if you give them this information – don’t do it.
  • Always check your Medicare claims and Medicare Summary Notices (MSNs) as early as possible for errors.
  • Know that Medicare:
    • Will never call you (or text you, email you, etc.) to verify your Medicare Number.*
    • Will never call you to sell you something.
    • Will never visit your home.

*If anyone calls you and asks for your personal information over the phone, just hang up.

Profile pictures of Medicare patients appear along with the blog title: Prevent Medicare Fraud! Information for Providers & Their Patients

You can help prevent Medicare fraud & protect your patients from identity theft.

Here is a list of resources to share with your patients:

Patients should call 1-800-MEDICARE if they suspect Medicare fraud. The Medicare.gov website states that patients should have this information ready when reporting Medicare fraud:

  • “Your name and Medicare Number.
  • The provider’s name and any identifying information you may have.
  • The service or item you’re questioning and when it was supposedly given or delivered.
  • The payment amount approved and paid by Medicare.
  • The date on your Medicare Summary Notice or claim.”

Prevent Medicare Fraud: Information for Providers & Practices


Providers should also take care to avoid negligent activity regarding Medicare participation within their practice, which can result in serious legal and financial consequences.

Start with the credentialing processCredentialingOne can manage the Medicare provider enrollment and revalidation processes for you, and conduct a health plan audit, so you can rest assured your providers are compliant with the requirements for participating in this complex program.

For more information on how to prevent Medicare fraud, enroll new providers, or revalidate existing providers, please contact us here.


By Stephanie Salmich

An annual health plan audit is performed.

Why an Annual Health Plan Audit is Critical to Your Success

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CredentialingOne Blog

Why an Annual Health Plan Audit is Critical to Your Success

Posted on Tuesday, December 3, 2019

Conducting an annual health plan audit is critical to the success of your practice. Over the life of a practice, providers and staff come and go and insurance companies add and terminate health plans. Keeping track of these changes is key to protecting your practice from legal issues and ensuring adequate cash flow.

Protecting Your Practice

When a new provider joins a practice, they must of course become credentialed and linked to the practice’s payor contracts in order to be considered “in-network.” However, most practices forget that they must notify their payors when a provider leaves their practice as well.

Payor contracts include language requiring a practice to send notification within a specific time frame when a provider terminates. Not only does notification of the termination date keep the practice compliant with these contracts, but it also protects the practice if the provider experiences malpractice issues or sanctions after leaving the practice.

Performing a health plan audit can ensure all payors are up to date on the providers currently associated with your practice.

Improving Front Desk Collections

A health plan audit is also crucial for front desk collections.

Turnover of front desk staff is not uncommon for any practice. It is vital that both your new and experienced staff members know the plans in which each provider participates. They also must be knowledgeable about the payors with whom your practice holds contracts.

Without a current roster of plan participation, the front desk will not know the appropriate co-pay or deductible to collect and your cash flow will bear the consequences.

An annual health plan audit is performed.

An annual health plan audit helps your practice maintain compliance and improves cash flow.


CredentialingOne’s maintenance and compliance services include an annual health plan audit. We can also provide health plan audit services on a standalone basis for clients.

The health plan audit process usually takes fewer than 30 days to complete.

Contact us today to learn more about how an annual health plan audit can protect both your practice’s liability and cash flow.


By CredentialingOne