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

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

Lengthy checklists representing the time-consuming process of primary source verification.

Primary Source Verification

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CredentialingOne Blog

Primary Source Verification

Posted on Friday, April 17, 2020

What is Primary Source Verification?

Primary source verification (PSV) is the process of validating a provider’s credentials through direct contact with the person or organization that actually issued the information.

Lengthy checklists representing the time-consuming process of primary source verification.

CredentialingOne can complete the time-consuming PSV process for you.

According to The Joint Commission, PSV is:

“Verification of an individual practitioner’s reported qualifications by the original source or an approved agent of that source. Methods for conducting primary source verification of credentials include direct correspondence, documented telephone verification, secure electronic verification from the original qualification source, or reports from credentials verification organizations (CVOs) that meet Joint Commission requirements.”

PSV requires detailed documentation, which should include:
  • Date the PSV was conducted
  • Method of verification (e.g. letter, fax, email, phone, website)
  • Agency and/or individual person contacted for verification and their contact information
  • The information that was specifically verified
  • Results of the PSV (e.g. questions asked and their answers)
  • Person who conducted the PSV and their signature

Why is Primary Source Verification Necessary?

Primary source verification is vital to accurate and credible credentialing. It is simply inadequate to accept information submitted by a provider or document photocopies at face value.

PSV protects your patients’ safety by helping to ensure your practitioners are qualified to care for them. Furthermore, it protects your organization from legal risks and compliance issues.

PSV is the standard form of verification for the healthcare industry and helps healthcare facilities meet the accreditation requirements of The Joint Commission and NCQA.

Primary Sources Vs. Secondary Sources

The Joint Commission has deemed some entities “designated equivalent sources,” meaning it considers them to provide information identical to that provided by the original source. Your options for PSV are contacting the original source or any designated equivalent sources.

You should only use secondary sources to verify credentials in cases where it is truly not possible to contact the original source (such as when the issuing agency or hospital has closed) and designated equivalent sources are unable to verify the information. For example, if an establishment is no longer in operation you may try contacting any successor organizations or find out where original documents may have been sent.

Primary Source Verification Services

PSV is a very involved and time-consuming process that entails manual, repetitive tasks that must be completed for EACH credential and for EVERY provider. Some designated equivalent sources also require payment to gain access.

Fortunately, CredentialingOne can contact/access each of these sources (original sources and/or designated equivalent sources) for you as well as document the completion of PSV for each of your providers’ credentials. We also monitor providers’ compliance, so you don’t have to manually track credentials and documentation and can ensure they’re renewed before they expire.

For more information on primary source verification and how CredentialingOne can help, contact us today.


By Stephanie Salmich

An emergency sign outside a hospital is shown, along with the blog title: COVID-19 Resources for Provider Privileging During a National Health Emergency.

COVID-19: Resources for Provider Privileging During a National Health Emergency

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CredentialingOne Blog

COVID-19: Resources for Provider Privileging During a

National Health Emergency

Posted on Monday, March 30, 2020

An infographic outlining different providers hospitals may call upon to help during the coronavirus crisis, which notes that many regulations are temporarily changed for provider privileging during a national health emergency.During a national health emergency such as that caused by the coronavirus, many facilities experience a provider shortage.

To combat COVID-19, you may need to expand your team of healthcare professionals by relying more heavily upon retired and volunteer providers, part-time clinicians, practitioners from other states, practitioners from other departments, and telehealth.

Provider Privileging During a National Health Emergency

During a health crisis, hospitals strive to grant privileges to these clinicians as quickly as possible while still protecting patients by providing them with qualified practitioners.

The federal and state governments, along with other regulatory entities, are temporarily adjusting some licensing and privileging requirements to accommodate the greater need for more providers and access to care due to COVID-19.

CredentialingOne can help you navigate any new and/or temporary rules and ensure your patients receive safe care from competent providers.


To start, we’ve compiled a list of resources to consult regarding provider privileging during a national health emergency:


An emergency sign outside a hospital is shown, along with the blog title: COVID-19 Resources for Provider Privileging During a National Health Emergency.

Many regulations are temporarily changed for provider privileging during a national health emergency.

1135 Waivers – the U.S. Department of Health & Human Services (HHS) is authorized to issue waivers during the COVID-19 national emergency. You can find information on blanket waivers and how to apply for individual waivers here. You must send individual waiver requests to your CMS Regional Office, and office email addresses can be found here.

Disaster PrivilegesThe Joint Commission has posted requirements for privileging, re-privileging/re-appointment, and telehealth privileging during a disaster.

Medicare Provider Enrollment – the Centers for Medicare & Medicaid Services (CMS) is offering new flexibilities regarding Medicare provider enrollment, including waiving certain screening requirements, allowing licensed providers to perform services outside their state of enrollment, and expediting applications; see its FAQs.

Medicare Telehealth CMS has expanded Medicare telehealth to include a wider scope of services so that more patients can access care from home; see its FAQs and Fact Sheet.

States Waiving Licensure Requirements/Renewals – the Federation of State Medical Boards (FSMB) created this table along with links to the original sources declaring the changes in response to the coronavirus.

States Expediting Licensure for Inactive/Retired Licensees – the FSMB created this table, which includes links to states’ resource pages.

The Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP) this program verifies registered healthcare volunteers’ credentials in advance, so they can respond more quickly to help in a crisis. (Hospitals should check with their insurance companies to determine how volunteer providers may/may not be covered by their malpractice insurance.)

For additional information, you can also contact your specific state medical association.


These resources may be updated as the COVID-19 situation progresses.

If you need further guidance on provider privileging during a national health emergency, please contact us – we’re here to help.


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