Earlier this year, the National Committee for Quality Assurance (NCQA) had healthcare organizations on their toes when they announced that they would be updating their credentialing standards in 2025. Previously proposed changes, including cutting verification timelines in half, had healthcare organizations considering how to best meet these new requirements.
The recently released 2025 updates include some adjusted timelines to give organizations more time to adapt, but NCQA has hinted they will continue to push for more strict standards in the years to come – putting the onus firmly on healthcare organizations to innovate to meet the needs of patients, providers, and regulators.
Why are the NCQA 2025 changes for credentialing and monitoring important?
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NCQA’s new 2025 credentialing guidelines reflect a growing appetite for innovation and improved patient safety within the healthcare landscape. Earlier iterations were established when paper files were the standard and verifications were received through direct mail, fax, and over the phone. The 2025 updates ensure that verification turnaround times better reflect current-state industry standards, which include increased automation and real-time verifications.
Initially, NCQA recommended the turnaround-time be cut in half from 120 days to 60 days; the final standards for 2025 include a decrease to just 90 days, reflecting the need for a phased approach. Adjusting to these changes now will prove crucial once the guidelines go under review again next year.
And that’s not the only change healthcare organizations must prepare for: credentialing information integrity guidelines now require improved reporting around audit logs.
Previously, the guidelines were vague and open to interpretation. The new standards emphasize the need for strong reporting and analytics that go beyond just credentialing automation. Healthcare organizations must look for solutions with comprehensive self-serve reporting capabilities to improve access and visibility into activities like potential changes to data, monitoring gaps, and more.
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What brand new requirements have been introduced and who do they impact most?
NCQA is introducing two brand-new guidelines for 2025 that have the potential to significantly increase patient access to quality, equitable healthcare: license monitoring for health plans and social demographic data capture for providers.
Health plans were not required to conduct license monitoring in the past, although most providers followed the license status of their employees as standard practice. More recently, telehealth expansion has complicated monitoring with requirements for licensing in all 50 states — increasing the volume of a license expiration within the two-to-three year recredentialing period.
Despite its time-intensive nature, regular monitoring offers many benefits. For health plans and providers, network monitoring highlights upcoming licensure expirations and provides visibility into disciplinary actions that may impact patient safety and claims reimbursement. To optimize efficiency and compliance, health plans need a solution that can automatically monitor provider licenses so that teams are not spending significant time and effort to meet these new requirements.
Along with network monitoring, NCQA is now encouraging (though not enforcing) social demographic data capture during provider intake. This includes information about providers like race, ethnicity, and languages spoken. The availability of this type of data is known to improve equity, which can help organizations meet the needs of a diverse patient population and optimize care outcomes.
Right now, health plans can make the greatest impact by choosing or building provider intake forms that capture the data upfront and provide an end-to-end seamless integration with provider directories. And importantly, starting this data collection now not only means higher quality and more equitable care for patients, but also not having to play catch up if and when this data capture becomes required and auditable.
In a world where efficiency is essential, artificial intelligence and automation can speed up processes by a factor of thousands over human capability, lessening administrative burdens, reducing operational costs, and improving the quality of patient care. Health plans that have been in the quality care trenches for years recognize that getting ahead now offers the best path forward in 2025 and beyond.
Photo: Elena Lukyanova, Getty Images
Janan Dave currently works as the VP of Operations at Verifiable, a start-up offering software and services solutions for healthcare organizations to ease the challenges surrounding provider network management. Janan has a background in public health and health policy and has spent the last decade helping scale operations at various healthcare startups. She is passionate about building smart solutions to reduce waste in the healthcare system, and promote better care especially for the aging population, family caregivers, and women. Janan studied public health at the University of Pennsylvania, and lives in Brooklyn, NY. She loves cooking and baking, and attempting to try all the amazing food NY has to offer.
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