Earlier this year, the National Commission for Quality Assurance (NCQA) announced that it would update its accreditation standards in 2025, alarming healthcare organizations. Previously proposed changes, such as cutting verification schedules in half, required healthcare organizations to consider ways to: to best meet these new requirements.
The recently released 2025 update includes some adjusted timelines to give organizations more time to adapt, but NCQA has announced stricter standards in the coming years. The onus is firmly placed on healthcare institutions to innovate to meet their needs. patients, healthcare providers, and regulators.
Why are the NCQA 2025 changes to credentialing and monitoring important?
NCQA's new 2025 Accreditation Guidelines reflect the healthcare field's growing appetite for innovation and improved patient safety. It was established in the past when paper files were the norm and authentication was received via direct mail, fax, or phone. The 2025 update will ensure that verification times better reflect current industry standards, including increased automation and real-time verification.
Initially, NCQA recommended cutting the turnaround time in half, from 120 days to 60 days. The 2025 final standard includes a reduction to just 90 days, reflecting the need for a phased approach. Adapting to these changes now will prove important when the guidelines are revisited next year.
These are not the only changes healthcare organizations must prepare for. Credential integrity guidelines call for improved reporting on audit logs.
Previous guidelines were vague and open to interpretation. The new standard emphasizes the need for strong reporting and analysis that goes beyond simple authentication automation. Healthcare organizations should look for solutions with comprehensive self-service reporting capabilities that improve access and visibility into activities such as monitoring potential changes and gaps to data.
What new requirements will be introduced and who will be most affected?
NCQA is introducing two new guidelines for 2025 that have the potential to significantly increase patient access to quality and equitable health care. It is licensing oversight for health plans and collecting socio-demographic data for health care providers.
While most healthcare providers have followed the licensing status of their employees as standard practice, health plans have not previously been required to monitor licensing. More recently, the expansion of telemedicine has complicated oversight with licensing requirements in all 50 states and increased license expiration dates within the 2-3 year recertification period.
Despite its time-consuming nature, regular monitoring has many benefits. For health plans and providers, network monitoring highlights upcoming license expirations and provides visibility into disciplinary actions that may impact patient safety and reimbursement. To optimize efficiency and compliance, health plans need a solution that can automatically monitor provider licenses so that their teams do not spend significant time and effort meeting these new requirements.
In addition to network monitoring, NCQA now encourages (though does not mandate) the collection of socio-demographic data during provider uptake. This includes information about the provider, such as race, ethnicity, and language spoken. The availability of this type of data is known to improve equity, helping organizations meet the needs of diverse patient populations and optimize treatment outcomes.
Currently, health plans can have the greatest impact by selecting or building a provider intake form that captures data upfront and provides seamless end-to-end integration with provider directories. And importantly, starting to collect this data now not only means higher quality and more equitable care for patients, but also a better response when this data collection becomes necessary and auditable. It means you don't have to.
In a world where efficiency is essential, artificial intelligence and automation can speed processes thousands of times faster than human ability, reduce administrative burden, reduce operational costs, and improve the quality of patient care. can. Health plans that have been committed to quality health care for many years recognize that moving forward now provides the best path to 2025 and beyond.
Photo: Elena Lukyanova, Getty Images
Janan Dave currently works as Vice President of Operations at Verifiable, a startup that provides software and service solutions that alleviate the challenges surrounding provider network management for healthcare organizations. Janan has a background in public health and health policy and has spent the past 10 years helping various healthcare startups scale their operations. She is passionate about building smart solutions to reduce waste in the healthcare system and promote better care, especially for older adults, family caregivers, and women. Janan studied public health at the University of Pennsylvania and lives in Brooklyn, New York. She loves cooking and baking and loves trying all the amazing food New York has to offer.
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