QUESTION:
We perform delegated credentialing/payer enrollment for our employed practitioners and have been receiving correspondence from health insurers with which we have delegated agreements that we need to make changes to our policies and procedures because of revisions to the NCQA Standards. Is this correct and, if so, can you provide us with more information on the changes that we need to make?
ANSWER FROM HORTYSPRINGER ATTORNEY CHARLES CHULACK:
It is indeed correct. The NCQA Credentialing and Recredentialing Standards that go into effect on July 1, 2025 include significant changes that will require, at a minimum, updating your policies that apply to delegated credentialing/payer enrollment. The most significant NCQA amendment is the elimination of the much maligned and close to incomprehensible “Credentialing System Controls” Standard. When we first heard of this decision by the NCQA, we were relieved (and our relief was shared by those on the frontlines of delegated credentialing).
Unfortunately, the Credentialing System Controls requirements have been replaced with a new “Credentialing Information Integrity” Standard. On its face, the new Standard is a little bit easier to understand, but it is process heavy and will require revisions to your documents. Without going too far into the weeds of the Standard, the NCQA is targeting “inappropriate documentation and updates” to credentialing information. Per the Standard, those performing delegated credentialing must have, among other things, policy language and corresponding processes for: (1) the credentialing information that falls under the integrity requirements, (2) the process for documenting updates to credentialing information, (3) a description of inappropriate documentation and updates, and (4) the auditing process for identifying inappropriate documentation and updates to credentialing information. This is scratching the surface of what is required under the Credentialing Information Integrity Standard, but it gives you an idea of what changes need to be made to address this topic.
The NCQA Standards also tightened up the time limits for verifications and notifying practitioners of credentialing and recredentialing decisions. By way of example, verifications of licensure, board certification, work history, and malpractice history must be reviewed by your Credentials Committee or Medical Director within 120 days of the verification (as opposed to 180 days which was required by the old standard). Moreover, practitioners now must be notified of a credentialing decision within 30 calendar days (compared to the previous requirement of 60 days).
Other changes to the Standards include a requirement that your application ask about practitioner race, ethnicity, and language and a statement that you do not discriminate or base credentialing decisions on these items. However, the application needs to note that providing this information is optional.
While the Q&A section of the Health Law Express doesn’t have the space to detail all the amendments for the 2025 NCQA Standards, we wanted to give you notice that changes will need to be made. We have walked many of our clients through the required changes to their policies and procedures and, frankly, the policy changes that are mandated are not difficult to make. That being said, the Standards are going to necessitate process updates, adjustments, and education for your credentialing staff and implementation may be a rocky road.
If you have a quick question about this, e-mail Charlie Chulack at cchulack@hortyspringer.com.