2025 Credentialing Changes
07/07/2025
2025 Credentialing Changes: What Healthcare Providers Need to Know
The biggest credentialing overhaul in decades just hit – here's what it means for your organization
Healthcare credentialing just got a major makeover. The NCQA's 2025 standards, which took effect July 1st, represent the most significant changes to provider verification requirements in years. If you're still operating under the old rules, you're already behind.
What Changed
The biggest shift? Speed and frequency. Organizations now have just 120 days to complete credentialing (down from 180), while Credentialing Verification Organizations (CVOs) get only 90 days. But that's just the beginning.
The real game-changer is monthly monitoring. Instead of checking provider credentials every few years during recredentialing, organizations must now verify every provider monthly against:
- OIG exclusion lists
- State medical board actions
- License status and expirations
- SAM.gov database (new requirement)
Why This Matters
The old system was built for a slower world. Providers could practice with expired licenses or federal exclusions for months before anyone noticed. The new requirements catch problems in real-time, not after the fact.
Think about it: an organization with 500 providers now runs 500 background checks monthly. Manual processes aren't just inefficient – they're impossible.
The Technology Factor
Organizations still using spreadsheets and phone calls are drowning. Modern credentialing software can automate monthly screenings, send expiration alerts, and maintain audit trails. The technology divide is real – those who've invested in systems are adapting smoothly, while others are struggling with compliance and delays.
Outsourcing Boom
Many organizations are turning to NCQA-certified CVOs to handle the heavy lifting. CVOs manage the verification grunt work while organizations focus on oversight and decision-making. This is especially critical for smaller practices that can't justify full-time credentialing staff.
The Federal Connection
While NCQA standards are technically voluntary, CMS increasingly aligns Medicare/Medicaid requirements with NCQA guidelines. Non-compliance isn't just an accreditation issue – it's a federal program participation risk.
New Requirements
Beyond monitoring frequency, the 2025 standards require collecting provider demographic data (race, ethnicity, languages spoken) to support network diversity initiatives. It's optional for providers but mandatory for organizations to offer.
Bottom Line
The 2025 credentialing changes aren't just regulatory updates – they're a fundamental shift from periodic verification to continuous monitoring. Organizations that embrace automation, invest in technology, and build ongoing compliance capabilities will thrive. Those that resist will struggle with both regulatory compliance and operational efficiency.
The message is clear: credentialing is no longer a periodic administrative task. It's continuous infrastructure that requires constant maintenance to keep healthcare systems running safely and efficiently.
Key Takeaways for Providers
- Act now: 120/90-day timelines are already in effect
- Invest in technology: Manual processes can't handle monthly monitoring
- Consider outsourcing: CVOs can manage complexity while you focus on oversight
- Plan for compliance: Federal alignment makes NCQA standards practically mandatory
- Embrace continuous monitoring: The periodic credentialing model is dead
Sources
- NCQA Standards and Guidelines for Credentialing Organizations, 2025 Edition
- CMS Provider Enrollment and Screening Requirements, 2025
- OIG List of Excluded Individuals and Entities User Guide, 2025
- HFMA Survey: Impact of New Credentialing Requirements, 2025
More detailed information: https://insights.wchsb.com/2025/06/18/the-credentialing-revolution/