Why Continuous Monitoring in Provider Credentialing Is the Future

Healthcare’s fast-paced and complex environment is demanding more dynamic solutions. It doesn’t take much for a claim to be denied. If the payer spots a known exclusion or out-of-date license, it’s a guaranteed denial. According to the Experian Health Report, provider ineligibility is the second highest reason for claim denial, accounting for 42% of denials. Sure, many of these claim denials can be overturned, but doing so is costing hospitals and health systems an estimated $19.7B per year. 

Hence the rise of continuous monitoring in provider credentialing.

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Led by changing NCQA credentialing standards, best practice is evolving away from traditional primary source verifications (PSV) that are completed one by one, often only at key points such as initial hire, recredentialing, or accreditation. 

Continuous monitoring in provider credentialing is changing the PSV standard with daily, weekly, or monthly checks to ensure provider eligibility and patient safety. For credentialing professionals verifying licenses or exclusions one by one, continuous monitoring is nearly impossible. 

In this blog, I’ll offer insight into continuous monitoring, the benefits, and how it is not just an enhancement but a necessity for modern credentialing. 

Traditional Monitoring vs. Continuous Monitoring in Provider Credentialing

Here’s a look at the key differences between traditional and continuous monitoring in provider credentialing.

Key Benefits of Continuous Monitoring in Provider Credentialing

Continuous monitoring provides real-time insights, enabling organizations to detect compliance gaps, credentialing expirations, and policy violations as they happen. This proactive approach immediately addresses issues rather than discovering them during an audit or when a claim is denied.

Improved Patient Safety

Continuous monitoring in provider credentialing facilitates real-time detection of provider license issues, sanctions, and exclusions, preventing unqualified individuals from delivering care. By automatically flagging concerns, healthcare organizations can act immediately to address provider issues, protecting patients from potential harm.

Reduced Risk

I’ve already mentioned the risk of denied claims impacting your organization’s revenue without continuous monitoring in provider credentialing. But, legal liability can also be very costly, especially if there’s an adverse outcome related to an unlicensed or sanctioned provider. You also run the risk of non-compliance with regulatory agencies, such as CMS and HRSA, and accreditation organizations, such as The Joint Commission (TJC) and NCQA. Penalties or loss of accreditation could be very costly. 

Greater Operational Efficiency

Traditional PSV monitoring involves time-consuming website checks and data tracking, leading to patient care — and revenue stream — interruptions. Continuous monitoring automatically pulls the data into the healthcare compliance platform and sends email notifications when status changes By streamlining verification, organizations can focus on delivering quality care instead of chasing paperwork.

How Continuous Monitoring Works in Practice

Continuous monitoring in provider credentialing requires software with advanced automation and real-time data tracking to help healthcare organizations stay ahead of credentialing risks. It’s critical that the solution offers verifications from the original source, image capture (required by TJC and DNV), automatic verification tracking, and status change notifications.

For continuous monitoring of exclusions, the software you choose should complete checks every 30 days (at minimum) to meet NCQA’s updated credentialing standards. You’ll need direct access to the databases, including the Office of Inspector General’s List of Excluded Individuals and Entities (OIG LEIE), the System for Award Management (SAM), and your state (if your state’s information is not included in the federal databases). 

Automated exclusions monitoring should track the date and database checked, so you’re audit-ready. Ideally, customizable reporting is available so that you can create reports based on the provider location, date of the most recent check, and status changes.

Continuous primary source verification requires direct access to the original sources, including state licensing boards and certification agencies. This is a critical part of the new standard for PSV, that requires direct partnerships to secure the data access needed. 

Automated license verification should pull the document directly into the software platform with the ability for a credentialer to verify the document’s accuracy and validity. Be sure the system tracks the person who completed the verification, the date, and trusted URL so you’re prepared in case there are questions.

When continuous monitoring is part of healthcare credentialing software, all provider data and validation is in one location and embedded in proven workflows. User-friendly dashboards and real-time notifications make it easy for administrators to stay informed. Organizations receive instant alerts when a provider’s license is expiring, revoked, or flagged for quick action. 

Challenges and Misconceptions About Continuous Monitoring

Despite its benefits, some healthcare organizations hesitate to adopt continuous monitoring in provider credentialing due to concerns about cost, complexity, and data access. However, with many state licensing boards charging per license verification, modern solutions are more affordable and accessible, even for smaller facilities. Easy-to-use credentialing platforms simplify the infrastructure and support needed, so healthcare IT teams love this solution.

A common misconception is that continuous monitoring is unnecessary since credentialing is already performed at regular intervals. However, relying solely on periodic checks creates compliance gaps where providers could be sanctioned or excluded between verification cycles. Since software flags these issues immediately, it can prevent legal and financial risks that will rise from these findings.

Another myth is that implementation is too complex. In reality, modern healthcare credentialing software seamlessly integrates continuous monitoring into existing workflows. 

User-friendly dashboards, automated alerts, and real-time updates simplify compliance without overwhelming administrators. Plus, with throttling and captcha technology being used by state licensing boards, data is more accessible through automated credentialing.

Why Continuous Monitoring is the Future of Credentialing

As healthcare regulations evolve, organizations face increasing pressure to keep a real-time pulse on risks. Traditional credentialing methods, which rely on periodic verification, create gaps in oversight, leaving organizations vulnerable to legal action and non-compliance.

Continuous monitoring in provider credentialing eliminates these risks by providing ongoing, automated verification of provider credentials, exclusions, and sanctions.

Beyond compliance, continuous monitoring supports a more agile and adaptable workforce. In healthcare today, providers work across multiple facilities and telehealth platforms, requiring seamless credentialing processes to prevent delays in patient care. 

Trust and transparency are also valued in modern healthcare. Payers, patients, and regulatory bodies expect high standards of credentialing oversight. Continuous monitoring demonstrates a commitment to quality and patient safety, ensuring that only properly credentialed providers deliver care. This strengthens relationships with payers, enhances reputation, and reduces liability.

Choose MedTrainer To Streamline Your Credentialing

Continuous monitoring in provider credentialing puts your organization a step ahead in today’s healthcare environment. MedTrainer brings automated exclusions monitoring, license verification, and more into one platform, reducing risk and protecting revenue.

Get started with MedTrainer today!