How to (Actually) Meet the 2025 NCQA Credentialing Standards

Hello and welcome to today’s webinar: How to actually meet the twenty twenty five NCQA credentialing standards. Before we get started, I’d like to review a few housekeeping details. Today’s webinar is being recorded and an online archive of today’s event will be available within one to two business days. If you have trouble seeing the slides at any time during the presentation please press F5 to refresh your screen on a PC or command R if you’re using a Mac. You may ask a question at any time during the presentation by typing your question into the Q and A box which is located at the right side of your screen and pressing enter. Finally, I’d like to remind you of AHIP’s antitrust statement located in the link just below the slide viewer. We will as always comply with that statement. Among other things, the antitrust statement prohibits us from discussing competitively sensitive information. We’re very fortunate to have with us today Donna Thielk, Chief Compliance Officer and Doctor. Tony Threat, Senior Product Manager both with Provider Trust as well as Saveta Polamis, Assistant Vice President, Product Management with NCQA. And at this time, I’d like to turn the floor over to Donna. Thank you and good morning or good afternoon depending on which coast you’re on. Sveta’s in the East Coast, so it’s afternoon for her and still morning for myself. I guess Tony’s on the East Coast too. So good afternoon to Tony as well. So thank you all for joining us. We are really excited today. The Provider Trust team is just so honored to have Sveta join us from NCQA. So we’re just gonna take a minute and just introduce ourselves. I’ll start and then I’ll turn it over to Tony and Sveta. So as you heard from Joanne, I am the Chief Compliance Officer. Someone other than me is switching slides. I am the Chief Compliance Officer here at ProviderTrust. I’ve been here, I have my ninth anniversary this month with ProviderTrust, which is hard for me to even believe. I had a full career prior to joining Provider Trust for a client of Provider Trust. So I’ve been on both sides of the seat. So I grew up in a very, very large health system, spent over thirty years in my career there. So I’m excited to be here at ProviderTrust, really having an opportunity to work with our clients, our enterprise providers and payers, and really understanding and navigating the journey that we have at ProviderTrust and with our clients. So thank you again for being here. I’ll kind of moderate through our day today. Tony, if you want to just take a minute and introduce yourself, that would be great. Thanks, Donna. Tony Threat. I’ve been at ProviderTrust almost six years now, primarily working with our healthcare payers. We have had the opportunity to expand into the payer market since twenty nineteen and a little bit before, and I’m excited to walk you through today how we think about provider data as it relates to the NCQA updated standards. Sveta? Thanks so much. Good afternoon, morning. Sveta Bohemia is the system vice president for product management at NCQA. I’ve had the pleasure for the last thirteen years to work on quality improvement across various domains of healthcare. Credentialing is a key domain that I have worked on for several years, and I look forward to this conversation today. In my role, I lead NCQA’s efforts for accreditation program updates and new development. And I’m sure I’ve had the pleasure of being with you on other topics like utilization management and population health and health equity. So I look forward to today’s deep dive into credentialing. Thank you, Sveta. All right, so what are we gonna talk about today? We’re gonna do kind of an overview of some of the twenty twenty five NCUA standards. We’re gonna break those down into a little bit of understanding and impact. And then we’re going to kind of do a brief history of what ongoing monitoring means here at Provider Trust. And then Tony is gonna walk us through a demonstration of one of our products that is really built for these new changes of kind of the credentialing world related to not only cred and recred timeframes, but ongoing. And then certainly we’ll have time at the end for questions and answer session. And by all means, please feel free to put your questions in the question and answer section throughout the presentation and we will do our very best to address those as we go. All right, so I thought it would be a great place to start in sharing a little bit about Provider Trust mission. When I looked at our mission and then some of the definitions of credentialing that NCQA puts forth, it was really interesting how they tied together. So I thought we would just start there. So at ProviderTrust, our mission is very simple. It’s to create safer healthcare for all. We come to work every day to push our industry towards that reality with the industry’s most accurate provider data. Our data is always verified against the primary source, empowering our provider and payer clients to protect themselves and the communities they serve from fraud, waste and abuse. Pretty straightforward. So Sveta, if you wouldn’t mind, this is the credentialing definition that I took out of the health plan. Would you mind just kind of sharing this and kind of the relationship or correlation? Yeah, absolutely. Thank you, Donna. Know, NCQA for, I’m sure through health plan accreditation and our other programs, and in general, whether it’s credentialing or other parts, we are always looking to present to you the best practices for implementing and sustaining high quality processes. Credentialing is no exception. And through the programs that we have developed, not only for processes, but actually implementation and ongoing execution, we’re always looking to create a network of quality accountability across the delivery system. I imagine most of your payers on this call, you may be delegating some of these functions and through our various programs and standards in different parts of the delivery system. We’re really looking to create that cohesive quality accountability that applies to health plans, health systems, physician groups, commercial CVOs, telehealth companies, really any entity that is accountable and has a network of providers. Thank you, Sveta. All right, so one of the things we wanted to highlight, make sure that we were all aligned to, as Speta said at the very beginning, right? There are all sorts of NCQA standards and guidelines. And we wanted to make sure that we’re all aligned, that what we’re focusing on today specifically are the new twenty twenty five standards and guidelines for accreditation of health plans and for the certification of credentialing and provider networks, specifically around the sections that relate to credentialing. So that’s where we’re gonna focus our time and attention today. And then just a little bit of background. So Provider Trust, we are a CVO and we have six certifications within that CVO and an important change that will be impacting Provider Trust in our next survey window, which will be in twenty twenty six, is that we’ll be surveyed under the new credential certification program. As we all know, the CVO component is being replaced and kind of merged into this. So we’re excited about that. We feel like some of the changes that are coming through in these twenty twenty five standards and guidelines really align with the service model that we have here at ProviderTrust, which is really helping support our clients in ensuring primary source verification of certain elements within the entire credentialing landscape. So that’s where we’re gonna focus our time today. So we wanted to start with a little polling question before we went through these changes. So Joanne, I’ll read this I think and then the team will present this poll for each of you to answer. So is your organization ready to meet the updated NCQA twenty twenty five requirements during your next survey? Answer one, not yet. Number two, planning complete. Number three, updates underway. Number four, we’re ready. Or number five, I have no idea what you’re talking about, but that’s why I’m here today. Lots to learn. So if you all just take a minute and complete the poll, that would be great. Looks like all of your answers are coming in. I’ll just give you another second or two. I know you have to put some thought into these answers. Remember, everything’s anonymous so you don’t have to worry. Svetta’s not looking to see which one of us are ready or which one of us are still learning. Okay, so results are in. So it looks like planning complete is only about four percent. Updates are underway, thirty five percent. Thirty percent have no idea and that’s why I’m here today. Or sorry, twenty two percent have no idea and that’s why I’m here today. So lots of opportunity. We’re really excited that we can walk through some of these and I think by the time we finish, hopefully your answers, you’ll feel comfortable in kind of moving forward. And we’re excited for Sveta to help us walk through some of these. All right, so where we wanted to start is giving Sveta really just an opportunity to share with us a little bit about the evolution of the NCQA certification program. I can say from Provider Trust and our experience when we very, very first started with our CVO, we had a lot of a learning curve both from our perspective and from the auditor’s perspective, really understanding how technology and automation was meeting these requirements. And as you can imagine, many of our credentialing processes were very manual, right? We had files that had to be, information had to be acquired and it had to be photocopied and it had to be put in a folder and the folder had to move from person one to person two. And then someone had to review it and they had to put their little checklist on and their stamp of approval. And then it had to go to the credentialing committee, right? It was very manual. And so when we first started and we said, Hey, we’re going out with technology and doing all these things. The auditor was like, Oh my goodness, I don’t even know what that means. So we’ve been really lucky to partner with NCQA and Speta has been a big part of that giving us a voice and an opportunity to really share kind of how our process works. And we’re excited about some of these changes. So Sveta, I would love for you to just take some time and kind of walk through the rationale or some of the motivation to making some of these changes. Absolutely. And that was a great backdrop, Donna. I often talk about pigeons and folders and faxes, and that’s sort of how things started back in the day when the credentials, when NCQA first gathered a group of experts in the 90s. And I actually spoke with one of those panelists not too long ago, but everything was folders and faxes and things have evolved. I mean, even in the last five years and fast forwarding to today with AI, not that we’re touching AI in this space, but technology has evolved tremendously in the last five years. And looking at that and looking at the risks related to credentialing and not only the risks, but the fact that we move, right? Everybody moves from our practitioners and providers to ourselves. And given that mobility and the availability of automation and technology, our standards also had to move in that direction with the idea that we are putting the patient safety at the heart of any of these changes. And in our public comment process and many, many conversations with various players in the industry, we reached the conclusion that this is no longer a manual process. I mean, it is in some cases, right? But in order to scale and to mitigate risk as much as possible in this space, automation is a key part of the process. And so, the standards do not require automation, the updates assume that organization should be able to, in some form, at least for many of these things, leverage automation in order to be able to work with more recent data, whether during their initial credentialing process, because that speeds up enrollment, provider enrollment, that speeds up your member access to providers, especially today when access is such an important part of member experience. And so we’re not specifically saying you ought to be automated and do this in a certain way, but as you will see in the conversation that’s to follow with examples, it’s sort of something that is required in a way to get to that more recent data in order to be able to monitor in an ongoing way. With, the goal of risk mitigation as much as possible, because at the end of the day, if an entity is accountable for a network of practitioners, they’re accountable for the experience of the members who are accessing that network and the quality of care that is being offered to those members. And so when we talk about the updates, there’s the health plan side through health plan accreditation and credentialing accreditation, where an organization has a credentialing committee. And then there’s the credentialing certification, which typically is for organizations like Provider Trust that are sourcing the data for entities that have the credentialing committee and are looking to make informed, very informed, accurate decisions about whom to accept in their network, and then be able to monitor any sanctions, exclusions for those providers, not just at the beginning, but throughout that three year period before recredentialing kicks in. That’s awesome. Thank you. That’s a great setup I think for us moving into some of the details. So the four areas that we’re going to specifically cover today are CR1, which is just kind of the overarching credentialing policies that relate to all of our credentialing activities and really set forth the guidelines that we have to follow. We’re gonna spend a little bit of time talking about the importance of information integrity. We’re going to talk about CR3, that credentialing verification. And then CR5 is ongoing monitoring. And this is one that I think as we walk through all four, I think you’re gonna hear us talk about ongoing monitoring through each one, because that really is a big change that’s an important component as Sveta has just talked about, right? Making sure that we think about patient safety, making sure that we think about visibility and access to information by our members and that sort of thing. Really just looking at the most current information about our practitioners and providers throughout their relationship is really important. So I think you’re gonna see that message throughout. So let’s get started. Let’s talk about the credentialing policy. And you’re gonna see in each of our slides, kind of the blue information. If you were looking at the standards and guidelines in the printed form or probably none of you printed, but maybe or maybe not, I might have a binder on my desk that does have these printed. This is the information at the beginning that just kind of helps us align. And then we’re gonna highlight a couple of important updates in the middle and then we’re gonna talk a little bit about the impact. So let’s begin and talk about CR number one, credentialing policies. And it states, the organization has a well defined credentialing and recredentialing process for evaluating and selecting licensed independent practitioners to provide care to its members. Seems so simple. But we all know if we were looking at CR1, it is very long. It has a lot of factors and a lot of elements that really help guide us. So again, we highlighted this particular factor six, talking about ongoing monitoring. But Sveta, if you wouldn’t mind really kind of sharing your perspective on why really in my, I think both of our perspectives, CR1 is really very important as we’re setting forth how we’re going to manage and monitor all of our requirements for these standards and guidelines. Indeed, so policies and procedures are important. They’re your artifacts and I think everyone on this call knows that, but they are the artifact that’s living that allows, despite changes in your organization, for someone to pick up that policy and procedure and know what is expected in terms of all the checklists related to setting up your credentialing process. We added factor six regarding ongoing monitoring notifications to the credentialing committee to close that loop. I imagine some of you, many of you perhaps were closing that loop with the credentialing committee. If there was a finding during the the three year ongoing monitoring period, the expectation is that that information goes to the credentialing committee or a similar committee that you’ve set up that is then accountable to make a decision. What do we do if something rises to the occasion that doesn’t meet your organization’s expectations, if you find a sanction and exclusion and so forth. And it’s critical that you have a good way to document that, that you have the flags that are necessary, right? To speed up that process and make sure that you’re not missing opportunities to intervene and that your credentialing committee has good artifacts and documentation about what may have happened and can make a decision, right? Do we send a, you know, you can, the worst case scenario, obviously is something terrible happens to the member, which is what everyone wants to avoid. And the credentialing committee having the artifact about red flags and so forth during ongoing monitoring period, we’ll have to document the action that was taken. NCQA does not dictate what action is taken, but we do want to make sure that that group is closed appropriately from, we found something that doesn’t meet our criteria to the credentialing community did something. Donna, I’ll hand it back to you in terms of how that works with provider trust. Absolutely. And maybe just, I might start just in the generic fashion. Like for us, one of the things that our clients routinely ask us for are our policies and procedures as well and really making sure that we have structure and process. So I think this CR1 is really important, like Sveta said, when there’s turnover in the organization or someone’s just coming in to monitor your activities, making sure that you have well documented processes is really important. And then specifically about what Sveta was describing about closing the loop, Tony is gonna show you during the demo later today, kind of how our product does that. But that component of getting the information timely, being able to document the findings is really important. One that at ProviderTrust, Toni’s gonna show you kind of the evolution that we’ve gone through on the health plan side, on the payer side, but this is something that ProviderTrust, we’ve been doing from the very beginning on our provider side. It’s something that’s been really important to us when we think about patient safety and the healthcare safety kind of overarching is really making sure that everyone is aware of a practitioner issue as quickly as possible, right? All of us want to make sure that our patients are receiving the best care possible. And so we, our systems alert at any point in time when we see an exclusion or a sanction, a licensure expiration, all of those things pretty much in real time. So we’ll have the opportunity as we go through today to share more of that with you. All right, let’s keep moving. And let’s talk a little bit about information integrity. And again, we’ll start out by just reading kind of the intent behind this particular standard. The organization demonstrates its commitment to protecting the integrity of credential information used in the credentialing process. And we talk about information integrity. And when you look at these factors, we see automation, right? And we see, we don’t see automation, but we see the components that automation helps ensure. So I’ll let Sveta start here and talking about really kind of how important it is that we make sure that the information that we’re capturing is accurate and of course very timely. Sveta, I’ll turn it over to you. Thank you, Donna. And for those of you familiar with the standard, I’ll just acknowledge that the standard name did change last year. It was system controls, now it’s information integrity. There were some challenges with the requirement because it wasn’t as specific about the scope of the data that had to be protected. And so, with this update that you see here, and I do recommend looking at the full set of standards, but we have specified the updates that are important to make sure that no one is working to change in any way, because the integrity of credentialing data is key to risk mitigation. Going back to that, mitigating the risk for your organization, for your members and so forth. And so, we’re not suggesting that anyone is intentionally doing that, but we do know, right, with staff turnover, depending on who has access, there’s opportunity for things to happen that may have a negative outcome. And so it’s important that whatever system you’re using, if you’re still doing a lot of this manually, this becomes critical. If this is something you’re doing in Excel, it’s very easy to, like they say, to have a fat finger situation or anything like that. So, to the degree possible, ensuring the data integrity of anything related to the licensure date. Pretty key, right? Changing one number makes a big difference, right? And fraudulently altering existing documents. Unfortunately, that does happen because of dates being so critical for compliance. We don’t wanna see that. And there are some things related to who can access your system. And hopefully if you have an automated system, if everything is captured on the cloud, perhaps it’s easier to avoid some of these issues. But we just wanna stress that irrespective of how you’re storing the data, it’s critical to ensure that the data is not altered in any way, unless there was something coming from the primary source saying, right away, there was a change and here’s the change. You, Sveta. Thank you. Thing I just kind of wanted to highlight here in the impact, when I was thinking about it and thinking about what are next steps, right? What should I be doing? How do I look at this? How do I think about this? I think really looking at your current practices, right? Where are my weaknesses? Where are the potential places where there’s a human being engaging? And thinking about what’s that person’s role? What are their accountabilities? How am I educating them? How am I monitoring that and following through? I think really if you map out your process of how the information flows and identify all those manual places or all the automated places, I think that’s a great place for you to think about how to manage this particular standard. And I would really encourage you to look at like where can I remove the risk, right? Like Sera said, where is there an opportunity for a simple mistake of something being fat fingered? Where is an opportunity for me to insert technology so that I can remove some of that risk? So I think this is one where it will take some time to really review your process and think about where my risks are and then put your mitigation strategy in place, right? How do I go through and remove that risk? So this is one of the controls that’s changed and I do think it gives us an opportunity to relook at how we’re ensuring that integrity and like Sveta said, how are we making sure the right people are seeing the right information and only touching that that they have to. I know at ProviderTrust we have an audit process where we look at every single piece of primary source verification that’s coming into our system and who has access to that. And we monitor it every month and audit it every month just to make sure that there isn’t anything that’s coming in that was changed or touched by a human. So it’s really important. And I think this is an opportunity where ‘ll take a little bit of time for us to, not us, but all of us as a whole, right? To think through the best way to mitigate this risk. All right, let’s keep moving. Let’s move on to CR three. So CR three is the credentialing verification, right? And I think from provider trust perspective, this is where we spend a lot of our time, right? Really making sure that we are providing the most accurate and up to date information for our clients. So the intent of this particular standard is the organization conducts timely verification of information to ensure that the practitioners have the legal authority and relevant training and experience to provide quality of care. So this is where we see some really important updates regarding license verifications and look backs and which states we need to look at. We look at Medicare and Medicaid exclusions and sanctions. And then a really important piece is updating that verification look back or that timeframe from one hundred and eighty days to one hundred and twenty days. And we have a couple slides after this that Sveta will help really kind of make sure that we’re understanding where the dates are changing, where that look back is. But Svetta, if you wanna just kinda highlight some of the important components of this, that would be great. Yeah, there’s a lot of moving parts. I’m sure you have noticed that the timeframe is probably the most obvious one that you may have heard through our public comment and in other presentations that we have done. So anyone who is going through health plan accreditation and credentialing accreditation, there’s the one hundred and twenty days. So at the point of making a credentialing decision, the data related to licensure, board certification, work history, it’s one hundred and eighty, but everything else is one hundred and twenty malpractice history and so forth. That can be more than one hundred and twenty days old. If you are working with an organization that has certification, they have less time to obtain that data and verify it. And so that you, the organization that has the credentialing committee have basically thirty extra days to work through that information. You also probably know that if your file is green across everything, and there are obviously a number of more credentials that are not listed here, we’ve only listed the ones that have a timeline related to them. But if obviously the file is green, you don’t have to go through a formal credentialing committee, but let’s say there is a flag somewhere, you do have to have a credentialing committee. You have that thirty day leeway to work with because the certified entity, the NCQA certified entity has a shorter timeframe to gather the data, complete the file and send that to you. On the slide that we started on, so two slides back, I just wanna highlight that there are, like I said, several moving parts here. So there’s the licensure and so forth, but then you’re also looking at limitations in any state where they’ve practiced in the last five years. So, sanctions and exclusions also play a big role, and that’s where you might end up seeing some red flags. I want to highlight also that if a provider you’re looking to add them, let’s say in one state in Maryland, they may have practiced in other states in the last five years. You need to know that, right? Because there may be a reason why that practitioner is no longer practicing there. And it’s important to understand, did they let their licensed labs because they’re no longer living in California or did something else happen? And we added exclusions, which are not necessarily captured under sanctions. Those are two different things and adds another layer of information that’s important for you to know before you accept someone in your network. So, a lot of moving parts to keep track of and dates. And we understand that’s challenging. And like I said, automation is not required, but the expectation is that you do have a full three sixty view of your practitioner throughout from the moment you decide to accept them all the way through the credentialing. Thank you, Svena. One thing that you’ll notice in the impact section, the very last sentence says, you know, now we have to monitor the state Medicaid agencies at the primary source for exclusions, right? And they’re notoriously disparate and can vary in data quality. And that’s one of the biggest challenges that we’ve seen for years and years and years on the provider side. And now as the health plans begin to incorporate that Medicaid exclusion monitoring, we know that that can be very difficult, right? We know some of the state Medicaid agencies, if you look at Texas or New York, they have really sophisticated lists that are very similar to the OIG where you can go in and put information and verify. And then you have other states that may have a name and maybe a city and a state, sometimes not even a street address and oftentimes no unique identifier like an NPI number. And it really can be very challenging. And one example that we were just talking about literally happened to one of our clients last week when we were talking with them. The South Carolina Medicaid source just added a whole new category called termination for cause and they added three hundred providers to that list. And so as we were looking at that list, we were finding new exclusions, right? Because it’s combined with the exclusion list as one new list. So we reached out to South Carolina and they did explain that you should treat those exactly the same, whether they’re an exclusion or whether it’s defined as termination for cause. The state of South Carolina considers those the same. And so those dates, or those three hundred practitioners, or those three hundred entities, they’re people or businesses, right? Not just people in this case, Dated back as far as ten years but they’ve just showed up on the list most recently. And so that’s one of the challenges with those lists. One thing I will say from a provider trust perspective that we have a little bit of an advantage of helping our clients is we monitor that, right? We monitor when someone was added to a list, we monitor when that list became available so that we can really help tell that story for you. So that if it’s just showing up today but it’s a date from three years ago, our system tracks all of those dates and we’re able to help support our clients in being able to navigate that, like as Spada said earlier, right? Whenever there’s an alert or an issue, really making sure you have good documentation around what you found, when you found it, what you did with it, all of that’s really important. So just an example perhaps of some of the Medicaid exclusion challenges that we have seen and why this is gonna be really important to think through how to meet these requirements. All right, let’s look at our last one, which is CR V. Sven and I will chat about that and then we’ll turn it over. Oops, sorry, gotta skip through these two slides we already did. All right, ongoing monitoring. This is one that I think we’ve all highlighted already, right? Is really important and one that I think kind of changes the game for the work that we have to do. So the intent is, the organization develops and implements policies and procedures for ongoing monitoring of practitioners sanctions, complaints and quality issues between recredentialing cycles and takes appropriate action against practitioners when it identifies occurrence of poor quality. So Sveta, I’ll let you kind of walk us through and then we’ll go from there. Yeah, I highlighted this throughout the conversation. The thing that I didn’t mention is when we say ongoing monitoring, we mean truly ongoing as much as possible. The standards for twenty twenty five really highlight that this is a monthly, at least monthly activity. Of course, you can do it daily if that’s within your reach and ability, depending on the size of your network and your capability. But now the requirement is that you’re looking at least monthly or within thirty calendar days of receiving an alert, if you’re subscribed to an alert, or if you have an organization that’s providing that to you. But again, you’re looking at Medicare, Medicaid sanctions and exclusions, limitations and expiration of licensure, because depending on how that’s documented, the expiration of licensure could be intentional or due to some issue. And then you still have the complaints from identified adverse events, right? So all of your partners that are working with your providers need to understand that that’s what you’re looking for. And that’s what a health plan is accountable for since the members are enrolled with the health plan. And, again, we recognize the number of things that need to be tracked. But at the end of the day, it’s really about patient safety and risk mitigation, given all of the regulatory requirements that go beyond NCQA, but that are aligned with what NCQA is, you know, it has included in the standards. You, Thank you. I think the next slide really just focused on the same thing, but we called out license and I think you just addressed that. And I do think maybe just as a highlight from both of these particular slides, since we have chatted about them a fair amount, really is that new license expiration, right? I think that is something new and really an opportunity for us to make sure that throughout the course of the relationship with our practitioners, providers that we’re monitoring those licenses to make sure that they have properly renewed them. It seems so simple but I can confidently say that over the course of my career we’ve had more than a few practitioners that just forgot, right, to submit the appropriate information and keep their license. And obviously that becomes quite a fire drill for all of us. So an important component. So it’s eleven thirty nine Central Time and we certainly want to give Tony some opportunity to walk through kind of the journey here at Provider Trust. And then we’ll circle back after that and Sveta and Tony and I will kind of wrap it up. So Tony, I will turn it over to you. Thanks, Donna. So one of the things we wanted to do quickly is to walk you through the timeline of how this product came to be. You know, we really have been, as Donna said, the healthcare ecosystem for about fifteen years now. Really about five years ago, as we were beginning to have conversations with payers specifically, we’re coming up against a problem and a question of, hey, we have providers who we have to pay, but they’re nonparticipating providers, and we don’t know much about them. Right? As a nonparticipating provider, obviously you get their name and their NPI and hopefully their taxonomy for billing purposes, but any additional information you may not have about that provider. And really the nexus of this question was, well, how could we provide our clients with more information about a provider? And obviously, providers have NPIs, and so started to it took us a little while, but we started to begin to build out proof of concept of what that could be. And using the NPI as the unique identifier, we’re able to put elements around that. One of the great things about provider trust and our history is that, you know, all of you know, that as you work with the exclusion list at a minimum, some of those lists may not have everything that you need, right? They may have a name, hopefully, right? They hopefully have a name and an address. Hopefully they have a name and address and a date of birth or an NPI, but oftentimes they don’t. And one of the things that we believe is that we should be able to have a full comprehensive understanding of the provider and the exclusions. And because of that work, it really led us into the verification product as well and our ability to verify licenses. It’s not easy to take a provider’s NPI and also associate credentials to that, whether that’s the state license, whether that’s the DEA license or the state controlled substances or board certifications. But through acquiring multiple sources, we’re able to begin to paint the picture of what a provider is and who they are, And so we’ve gone through some iterations of that. Just taking the license and affixing that to the NPI, of course, was our proof of concept. We then changed the name a few times, and really, it goes into that ongoing component. So what we believe now, of course, and going along with the NCQA updated guidelines, is that a profile should be just that dynamic, and we should be able to have the ongoing updates. So whether it’s ongoing source updates each month from the exclusion lists or the sanction lists, if it’s ongoing licensure updates, we believe that that should happen monthly. And so ultimately, as we launched it in the fall twenty twenty four, you can see the new branded name of Dynamic NPI. I believe the next slide is quick question, and as we answer that, I’ll get the demo ready to go. So, again, this is anonymous. Does your organization have an existing solution for ongoing monitoring of credentials? We have four answers here: yes, we are in the process of implementing one no, or I’m not sure. And again, this is anonymous, so welcome your answers. Thanks, Tony. Wyanne says the answers are coming in. We’ll give you all another little bit, and then we’ll share the results. Definitely interested in the ongoing monitoring component. One of the things that we’ve seen for sure in the last, I would say, three to six months is a big uptake in conversations about how we produce and go about ongoing monitoring. And so the answers are in. Have sixty seven percent of you said yes, which is great. Eight percent say you’re implementing one, and no, zero percent. But we do have twenty five percent who say they’re not sure, so we’d welcome to have that extended conversation with you. I’m going to show the demo really quickly. As I pull it up here, what I want you to know is that it is a prototype demo. We did not want to show a specific provider, but please know that the demo is accurate to what we have in product. It’s pulling up here. Just want to make sure that you all can see the screen that I can see. It’s basically There we go. All right. All right, great. So now we have the demo up and running. And so, again, because we call it dynamic NPI, what we will show you here is just a quick search of an NPI. And then after the search of the NPI, what we’ll begin to see is that profile. So, again, imagine I’m searching an NPI there, I’ve typed it in, we can see the results here for Jane Smith. Again, this is a fictitious answer. Again, know that the data behind this is true and real. And what you’ll see immediately on this screen is that instant response. And so we have already, like I said in our dataset, a fixed licenses. We know that we can first get licensure from NPEs, and that’s not the only source that we rely on. We do know that there are opportunities for improvement with the data set, but we do pull in those licenses. On the right hand side, you’ll see some additional profile information, really demographic information as it relates to addresses, any additional information that we’re able to pull from there. And then we have not only the licenses that are provided by the source that many folks can access, We have what we call provider trust network licenses. So again, because provider trust is in the market for ensuring that we have the most up to date data, make sure that we have complete data sets across a variety of sources, what we’re looking to do, again, is affix all of that information to the provider’s profile. So you can see at the bottom there that there is a North Carolina license, there’s also a DEA license. If this practitioner had been practicing in a state that required a state controlled substance, that would be available as well. I want to make the point here as fast forward here through this quick demo, is that this information is all up to date. So one of the things that we know in current regulation is not only about the board action, which you’ll see show up here in just a second, but also about the expiration license, the licenses that expire. And so if a license is coming up for expiration next month, we have a process that goes and checks that multiple times prior to the expiration to ensure we’re having the most up to date data, but also we do that verification monthly so you have that information. That would be a part of that ongoing process that we’d want to make sure is available to you. In addition to that, as you’re thinking through how this would affect you and your organization, some additional standards you might want to think about is that, of course, all this data is coming back in what we would call, you know, in data or JSON format, right? So this would be available to you and your organization and should be available to you and your organization to use not only in a product like ProviderTrust application here, but in your source systems as well, right? Because we know that when these updated standards are happening, you obviously have products that you work in every day, whether it’s your credentialing platform, your provider data network platform, or otherwise, and so this data needs to be put in those places where you work. That also should include not just the data that you see here that is pulled from those sources, but also should include the board action. And again, we are monitoring these license boards monthly so that we have the most up to date board action information if that happens. Oftentimes, if that does happen, right, that’s going to happen in between a period. It’s not going to happen, obviously, right around your credentialing or recredentialing time frame. And that information should come with screenshots. So with the license itself or the board action, it should come with screenshot information, which we have available. So the long PDF of all of the court order information, any information from the primary source, we have those screenshots available as well. So then, as we go forward, what you’ll see here is that we’ll just fast forward just a little bit. We do have the board certifications as well. Right? We know that a full credentialing packet requires to have those credentials. And so with ABMS here, you can see, again, the information we’re able to pull from that. That also would, of course, include a primary source screenshot. And we know with ABMS specifically, there’s an ability to capture all of the provider’s specialty information, and that all comes back in. Again, this would be something that you’d want to have updated. We know that sometimes folks only need the board information maybe at the credentialing or recredentialing events, but because we’re able to pull this information in monthly due to our sources, what we believe is that the recredentialing experience shouldn’t really be an event anymore if you have all this up to date information available to you in your source application. Fast forward just a little bit more, and you’ll see here actually, let me back it up just a little bit. So there’s a tab up here called sanctions. I clicked on that, and you can see here the federal exclusion lists, the state Medicaid sanctions, as well as additional lists here at the bottom, the preclusion list, the Medicare opt out, and the NPI status. Obviously, we are able to get these sources monthly. We have them as they update and are available. And one of the things that we note with our clients and folks that we have the opportunity to partner with is that the state Medicaid lists are one of the harder lists to acquire. Some of them require faxing or other information, but there are forty four lists out there and available. And this is one of the ones that for sure would take some time to acquire. And the forty four lists are there are forty three states, then of course the Washington D. C. List. So that all comes back, and each of them, again, have their own level of quality and availability of information that you’d want to be able to pull back into your organization. So in this experience, what I’m showing you here is that we have done a search with an NPI and pulled back this immediate response. These profiles, again, just to reiterate, are profiles that are being monitored in an ongoing fashion. So they aren’t just right now. We don’t have special ability to go to the sources and pull back as they stand. We are continually monitoring that data, and you are able to access that information as they come through. One thing will happen here really quickly is that we’ll click the Add to Monitoring button, and you can see an interface that would allow you to add that provider into the ongoing component. Again, because what is happening here, that we are monitoring this in an ongoing fashion, you want to also get those ongoing updates. By adding them into your population, you get those ongoing updates available to you. You can subscribe to that NPI for a period of time. You might even need to add additional information that you have to the provider that you have found available. This would be a part of the interface. And really, what’s going happen when I click the Add to Population button, you’re going to see that the interface doesn’t really change because, again, the data itself is what powers this user experience, and the data would update. You would see new license verifications each month. You would see changes in status of sanctions if they happen to get on a state sanction list or a federal exclusion list, or if anything updates in between the time that you were able to credential this provider, and of course, in that ongoing cycle between the initial credentialing and the three year period. So that’s really how we think about this opportunity with the ongoing and updated NCQA standards. And Donna, I’ll turn it back to you so we can wrap up the webinar. Thanks, Tony. I was reading some of the comments from the moderator. It looks like maybe the demo was a little bit hard to see, that it was a little small. So I would encourage you after this session if there’s any questions that you have, we would love to be able to show you that in real time and help you see it a little bit more up close and personal. So I’m sure that when we watch this recording we can blow it up and look at it in a different fashion. But by all means, don’t feel like you only got to see a small snippet today. We’re happy to share that with you. All right, so I know there have been a few questions. Joanne, I apologize. I can’t remember if I was supposed to read the questions or if someone Yeah, I’ll take over from here, Donna. So thank you. Thanks, Donna. At this time, we’re going to address some questions that came in during the presentation. And let’s take our first question in chat, reads, one moment let’s just get to it here, is CR5 only applicable if you have a Medicaid plan or for all health plans? Sveta, I think that one’s for you. Yes, I couldn’t unmute fast enough. Yes, it applies. So the requirement applies to all lines of business. So Medicare, Medicaid, commercial and exchange. Are looking at practitioners typically participate with various lines of business. And if they have an issue that was captured in Medicaid sanctions, you should know about that, even if you’re a commercial plan. It’s unlikely though, you have a situation where a provider literally participates with one line of business and they’ve never been in multiple states, I mean, I’m sure it happens somewhere. But, the CR V is applicable to, all lines of business. If you’re going through health plan accreditation, I think if you have additional questions about your specific context, we encourage you to, email us or submit your question via myncqa dot org, where everything will be captured and artifacted, you will have that for whatever use case you’re asking the question. Great, thank you. And our next question is, what does NCQA consider a reliable adverse source to find complaints or performance issues? If I am looking at the standards, which I am right now, just to make sure that we are using the same language here, and this is factor five in ongoing monitoring, collecting and reviewing information from identified adverse events. We, we are not specific. So, we’re, NCQA in the standards is, is broad because we say adverse events include injury or harm while a member is receiving care from a practitioner. And that could be captured in various places, but we’re not specific to say you ought to obtain that. You may be getting the complaint from the patient themselves, and that could trigger some investigation, or it may come up in any of the other sources, that you’re going into for sanctions and exclusions. In some of those cases, as you know, it takes a while for something to rise to the occasion of sanction and exclusion because of all the things that have to happen. So, I know health plans have their own way of tracking complaints and investigations. So, some of this may be coming starting off with an internal health plan view or if you’re a health system, that may happen. It literally could originate, your own organization. I hope that’s helpful. But we’re not prescriptive that you ought to have this specific source for that specific, factor. And maybe Donna, Tony, you might have, you know, provider trust might have something different. Handing back to you. Thanks. I think really important, the component that you talked about the timeline, right? One of the things that we have seen, and I’m sure many of you are very familiar, right? There may be a complaint that’s filed, then there’s an investigation at the board level. And then if it’s a really serious, there may be a state level investigation and eventually, to the OIG. So it takes a long, long time. We see even a state exclusion getting to the federal level at the OIG to average over two fifty days. So recognizing your internal systems may be your best source initially and then watching the license is probably the next best place to go. I think, go ahead. Yep, thanks Joanne. Sure, I think we can squeeze one more question in here, Donna. What’s your best advice for our participants to take back to their organizations from this presentation today? Well, from NCQI, I will give the NCQI perspective really quick is, like I said, this is really important. It’s the unsung hero of healthcare. I think there’s a lot of things that our members, I, as a patient, don’t realize how much work is being done in the background to keep me safe when I participate in our healthcare system. So, there’s a lot of moving parts. We advise every participating organization to read carefully and manage their work because this matters and it does make a difference. And we know it’s hard and we thank you for your commitment to quality. Thanks, Sveta. I know we only have one minute, so I think I’ll wrap on behalf of all of us. But Tony, if there’s something you’d like to share, please, by all means. I think, you know, really just building off what Sveta said, I think for us as a credentialed organization, right, there’s a lot of moving parts and a lot of changes and we are passionate about our commitment to patient safety and the healthcare continuum. And we really appreciate NCQA and the role that they’ve played in continuing to evolve these standards. And so we want to thank Sveta for joining and being part of this collaborative presentation today and truly appreciate each and every one of you for joining us. And I think absolutely our best advice is get started, right? Reach out, ask questions, get started. As a representative of Provider Trust and Chief Compliance Officer, we’d love any opportunity to talk with you and see how we can best meet that need. But we look forward to working with all of you and continuing our partnership with NCQA through all these changes. So thanks again and we hope you all have an absolutely wonderful day. Joanne, we’ll turn it back to you. Thank you so much, Donna. And to our speakers, thank you for that great presentation and for sharing your Thank you to the audience for participating in today’s webinar. This concludes today’s presentation. Enjoy the rest of your day.