NCQA Credentialing Collaborative Explores the Future of Credentialing

In June, NCQA brought together leaders from more than 50 healthcare organizations to discuss the future of credentialing. One theme emerged consistently throughout the discussion: the industry is ready to modernize credentialing processes while maintaining the trust, rigor and accountability that protect patients.

“Credentialing is an important process to protect patient safety and prevent healthcare fraud, but we know there are bottlenecks in the process that can delay access to care,” says Tsveta Polhemus, NCQA’s Assistant Vice President of Product Management. “We are listening to the market and learning how we can evolve our programs while maintaining trust in the data.”

What Is the Credentialing Collaborative?

The Credentialing Collaborative is a group of leaders representing health plans, technology vendors, credentials verification organizations, data aggregators, care delivery and policy organizations that provide feedback on the current and future state of credentialing. The group held its first meeting in June, and two additional meetings are planned for later this year.

The Collaborative is focused on:

• Reducing inefficiencies in primary source verification and ongoing monitoring of practitioner credentials by building trust in technology and automation.
• Shifting toward continuous monitoring and exception-based review to enable a more efficient recredentialing process.
• Exploring governance and trust frameworks for shared credentialing models to enable safe, reliable reuse of data.
• Identifying criteria for trusted and approved sources of credentialing data to support less arduous credentialing across states.

“Credentialing data is extremely dynamic and there is an opportunity for error as it moves through the system,” says Polhemus. “In order to scale operations and maintain rigor, organizations need automation, especially for large national health plans or virtual care organizations with networks that span all 50 states.”

Feedback from the Credentialing Collaborative will help NCQA modernize its credentialing standards to reflect evolving care delivery models, workflows and technology.

What Has NCQA Learned So Far?

Participants emphasized that credentialing serves an essential purpose: ensuring providers are qualified, competent and safe to deliver care. At the same time, many acknowledged that today’s processes contain significant duplication, manual effort and administrative burden.

Importantly, participants do not view modernization as lowering standards. Instead, they see it as an opportunity to strengthen oversight and eliminate unnecessary work.

Here are some key themes that emerged from the discussion:

Continuous monitoring could transform recredentialing.

Many organizations already perform monthly or near-real-time monitoring of licenses, sanctions, exclusions and other credentialing elements. Participants suggested that continuous monitoring could lower the burden of recredentialing, while acknowledging that certain essential tasks would still be needed (e.g., provider attestations, disclosure questions, assessment of exceptions).

Trust and auditability are essential.

Participants agreed that technology-enabled credentialing processes must be transparent, reproducible and auditable, based on authoritative sources and supported by clear provenance and timestamps. They suggested that future standards should focus less on documenting individual human actions and more on demonstrating that systems and controls function reliably.

Technology requires human oversight.

Participants emphasized that technology should support—not replace—sound oversight. There was broad agreement that routine verification activities can increasingly be automated, while human expertise remains essential for evaluating exceptions, risks and complex situations.

Trusted sources reduce redundant verification activities.

Participants expressed strong interest in expanding the use of authoritative sources, aggregators and approved verification services. Many stakeholders suggested that greater clarity from NCQA regarding approved and equivalent sources and evaluation criteria could reduce confusion and drive broader adoption of modern verification methods.

Alignment promotes efficiency.

Participants highlighted the importance of industry alignment. Many noted that differences across organizations, states and regulatory programs significantly contribute to administrative complexity and provider burden. Greater consistency could help create a more efficient experience for healthcare organizations and practitioners.

Organizational readiness varies.

Organizations that perform credentialing differ in levels of digital readiness and access to technology. As credentialing standards evolve, NCQA needs to create a clear pathway for organizations to change—and allow sufficient time to do so.

What’s Next

Our June convening reinforced stakeholders’ commitment to building a credentialing ecosystem that is more efficient, trusted and responsive to the needs of today’s healthcare system. NCQA uses an evidence-based approach to develop and refine its standards, which includes thorough review and vetting by subject matter experts and public comment.

“These conversations are helping shape NCQA’s understanding of where the market sees opportunity for improvement and where there may be emerging consensus around future directions,” says Polhemus. “We are grateful to the organizations that shared their perspectives and look forward to continuing the dialogue in future collaborative sessions.”

Learn More

Listen to our recent podcast, Credentialing: The Unsung Hero of Healthcare Quality, to learn more about credentialing and its impact on access to care.

Sign up for our mailing list to stay up to date on the progress of the Credentialing Collaborative.

Thanks to Our Partners

NCQA appreciates the insights from the organizations participating in the Credentialing Collaborative.

• Aetna Better Health of Illinois (Medicaid)
• American Medical Association (AMA)
• AmeriHealth Caritas
• Andros Technologies Inc.
• Baton Health
• BlueCross BlueShield of North Carolina
• BlueCross BlueShield of Rhode Island
• BlueCross BlueShield of Tennessee
• Capital Health Plan
• Centene
• Certify
• CHG Healthcare
• Cigna
• Council for Affordable Quality Healthcare (CAQH)
• CoxHealth
• Doctors Healthcare Plans, Inc.
• EXLService Philippines, Inc.
• Federation of State Medical Boards
• Gemini Diversified Services, Inc.
• Greeley
• Health Choice Network
• Health Plan of San Mateo
• Humana
• Johns Hopkins Health Plans
• Kaiser Foundation Health Plan
• KFMC Health Improvement Partners
• Koehler Quality Group, LLC
• Martin’s Point Health Care
• Medical Associates Health Plans
• Medical Mutual of Ohio
• MemorialCare Select Health Plan
• Michigan Department of Health and Human Services
• Molina Healthcare
• MultiCare Health System
• Northwestern Medicine Physician Network
• PrimeWest Health
• Professional Credentials Exchange, Inc
• ProviderTrust
• Quest Analytics
• Regence
• Service Coordination Unlimited (SCU)
• South Texas Physician Alliance
• State of Michigan, Bureau of Specialty Behavioral Health Services
• TECQ Partners, Inc.
• Tenon Consulting Solutions
• The Noble Group
• Trinity Health Livonia Hospital
• UnitedHealth – Optum
• UnityPoint Health – Meriter Hospital
• University of Pittsburgh Medical Center (UPMC)
• University of Utah Health Plans
• Verifiable
• Verisys