What is Provider Recredentialing?

Patient safety and regulatory compliance depend on maintaining accurate and up-to-date provider records. That’s why the credentialing process doesn’t end once a provider gets their original license, joins a network, and starts practicing. Instead, healthcare organizations must regularly reverify a provider’s qualifications, licensing, and certification to ensure that every provider in their network is qualified to practice.

That process is known as recredentialing.

Provider re-credentialing is the ongoing process of reviewing a provider who has already been credentialed to ensure they continue to meet the required standards. In other words, it’s a periodic check-up on their credentials.

Typically, providers must be re-credentialed every 2–3 years, though the exact timeframe depends on factors such as state regulations, payer/health plan requirements, and the provider’s specialty.

Healthcare licenses and credentials are never stagnant. Healthcare providers may obtain one license at the start of their career, but licensing standards are subject to change. This would require them to get additional training or acquire new credentials or licenses if they wanted to practice in specific clinics, hospitals, specialties, or subspecialties.

Additionally, many providers get new licenses and certifications throughout their careers. For example, an internal medicine doctor may obtain a board certification in a subspecialty, such as cardiology or geriatrics. Alternatively, a nurse may return to school to get an advanced practice license, such as becoming a nurse practitioner or a clinical nurse specialist.

A provider’s credentialing can also change negatively. Providers may lose privileges to practice in specific hospitals or face disciplinary actions. Some providers face sanctions or actions from federal programs. Licenses also expire, and failure to take continuing education courses or to make necessary updates can result in changes to their credentials.

Whatever the reason for the changes, provider recredentialing is crucial for maintaining high standards of care and ensuring that providers continue to meet the licensing, training, and performance requirements. This process protects patients, helps organizations remain compliant with accreditation standards, and supports overall trust in the healthcare system.

Why Provider Recredentialing Matters

Recredentialing involves verifying that licenses, certifications, and other credentials are still valid and up to date.

From these reasons, you can probably ascertain how important this is: Without accurate provider credentialing information, patients can’t be assured that they are receiving care from appropriately trained and licensed healthcare professionals, and health plans can’t know that they are referring their members to the right providers.

Most accrediting bodies, including the National Committee for Quality Assurance (NCQA) and the Centers for Medicare & Medicaid Services (CMS), require recredentialing every two to three years. However, the truth is that two years is far too long. At the rapid rate our healthcare system is moving, payers must have access to the most accurate and regularly changing certification data in real-time.

Recredentialing helps organizations avoid:

• Compliance violations
• Patient safety issues
• Liability exposure
• Network inefficiencies
• Spiraling costs

CertifyOS’s credentialing and recredentialing process seamlessly integrates with NCQA in real time to ensure that every provider's credentialing data is up-to-date and accurate.

The Recredentialing Process: Step by Step

It’s critical that health plans and payers continuously recertify providers to ensure that their certifications match the promises delivered in the network. Without recertification, patients couldn’t be assured that the providers in their health plan’s networks are qualified to provide the care they need.

So, how exactly do recredentialing bodies ensure that provider data is accurate and updated regularly? This is the process that they follow:

1. Application update: First, providers submit updated work history, licenses, and certifications.
2. Primary source verification: Then, licenses and certifications are confirmed with issuing entities.
3. Sanctions and disciplinary check: Next, the data is screened against state medical boards, OIG exclusion lists, and other sanction databases.
4. Performance review: The bodies then evaluate provider quality, patient outcomes, and peer reviews.
5. Approval and documentation: Finally, a final decision is recorded and stored for compliance and audit purposes.

Fortunately, CertifyOS can do all of these steps in real-time using our tech-forward infrastructure. Our API seamlessly integrates with primary sources to ensure that the original certification and re-certification processes are smooth and accurate.

Why Systems and Payers Should Care About Provider Recredentialing

At a fundamental level, accurate provider data means that patients get the best care possible at the lowest cost. This is the foundation of our entire healthcare system and is essential in ensuring that our system continues to deliver high-quality care at costs that members can afford.

Additionally, accurate provider recredentialing:

• Ensures ongoing compliance with accreditation standards
• Protects patients by verifying that providers remain qualified
• Improves data accuracy across provider directories
• Reduces organizational risk
• Supports network growth and efficiency

Common Challenges in Recredentialing

Provider data presents a challenge for both systems and payers, and credentialing and recredentialing are no exception. Health plans struggle under the weight of a growing administrative burden, and providers and systems struggle to keep up with the load. Providers simply don’t have the time to continuously update their certifications in payer databases. This leads to:

• Administrative complexity in gathering and verifying updated information
• Provider delays in submitting updates
• Data management issues due to inconsistent systems
• Risk of compliance penalties if deadlines are missed

Best Practices for Streamlined Recredentialing

Still, there are ways for payers to stay on top of recredentialing. CertifyOS’s credentialing system addresses the common challenges to both credentialing and recredentialing by offering NCQA-certified credentialing in just two minutes. Yes, you read that right. Two minutes.

Our APIs and webhooks provide the most up-to-date data and real-time updates, while automated monitoring for sanctions, exclusions, and expirations ensures that data remains accurate.

CertifyOS also offers configurable, future-ready workflows, allowing you to adapt to changing regulations and certification rules. This way, if a state or Federal requirement changes, the provider data for their entire network will be updated in real-time by an API to ensure compliance.

By implementing continuous monitoring of licenses and sanctions, payers and health plans can ensure that all providers in their networks are appropriately certified and recertified.

Provider recredentialing is more than just a compliance requirement; it’s a critical step in maintaining patient safety, organizational integrity, and delivering high-quality healthcare. By implementing efficient recredentialing processes supported by technology and best practices, healthcare organizations can ensure their provider networks remain reliable, compliant, and ready to deliver excellent care.