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Medicaid certification for network adequacy is entering a new era of regulation. Beginning in 2026, health plans face stricter federal standards, independent validation requirements, and continuous monitoring expectations that change how organizations demonstrate compliance.

This article explains what is changing in 2026, why network adequacy has become more complex, and how your organization can proactively meet network adequacy expectations with confidence.

What Is Changing in Network Adequacy Requirements for Medicaid Managed Care and Marketplace Certification

Recent rulemaking and regulatory guidance related to network adequacy are increasing oversight across both Medicaid managed care and marketplace plans.

CMS continues to refine network adequacy requirements through strengthened oversight, clearer quantitative standards, and expanded validation processes. In recent years, CMS has emphasized improved validation of care provider directories and strengthened external quality review. For 2026, that scrutiny becomes operationalized.

With over 70% of Medicaid and CHIP beneficiaries receiving some or all of their care through a managed care plan, these changes affect Medicaid managed care, Medicare Advantage plans, and marketplace programs alike.

Federal Time and Distance Standards Expand to State Marketplaces

Beginning January 1, 2026, state-based marketplaces must adopt quantitative time and distance standards mirroring those already required for federally-facilitated exchanges. This signals a broader CMS commitment to standardizing network adequacy across all health coverage programs, including Medicaid managed care.

A notable portion of federal exchange plan issuers failed to meet 2023 standards, with inaccurate provider directories identified as a primary cause. For Medicaid managed care plans, this underscores the critical role accurate provider data plays in meeting federal requirements.

Independent Network Adequacy Reviews

State marketplaces will now conduct independent network adequacy reviews before granting QHP certification, a meaningful departure from previous self-attestation approaches requiring external validation that providers are genuinely available to serve members.

Plans must demonstrate that their provider network meets established network adequacy requirements, including:

• Compliance with time and distance standards
  
• Accuracy of provider directories
  
• Access to covered services across the full service area
  
• Provider availability and appointment access

For Medicaid managed care, oversight is intensifying. CMS released updated EQR protocols in 2023 that added a mandatory network adequacy validation component for each managed care plan.

Results from Network Adequacy Validation activities must be included in EQR technical reports due April 30, 2025, meaning plans should anticipate increasingly rigorous examination of their network data submissions.

Telehealth Provider Status Becomes a Requirement

For plan year 2026, plans must report whether network providers offer telehealth services. This adds a new dimension to network adequacy and access reporting.

States vary in how telehealth services count toward network adequacy standards. Some allow telehealth credit toward time and distance standards. Others limit telehealth recognition to certain provider types.

Health plans must now integrate telehealth data into provider data governance processes to support certification and ongoing compliance.

Why Network Adequacy Compliance Is More Challenging in 2026

Network adequacy standards are becoming more data-driven, more transparent, and more enforceable.

Three core challenges are driving increased risk:

1. Inaccurate and Fragmented Provider Data

Network adequacy depends on accurate provider data.

Federal reviews in 2023 have found that more than half of the plans’ network providers in Medicare Advantage were inactive and did not provide a single service to enrollees over the course of a year. Research consistently shows that a majority of individuals who use provider directories encounter incorrect information, contributing to “ghost networks” where listed providers are not actually available.

Common provider data issues include:

• Incorrect specialty classification
  
• Outdated practice addresses
  
• Inaccurate provider type mapping
  
• Failure to reflect accepting new patients status
  
• Misaligned mental health and substance use disorder designation

When provider directories are inaccurate, network adequacy and access calculations become unreliable. Even minor data discrepancies measured at the centimeter level of geospatial analysis can impact time standard calculations.

Organizations seeking to address fragmented provider data often benefit from robust healthcare provider data management capabilities.

2. Point-in-Time Compliance Is No Longer Enough

The No Surprises Act established a 90-day provider attestation requirement. Combined with secret shopper surveys and EQRO validation, this creates demand for continuous data accuracy rather than periodic directory updates.

Research has shown that even after corrections,  provider directories continued to have inaccurate information even after initial identification of errors, highlighting the challenge of maintaining ongoing accuracy. Managed care plans must transition from viewing certification as an annual submission event to maintaining certification readiness as an ongoing operational state.

Core Network Adequacy Standards Health Plans Must Address

While specific numeric thresholds vary by state, the categories of quantitative standards used to evaluate Medicaid managed care networks remain consistent. 

A managed care plan must demonstrate a network that is sufficient in number and types of providers across its service area. Regulators expect plans to maintain a network that delivers timely access to covered health care services and supports quality health care for all enrolled members.

Time and Distance Access Requirements

Time and distance standards define the maximum travel time or driving distance members should experience when seeking care. Calculations occur at the county level, with different thresholds based on county classification and provider specialty.

County types typically include:

• Large metro
• Metro
• Micro
• Rural
• Counties with Extreme Access Considerations

In rural areas, standards may allow greater travel distances, but plans must still demonstrate reasonable access and document how members maintain timely access to services across the service area.

These access standards ensure covered services will be accessible to enrollees without unreasonable delay.

Appointment Wait Time Expectations

CMS has proposed appointment wait time standards for routine visits.

For example:

• Routine primary care: appointment wait within 15 business days
  
• Routine behavioral health: appointment wait within 10 business days
  
• Specialty care: defined time standard depending on urgency

Wait-time standards for routine visits are validated using secret shopper methodologies. Plans must demonstrate compliance with network adequacy standards through documented results.

Essential Community Provider (ECP) Access

Health plans must demonstrate good faith efforts to contract with essential community providers serving low-income populations and communities with limited access.

Network adequacy evaluations examine providers across multiple categories:

• Primary care for adults and children
• Specialty care services
• OB/GYN providers
• Behavioral health specialists
• Hospital facilities
• Pharmacy services 
• Pediatric dental providers
• Long-term services and supports

States must also incorporate cultural and linguistic competency considerations into their standards.

Who and What Must Be Included in Network Adequacy Evaluations

Medicaid certification requires plans to demonstrate a provider network sufficient in both number and types of providers needed to deliver all covered services across the plan’s service area.

Providers Across Specialties and Care Settings

A health plan must demonstrate that its plan’s provider network is sufficient in number and types of providers across care settings and specialties. This includes:

• Primary and specialty care
• Mental health and substance use disorder treatment
• Acute care hospitals
• Skilled nursing facilities
• Diagnostic radiology
• Pharmacy
• Dental services
• Therapy services

At least ten states use provider-to-enrollee ratios to ensure sufficient provider capacity. These ratios vary considerably by state and provider type.

Delegated Entities and Managed Care Network Data Risk

Plans relying on independent practice associations, medical groups, or contracted vendor networks face distinct certification challenges. These delegated entities frequently do not update network data promptly or use consistent data formats.

When delegated provider data contains errors, such as outdated locations, incorrect accepting-new-patients status, or unreported provider departures, the plan’s documentation becomes compromised. The plan remains accountable for accuracy regardless of which entity supplied the information.

Risks of Falling Short of 2026 Network Adequacy Standards

States possess several enforcement mechanisms for network adequacy deficiencies:

• Corrective action plans
  
• Monetary penalties
  
• Enrollment freezes
  
• Contract termination

Independent reviews, secret shopper surveys, and heightened CMS oversight are expected to increase enforcement activity beyond the historical reliance on corrective action plans.

Beyond formal penalties, plans face reputational and operational consequences. Member complaints, lower performance scores, and weakened competitive positioning in state procurement all represent meaningful business risks.

How Health Plans Can Prepare for 2026 Now

To meet network adequacy requirements, health plans must shift from reactive correction to proactive governance.

Strengthen Provider Data Verification Processes

Effective verification requires drawing from multiple authoritative sources:

• Primary source verification from state licensing boards
• NPI Registry checks
• Sanctions and exclusions screening
• Automated alerts when data changes or conflicts arise

Verification must operate continuously. The 90-day attestation cycle and secret shopper surveys demand real-time accuracy, making ongoing monitoring essential for maintaining compliance.

Plans seeking rigorous provider data verification processes benefit from systems designed specifically for this purpose. For health plans building the verified provider data foundation that Medicaid network adequacy certification requires, healthcare payer solutions deliver continuously monitored data across all provider types and U.S. jurisdictions.

Integrate Telehealth Data Into Provider Workflows

Telehealth services must now be incorporated into network adequacy reporting.

Plans should:

• Update credentialing forms
  
• Track telehealth offerings by provider type
  
• Monitor changes continuously

Telehealth impacts network adequacy and access calculations and supports compliance with new network adequacy standards.

Use Analytics to Identify Risk Early

Geographic analytics tools can map provider locations against member distribution to identify counties and specialties where the plan’s network faces time and distance or ratio requirements at risk before certification deadlines.

Plans benefit from preparing exception request documentation in advance for known high-risk areas, enabling rapid submission when circumstances require an alternative access approach.

Managing Exceptions When Standards Cannot Be Met

When provider supply constraints prevent strict compliance with network adequacy standards, plans may request exceptions.

To secure approval, plans must demonstrate:

• Good faith contracting efforts
  
• Evidence of outreach
  
• Alternative access strategies
  
• Comparable reasonable access outcomes

Exception documentation must be structured, timestamped, and defensible.

Why Provider Data Accuracy Is the Foundation of Network Adequacy

Every certification element relies on accurate provider information:

• Time and distance calculations
• Provider ratio compliance
• Wait time validation
• Directory accuracy
• Exception documentation

Network adequacy standards for Medicaid and marketplace certification increasingly depend on validated, continuously monitored provider data.

Plans that ensure provider data accuracy will more reliably meet network adequacy and adapt to future regulatory shifts.

Preparing for 2026 and Beyond

When plans cannot meet numeric thresholds due to provider supply limitations, they may request formal exceptions.

To obtain approval, a managed care plan must demonstrate documented outreach efforts, recruitment activities, and alternative strategies to preserve access. Regulators evaluate whether alternative arrangements still support reasonable access and protect members’ availability and accessibility of services.

Exception review processes are governed by federal requirements and plan contract terms. Documentation must show that the plan attempted to establish network adequacy standards aligned with regulatory expectations, including network adequacy standards for Medicaid.

Structured documentation supports defensible network compliance and strengthens overall provider network adequacy validation during audits.

Sources

1. Centers for Medicare & Medicaid Services (CMS). Medicaid and Children’s Health Insurance Program Managed Care Access, Finance, and Quality Final Rule (CMS-2439-F). https://www.cms.gov/newsroom/fact-sheets/medicaid-and-childrens-health-insurance-program-managed-care-access-finance-and-quality-final-rule
2. Centers for Medicare & Medicaid Services (CMS). HHS Notice of Benefit and Payment Parameters for 2025 Final Rule. https://www.cms.gov/newsroom/fact-sheets/hhs-notice-benefit-and-payment-parameters-2025-final-rule
3. Medicaid.gov (Centers for Medicare & Medicaid Services). Quality of Care External Quality Review. https://www.medicaid.gov/medicaid/quality-of-care/medicaid-managed-care-quality/quality-of-care-external-quality-review
4. U.S. Department of Health and Human Services Office of Inspector General (HHS OIG). Many Medicare Advantage and Medicaid Managed Care Plans Have Limited Behavioral Health Provider Networks and Inactive Providers. https://oig.hhs.gov/documents/evaluation/11233/OEI-02-23-00540.pdf
5. The American Journal of Managed Care (AJMC). Persistence of Provider Directory Inaccuracies After the No Surprises Act. https://www.ajmc.com/view/persistence-of-provider-directory-inaccuracies-after-the-no-surprises-act

For healthcare compliance leaders, exclusion screening is not a routine administrative task; it is one of the most scrutinized elements of regulatory oversight. Civil monetary penalties, repayment exposure, audit findings, and reputational risk often trace back to one question: Did the organization screen correctly and consistently?

Yet confusion persists about how different healthcare exclusion databases operate and whether a single source is enough.

Understanding how FACIS compares to government exclusion lists is not simply an academic exercise. It is central to building a layered, defensible compliance framework that withstands regulatory review.

What Is FACIS?

FACIS (Fraud and Abuse Control Information System) is a healthcare-focused sanction and disciplinary database that aggregates regulatory data from multiple federal and state sources.

Unlike a single government exclusion list, FACIS compiles and categorizes records across agencies and presents them in a standardized format designed for healthcare compliance workflows.

This distinction matters: FACIS is not itself a regulatory mandate. It is a consolidated intelligence source that enhances visibility into healthcare-related sanctions.

What Data Sources Feed FACIS?

FACIS aggregates information from:

• Federal healthcare enforcement sources
• State licensing boards
• State Medicaid exclusion lists
• Federal debarment records
• Additional healthcare regulatory authorities

Records are curated and categorized to support structured review and risk assessment. Rather than replacing required databases, FACIS consolidates and organizes sanction intelligence to support broader oversight.

How FACIS Differs From Government Exclusion Lists

Government exclusion lists reflect the authority of a single agency. FACIS, by contrast, aggregates multiple enforcement and disciplinary sources into one healthcare-specific dataset.

From a compliance perspective, that difference is significant.

Key Characteristics of FACIS

FACIS differs in several ways:

• Aggregation vs. single-source authority – OIG and SAM represent specific regulatory bodies. FACIS compiles across multiple jurisdictions.
• Broader sanction visibility – FACIS may include disciplinary actions or license restrictions that do not rise to formal exclusion status.
• Structured categorization – Data is standardized for healthcare compliance use.
• Healthcare-specific focus – Designed for screening providers, vendors, and affiliated entities in regulated healthcare environments.

The distinction is not about superiority. It is about scope and function.

Required Healthcare Exclusion Databases

Certain databases carry clear regulatory expectations. Screening against them is not optional.

OIG List of Excluded Individuals and Entities (LEIE)

The LEIE is maintained by the U.S. Department of Health and Human Services Office of Inspector General.

• Screening is mandatory for participation in federal healthcare programs.
• Updated monthly.
• Individuals or entities listed are prohibited from receiving payment from federal healthcare funds.

Failure to screen against the LEIE exposes organizations to significant financial and enforcement risk.

System for Award Management (SAM)

SAM is a federal debarment database maintained by the General Services Administration.

• Covers entities barred from federal contracting.
• Not healthcare-specific but relevant for federally funded organizations.

Many compliance frameworks include SAM screening as part of a defensible review process.

State Medicaid Exclusion Lists

State Medicaid programs maintain independent exclusion authority.

• Update frequency and format vary by state.
• Some exclusions may appear at the state level before federal publication.

For multi-state organizations, this fragmentation increases complexity and increases the importance of structured screening processes.

FACIS vs. OIG, SAM, and State Exclusion Lists

Key Differences at a Glance

In an audit scenario, understanding these distinctions becomes consequential. Regulators expect clarity about which databases are required and how additional sources are incorporated.

Why FACIS Alone Is Not Sufficient for Healthcare Compliance

Regulatory Screening Requirements

Federal guidance requires screening against:

• OIG LEIE
• SAM
• Applicable state Medicaid exclusion lists

FACIS does not replace these obligations. It complements them.

Compliance leaders should approach exclusion screening as a layered control, not a single-source solution.

Risk of Compliance Gaps

Over-reliance on any one database creates exposure.

Common vulnerabilities include:

• Missing state-level exclusions
  
• Manual reconciliation errors
  
• Incomplete coverage of disciplinary actions
  
• Inconsistent documentation practices

In regulatory reviews, it is often not just whether screening occurred, but whether it was structured, consistent, and defensible.

Where FACIS Adds Value

When integrated appropriately, FACIS enhances visibility beyond formal exclusion lists.

Expanded Risk Visibility

FACIS may surface:

• License restrictions
  
• Disciplinary actions
  
• Early-stage enforcement findings

These records provide a broader context for credentialing, contracting, and risk assessment decisions.

Expanded visibility supports proactive governance, not reactive remediation.

Vendor and Third-Party Due Diligence

Healthcare compliance extends beyond clinicians.

Organizations increasingly screen:

• Vendors
  
• Contractors
  
• Non-clinical workforce members

FACIS can contribute to enterprise-wide oversight strategies by expanding sanction visibility across affiliated entities.

Pre-Credentialing and Investigative Screening

Credentialing and investigative workflows often require more than confirmation of exclusion status.

Broader sanction intelligence supports:

• Early risk detection
  
• Internal review processes
  
• Strengthened documentation

This layered approach aligns with responsible compliance leadership.

Best Practices for Using FACIS With Other Exclusion Databases

Layered Screening Strategy

A defensible screening model typically includes:

• OIG LEIE
  
• SAM
  
• State Medicaid exclusion lists
  
• FACIS as a complementary intelligence layer

Clear workflows should define:

• Frequency of checks
  
• Responsible parties
  
• Documentation standards

Layered screening strengthens audit defensibility.

Continuous Monitoring and Documentation

Monthly screening is widely recognized as a minimum standard. Many organizations implement ongoing healthcare monitoring to reduce exposure between update cycles.

Equally important is documentation:

• Screening logs
  
• Match resolution protocols
  
• Audit-ready reporting

Governance maturity is demonstrated through consistency, not just database selection.

The Importance of Data Accuracy in Exclusion Screening

Common Data Challenges

Even with appropriate sources, exclusion screening presents operational challenges:

• Name variations and aliases
  
• Common surnames
  
• False positives
  
• Fragmented state data
  
• Timing gaps between updates

Without structured validation processes, both missed matches and unnecessary escalations can occur.

Strong compliance programs rely on accurate, curated data and disciplined review procedures to protect patients and safeguard reimbursement integrity.

FACIS Is a Complement, Not a Replacement

FACIS plays a meaningful role in the healthcare exclusion landscape, but it is not a substitute for required government databases.

OIG, SAM, and state exclusion lists remain foundational to regulatory compliance. FACIS enhances visibility by consolidating and structuring broader sanction intelligence.

For healthcare compliance leaders, the most defensible strategy is layered, clearly documented, and consistently applied. Understanding how each database functions and how they work together within a structured healthcare exclusion screening framework strengthens governance, reduces exposure, and reinforces organizational credibility.

In an environment of increasing scrutiny, clarity and discipline in exclusion screening are not optional. They are essential to sustaining trust in healthcare operations.

Healthcare organizations that employ or contract with excluded individuals face severe civil monetary penalties, repayment of all associated claims, and potential loss of Medicare and Medicaid participation. The stakes are clear: exclusion screening is not optional for any organization receiving federal healthcare funding.

This guide explains what exclusion screening is, why it matters for patient safety and regulatory compliance, who must be screened, which databases to check, how often to perform screenings, and how to build an audit-ready program.

Because screening is only as effective as the data behind it, we also explore how real-time, verified data supports organizations participating in federal and state healthcare programs.

What Is Exclusion Screening in Healthcare?

Exclusion screening is the process of verifying that employees, providers, vendors and contractors, and affiliated parties are eligible to participate in federally funded healthcare programs.

Healthcare organizations must confirm that the individuals and entities they work with do not appear on government exclusion lists. If a party is listed, they are prohibited from receiving payment through Medicare, Medicaid, and similar programs.

In practical terms, exclusion screening ensures your organization does not:

• Submit claims tied to excluded individuals
• Contract with barred providers or suppliers
• Receive reimbursement for services connected to sanctioned parties

Exclusion status applies more broadly than many organizations realize. It can include:

• Clinical providers
• Administrative or billing staff
• Executives and board members
• Vendors and contractors
• Volunteers and trainees

Even individuals who never treat patients directly can create liability if their work connects to claims, billing, or operational functions supported by federal funding.

Government agencies maintain exclusion lists identifying individuals and entities from federally funded healthcare programs who have been barred due to fraud, abuse, misconduct, or other violations. Screening verifies that your workforce and affiliated partners remain eligible.

Who Manages Healthcare Exclusions?

Multiple federal and state bodies share responsibility for maintaining exclusion lists and enforcing participation bans.

The Department of Health and Human Services oversees the Office of Inspector General (OIG), which serves as the primary federal exclusion authority. 

The OIG has authority under Sections 1128 and 1156 of the Social Security Act to exclude individuals and entities from all federal healthcare programs.

The primary agencies include:

• OIG – Maintains the List of Excluded Individuals/Entities (LEIE)
• GSA – Operates the System for Award Management (SAM.gov), which tracks federal debarments
• State Medicaid agencies – Maintain their own exclusion lists and can prohibit participation for reasons beyond federal requirements
• CMS –  Publishes the Medicare Preclusion List, this list overlaps with but differs from the OIG’s List of Excluded Individuals/Entities (LEIE).

Why Exclusion Screening Matters

Three fundamental concerns drive the need for exclusion screening in healthcare settings:

• Protecting patients
• Meeting regulatory compliance obligations
• Shielding organizations from severe financial consequences

Patient Safety and Quality of Care

Individuals end up on exclusion lists for serious reasons. Common causes include:

• Healthcare fraud convictions
• Patient abuse or neglect
• Professional misconduct involving controlled substances
• Delivery of substandard care

Screening helps ensure compliance with exclusion requirements while confirming that only qualified, vetted professionals provide patient care. CMS states that exclusion lists exist “to ensure patient protections and safety and to protect the Trust Funds from prescribers and providers identified as bad actors.”

When organizations verify exclusion status, they create an important safeguard against individuals whose past conduct raises legitimate concerns about patient welfare.

Regulatory and Legal Compliance

Federal and state regulations prohibit organizations to employ or contract with excluded parties. The Social Security Act Section 1128, OIG guidance documents, and state Medicaid contracts all establish these obligations.

Many states go further by mandating monthly screenings and requiring written certification. The Affordable Care Act Section 6501 extended Medicaid exclusion requirements across all states. Courts have also held that failure to screen can constitute constructive knowledge under the False Claims Act. Exclusion regulations apply to all entities receiving federal healthcare funding.

Financial and Reputational Risk

The consequences of exclusion violations can be severe.

Organizations may face:

• Civil monetary penalties
• Mandatory claim repayment
• Potential program exclusion
• False Claims Act liability
• Reputational damage

Financial penalties can apply per item or service furnished by an excluded individual. In some cases, penalties are compounded with treble damages.

Beyond direct costs, investigations disrupt operations, strain internal resources, and weaken stakeholder trust. For large health systems, health plans, pharmacies, and life sciences organizations, even temporary disruption can have enterprise-wide impact.

Consequences of Noncompliance

Organizations that fail to screen employees and vendors face a variety of potential consequences:

• Civil monetary penalties – Fines assessed per item or service, with potential treble damages
• Claim repayment – All reimbursements connected to the excluded individual must be returned to the government
• Program exclusion – The organization itself can lose participation in federal healthcare programs
• False Claims Act liability – Inadequate screening may be interpreted as deliberate ignorance or reckless disregard

The OIG has consistently maintained that organizations bear responsibility for knowing whether their workforce includes excluded parties. Claiming ignorance provides no protection when an organization could have discovered the exclusion through proper screening.

Once excluded from participating in federal programs, individuals face a lengthy reinstatement process requiring formal application to the OIG. During that time, operational workflows may stall, claims may be denied, and contractual relationships may be jeopardized.

A proactive screening strategy significantly reduces these exposures and supports long-term compliance stability.

Who Should Be Screened?

The OIG applies a broad interpretation of screening requirements.  Any individual whose role touches reimbursement or operations tied to federal healthcare dollars should be screened. This includes:

This includes:

• Licensed Clinical providers
• Administrative and billing staff
• Board members and executives
• Volunteers and trainees
• Vendors and contractors

Service providers of all types require verification, from pharmacist to administrator. The payment prohibition extends further than many organizations realize.

An individual who never sees a patient can still taint a claim. Preparing surgical equipment, entering billing information, or performing other behind-the-scenes tasks all create potential exposure.

Any organization receiving federal or state healthcare funding must check exclusion status. Hospitals, health plans, pharmacies, long-term care facilities, laboratories, and similar entities all fall within this scope.

Which Exclusion Lists Must Be Checked?

No single database captures all exclusions. Organizations must check multiple federal and state sources to achieve comprehensive compliance coverage. Comprehensive screening addresses both federal and state exclusion requirements.

Federal Exclusion Lists

Three primary federal databases form the foundation of exclusion screening:

• OIG LEIE – The List of Excluded Individuals/Entities serves as the central federal exclusion registry
• SAM.gov: The System for Award Management tracks debarment from federal contracts and procurement activities
• CMS Preclusion List: Applies specifically to Medicare Advantage and Part D plan participants

Both OIG and SAM databases must be checked for complete federal coverage. Thorough screening programs also check additional federal sources. OFAC sanctions lists, DEA registrations, and FDA debarment records round out a more complete healthcare sanction screening approach.

State Medicaid Exclusion Lists

More than 40 states operate exclusion lists independent of the federal LEIE. These lists may include entities from federally funded healthcare programs that are not yet reflected in federal databases.

Because reporting timelines differ, entities from federally funded healthcare programs at the state level may not appear immediately in federal systems. Formats vary widely, from PDFs to spreadsheets, creating administrative burden and increasing the likelihood of gaps when managed manually.

Solutions like healthcare background screening consolidate these fragmented sources into unified, verified datasets that address both federal and state health care programs.

How Often Should Exclusion Screening Be Performed?

The OIG recommends screening:

• At the time of hire or contracting
• At least monthly thereafter

Monthly screening aligns with LEIE update cycles and satisfies many state contract requirements. NCQA standards similarly require monthly review of sanctions and exclusions.

However, many leading organizations are moving toward continuous monitoring models through OIG exclusion monitoring. This approach minimizes the compliance exposure that can accumulate between scheduled screening runs and helps ensure compliance with federal requirements.

Challenges of Manual Exclusion Screening

Manual screening presents operational challenges, particularly for organizations with thousands — or millions — of records to monitor.

Common limitations include:

• Name-only searches that produce excessive false positives. Here, maiden names, hyphenated surnames, nicknames, aliases, and common names require manual investigation.
• Inconsistent state database formats
• Limited batch search capabilities
• Administrative time spent reconciling aliases and variations

As workforce size grows, manual processes strain compliance teams and increase the likelihood of oversight.

State lists compound these problems with inconsistent formats, incomplete data fields, and irregular update schedules. Repeating this entire process monthly for every employee, contractor, and vendor quickly becomes unsustainable at scale.

How Automated Exclusion Screening Supports Compliance

Automated exclusion screening platforms consolidate federal and state sources into unified workflows.

Advanced matching logic incorporates multiple identifiers, including name, date of birth, NPI, and address, reducing false positives while increasing accuracy.

Real-time monitoring capabilities allow organizations to:

• Receive alerts when exclusion status changes
• Maintain centralized documentation
• Generate audit-ready reports
• Integrate data via API, portal, or file exchange

Automation not only reduces administrative burden but strengthens oversight for individuals and entities from federally regulated programs.

When implemented strategically, automated screening supports faster onboarding, streamlined credentialing, and stronger payment integrity controls.

Best Practices for an Effective Exclusion Screening Program

Strong exclusion screening programs share several characteristics:

• Screen comprehensively – Cover all employees, contractors, vendors, board members, volunteers, and trainees without exception
• Screen at the right times –  Verify status before hire or contracting and at least monthly, with continuous monitoring as the goal
• Check all required databases – Include federal sources (LEIE, SAM, CMS Preclusion List) plus all applicable state Medicaid exclusion lists
• Document everything – Maintain detailed records of all screening activities, databases checked, results, and any follow-up actions

Exclusion status alone does not confirm that a provider holds valid, active licensure. Combining exclusion screening with healthcare license verification creates a more complete compliance picture.

When evaluating screening partners, organizations should consider security certifications such as HITRUST, SOC 2/Type 2, and ISO as indicators of data protection practices.

Making Exclusion Screening a Compliance Priority

Exclusion screening is a critical safeguard within comprehensive compliance programs. It protects patients, preserves reimbursement eligibility, and reduces exposure to enforcement action.

For organizations receiving federal funding, screening is essential to maintaining operational stability and regulatory standing. The strength of your program ultimately depends on the accuracy, timeliness, and completeness of the data behind it.

Verisys delivers real-time, verified healthcare data that supports credentialing, monitoring, and risk mitigation at scale. Explore our provider data compliance solutions to learn how we help healthcare organizations stay compliant with confidence.

Sources

1. National Committee for Quality Assurance. (n.d.). Health plan accreditation (HPA) FAQs. https://www.ncqa.org/programs/health-plans/health-plan-accreditation-hpa/faqs/all/

Why Eligibility and Payment Integrity Matter More Than Ever

Every improper payment tells a story,  not just about a claim, but about the controls behind it.

For health plans, eligibility and payment integrity are no longer back-office functions. They are board-level accountability issues tied to financial stewardship, regulatory exposure, and operational credibility.

As CMS scrutiny intensifies and audit activity increases, the question is no longer whether eligibility is being checked. It is whether eligibility is being validated in context, with the full picture of provider risk in view.

Rising Claim Denials and Overpayments

Improper payments continue to strain health plan performance. Inaccurate eligibility validation, outdated provider information, and incomplete risk signals can result in:

• Claims paid for ineligible or non-compliant providers
• Retroactive reversals and recovery efforts
• Increased administrative overhead
• Escalating denial rates

Each denied or recouped claim carries downstream consequences — provider abrasion, member disruption, and internal rework. As volumes increase, even small gaps in eligibility validation can create significant financial exposure.

Regulatory and Audit Pressure

Regulators are placing greater emphasis on payment integrity controls. CMS oversight, state audits, and public reporting initiatives require plans to demonstrate structured, defensible eligibility verification processes.

Payment integrity reviews increasingly evaluate:

• How eligibility is validated at the point of claim
• Whether licensure and sanction status are incorporated
• Documentation of monitoring practices
• Controls surrounding delegated networks

For health plan leadership, eligibility and payment integrity are no longer isolated compliance functions. They are enterprise accountability issues.

How the Market Approaches Eligibility and Payment Integrity

Most traditional market approaches rely on established but fragmented models.

Point-in-Time Eligibility Checks

Eligibility is often validated at the moment of service or claim submission. These checks typically confirm enrollment status and coverage parameters.

However, point-in-time validation frequently operates in isolation, disconnected from broader provider risk indicators such as licensure restrictions, sanctions, or exclusions.

Rules-Based Payment Integrity Programs

Many payment integrity programs are structured around post-payment review models. Algorithm-driven rules flag anomalies after claims have been adjudicated.

While recovery programs can recapture funds, they are inherently reactive. Improper payments are identified only after they occur, requiring manual intervention and recovery cycles.

Fragmented Vendor Ecosystems

Eligibility verification, sanctions screening, licensure checks, and payment integrity analytics are often handled by separate vendors.

This fragmented model can result in:

• Disconnected data sources
  
• Inconsistent update cycles
  
• Operational handoffs between teams
  
• Limited visibility into consolidated provider risk

The result is a series of point solutions rather than an integrated governance framework.

Limitations of Traditional Market Approaches

As oversight increases, limitations in traditional models become more apparent.

Reactive vs. Preventive Integrity Models

Recovery-based integrity programs focus on identifying improper payments after funds have been disbursed. This approach:

• Requires retroactive adjustments
  
• Generates administrative rework
  
• Strains provider relationships

Preventive models, by contrast, seek to identify risk signals before payment occurs, reducing both financial exposure and operational disruption.

Data Silos and Inconsistent Sources

When eligibility checks are separated from licensure monitoring and sanctions data, plans may lack a complete view of provider risk.

Common challenges include:

• Version inconsistencies across systems
  
• Timing gaps between updates
  
• Duplicate or conflicting provider records

Without unified intelligence, eligibility validation may confirm enrollment status while missing other compliance risks.

Limited Visibility Into Provider Risk

Eligibility status alone does not reflect a provider’s full risk profile. Exclusions, licensure restrictions, disciplinary actions, and sanction updates can materially affect claim eligibility.

When these signals are disconnected, plans operate with partial visibility.

Verisys’ Approach to Eligibility and Payment Integrity

Verisys approaches eligibility and payment integrity through integrated provider intelligence rather than isolated point checks.

Eligibility in the Context of Provider Risk

Eligibility validation is most effective when contextualized within broader provider data. Verisys aligns eligibility verification with:

• Current licensure status
• Sanctions and exclusions
• Enrollment and opt-out indicators

By incorporating multiple authoritative sources into eligibility workflows, plans gain a more complete view of provider status at the point of claim. 

This integrated model is foundational to Verisys’ healthcare payment integrity solution, which connects eligibility checks directly to continuously monitored provider intelligence.

Preventive Payment Integrity

Instead of relying solely on post-payment recovery, Verisys supports pre-adjudication validation. Eligibility and provider risk signals are integrated earlier in the claims lifecycle.

This preventive model reduces:

• Improper payments
• Recovery cycles
• Administrative correction costs

Preventive controls strengthen financial stewardship while improving operational efficiency.

Unified Provider Intelligence

At the core of Verisys’ model is a consolidated provider data foundation. Rather than managing multiple disconnected feeds, plans operate from unified intelligence that:

• Aggregates licensure, sanctions, exclusions, and enrollment data
• Supports continuous monitoring
• Reduces reconciliation across silos

Unified provider intelligence enhances both eligibility accuracy and payment integrity maturity.

Key Differences: Market vs. Verisys

Point Solutions vs. Integrated Intelligence

Traditional market models often rely on separate tools for eligibility, sanctions, and payment analytics. Verisys integrates these signals within a single provider-centric framework.

Post-Payment Recovery vs. Pre-Payment Prevention

Recovery programs address improper payments after funds are disbursed. Verisys emphasizes validation prior to adjudication, reducing exposure before it materializes.

Static Data vs. Continuous Monitoring

Static eligibility files and periodic updates can create gaps. Continuous monitoring ensures provider status changes are reflected in near real time, supporting proactive decision-making.

Impact on Payment Integrity Outcomes

Differentiation is most meaningful when tied to operational results.

Fewer Improper Payments

Preventive eligibility validation reduces the volume of claims requiring reversal or recovery. Lower improper payment rates translate to reduced financial leakage and fewer administrative interventions.

Reduced Audit Findings and Rework

Integrated, documented controls strengthen audit defensibility. When eligibility validation incorporates licensure and sanction status, plans are better positioned to respond to regulatory review.

Reduced rework also decreases internal resource strain.

Improved Member and Provider Experience

Fewer retroactive denials and payment corrections contribute to smoother provider interactions and fewer member disruptions.

Payment integrity maturity supports not only compliance but also overall plan stability.

Use Cases Where Verisys Delivers the Most Value

High-Volume Claims Environments

Large health plans processing high claim volumes face amplified exposure from small eligibility gaps. Integrated validation scales more effectively than manual reconciliation.

Complex Provider Networks and Delegated Models

Delegated entities introduce additional risk layers. Unified provider intelligence improves oversight across complex network structures.

Organizations Under Audit or Regulatory Review

Plans facing heightened oversight benefit from documented, preventive controls and consolidated provider data frameworks.

Choosing the Right Eligibility and Payment Integrity Strategy

Questions Organizations Should Ask

Health plan leaders evaluating their current approach may consider:

• Is eligibility validated in isolation, or in the context of provider risk?
• Is payment integrity primarily reactive or preventive?
• Are provider data sources unified or fragmented?
• Is monitoring continuous or periodic?

The answers to these questions often reveal the maturity of a plan’s payment integrity framework.

Moving Beyond Eligibility Checks to True Payment Integrity

Eligibility verification alone is no longer sufficient in today’s regulatory climate. Health plans must look beyond point-in-time checks and recovery-driven models toward integrated, preventive strategies.

By aligning eligibility validation with comprehensive provider intelligence, plans strengthen governance, reduce improper payments, and improve audit defensibility. Verisys’ healthcare payment integrity solution reflects this integrated approach — connecting eligibility, provider risk, and continuous monitoring within a unified data framework.

In an environment of rising scrutiny and operational complexity, moving beyond isolated eligibility checks to true payment integrity is not just an efficiency decision — it is a strategic imperative.

Hiring a new practitioner is a complex process for many healthcare entities. A physician onboarding checklist can help guide this process by clearly outlining the key steps required to onboard a new provider. For a physician or nurse signing on as a new provider, adjusting to a new workplace can also be difficult. A clear onboarding process can make the transition easier for everyone.

Although onboarding processes vary from one organization to another, every provider should have a clear idea of what steps need to be followed; after all, healthcare best practices don’t happen by accident. A checklist can help onboarding go more smoothly, and a streamlined onboarding process benefits the entire practice.

Why You Need a Physician and Nurse Onboarding Guide

A physician onboarding plan isn’t just nice to have, it’s a necessity. Some practices and practitioners may reason that their time is better spent on their area of expertise rather than learning about business processes. However, when onboarding is done right, it can lead to improved outcomes for everyone.

The same holds true for other parts of provider onboarding. Onboarding best practices include creating online portals so new physicians can supply as much documentation as possible prior to their first day of work. In the following Physician Onboarding Plan (which can also serve as a Physician Assistant (PA) or Nurse Practitioner (NP) Plan), many elements can easily be uploaded to an online portal, leaving the provider and staff more time to focus on other practical aspects of onboarding.

Benefits of a Successful Onboarding Process

• Retention: A smooth onboarding experience shows new staff you value their comfort and success, building loyalty and improving retention while reducing long-term turnover costs.
• Efficiency: A consistent onboarding workflow helps teams follow the same procedures, allowing new staff to understand day-to-day processes more quickly.
• Collaboration: Early relationship-building during onboarding establishes trust faster—especially when all staff receive the same training and expectations.
• Morale: Prioritizing training and teamwork supports career growth, job satisfaction, and a positive workplace culture.
• Patient satisfaction: When employees feel engaged and aligned, it shows, leading to better teamwork and a more positive patient experience.

A practitioner dissatisfied with the onboarding process is more likely to leave within the first year. This could negatively impact your practice’s culture, patient interaction, communication, and ultimately, your bottom line. Therefore, a credentialing and onboarding plan for all new practitioners can make a significant difference.

Physician Onboarding Checklist and Key Requirements

This list is not an exhaustive one. Your credentialing and onboarding healthcare plan may differ according to the needs and services of your practice, the type of practitioner you hire, and individual state laws.

Credentialing and Onboarding for Physicians and Nurses

Credentialing and privileging a new practitioner can take months. For a new physician, credentialing includes obtaining the following documentation:

• State license
• Board qualification/certification status
• Surgical logs
• Documentation of hospital privileges
• 10-year insurance claims report
• Updated curriculum vitae
• ACLS/BLS certification
• DEA certificate
• Immunization records
• School diploma
• Professional reference(s)
• Residency diploma
• Driver’s license
• Social Security card

For Physician Assistants and Advanced Practice Registered Nurses, documentation is similar, but with some key differences. Credentialing is legally required if the practitioner will be performing direct patient care. It can include:

• State license
• Updated curriculum vitae
• Immunization records
• Diploma and transcripts
• Professional references
• Driver’s license
• Social Security card
• Focused Professional Practice Evaluation
• An Ongoing Professional Practice Evaluation

As part of healthcare onboarding best practices, many organizations begin credentialing and privileging months before a new physician or nurse practitioner starts practicing. A well-organized process, combined with a trusted third-party provider like Verisys, can help move credentialing forward more efficiently. Completing required documentation in advance allows delays to be identified and resolved early, leaving more time for the rest of the onboarding process. In the Physician Onboarding Plan below (which can also be used for physician assistants and nurse practitioners), many required elements can be submitted digitally, allowing providers and staff to focus on practical, in-person onboarding needs.

Streamline Physician Onboarding With Verisys

Healthcare onboarding can be a long and complicated process due to regulatory requirements, but it’s a worthwhile investment for your providers, your practice, and your patients. Verisys can save you time and money by making your healthcare onboarding process much more efficient. With our healthcare provider datasets and technology, we can do the work behind the scenes to help you follow best practices in provider credentialing and onboarding. Contact Verisys today to learn how we can expedite these processes for you.

Learn more about how Verisys can assist your HCOs in meeting all government and regulatory standards.

Human Capital Management (HCM) in the healthcare industry is the strategic approach to recruiting, managing, developing, and retaining healthcare professionals to support high-quality patient care, operational efficiency, and organizational performance. In a complex and highly regulated industry, healthcare HCM extends beyond traditional HR to include workforce planning, credentialing, compliance, training, and engagement—ensuring the right clinicians and staff are in place to meet evolving patient and system needs.

Given the critical role of healthcare providers in delivering care, HCM in this context goes beyond traditional HR functions to include strategies that ensure the recruitment, retention, development, and engagement of skilled healthcare professionals. The goal is to improve patient care quality, operational efficiency, and organizational performance.

HCM in healthcare is about strategically managing the most valuable asset of any healthcare organization—its people—to ensure the highest level of patient care and organizational success. 

Key Strategies of Healthcare Human Capital Management (HCM)

Recruitment and Onboarding:

Attracting and hiring qualified healthcare professionals who align with the organization’s culture and values. Effective onboarding processes are essential to integrate new hires into the healthcare system quickly and efficiently.

Talent Management:

Developing and retaining skilled healthcare practitioners by offering continuous education, professional development opportunities, and clear career pathways. This is crucial in a field where ongoing learning and adaptation to new medical practices and technologies are vital.

Workforce Planning:

Anticipating future staffing needs based on patient care demands and healthcare trends. This involves strategic scheduling, forecasting workforce requirements, and ensuring a balanced mix of skills and specialties to meet those needs.

Performance Management:

Implementing systems to evaluate and enhance healthcare workers’ performance, including setting objectives, providing regular feedback, and recognizing achievements. This is critical for maintaining high standards of patient care and operational effectiveness.

Employee Engagement and Satisfaction:

Fostering a positive work environment that motivates staff, reduces turnover, and enhances job satisfaction. Engaged employees are more likely to deliver higher quality patient care and contribute to a positive organizational culture.

Compliance and Credentialing:

Ensuring all healthcare professionals meet the necessary licensure, certification, and accreditation standards. This is fundamental in healthcare to maintain legal compliance and uphold the highest standards of patient safety and care quality.

Diversity and Inclusion:

Creating an inclusive workplace that values diversity among healthcare professionals, which can lead to more innovative solutions and a more compassionate understanding of the diverse patient population served.

How HCM Goes Beyond HR

Human capital management treats employees as long-term strategic assets rather than short-term operational costs, recognizing that workforce stability and expertise directly impact patient care and organizational performance. 

HCM aligns workforce planning with broader organizational goals and patient care demands, ensuring the right people with the right skills are available when and where they are needed most. By leveraging workforce data and analytics, human capital management enables healthcare organizations to anticipate staffing needs, identify risks early, and prevent gaps in care before they affect patients or staff.

 Advancing Human Capital Management in Healthcare

In essence, HCM in healthcare is about strategically managing the most valuable asset of any healthcare organization—its people—to ensure the highest level of patient care and organizational success. Given the complex and dynamic nature of healthcare, effective HCM practices are vital for adapting to changes, addressing challenges, and seizing opportunities in the healthcare landscape. Verisys’ HCM support helps organizations through its advanced provider compliance solutions and data management solutions. Our comprehensive suite of services, including workforce verification and monitoring, credentialing, and provider data management services delivers effective HCM operations.

Learn how Verisys can help with your HCM –>

Healthcare exclusion monitoring is critical to healthcare compliance because employing or contracting with an excluded provider can result in severe financial penalties, loss of federal program eligibility, and reputational damage. Federal and state exclusion lists identify individuals barred from participating in government-funded healthcare programs, and failure to properly screen and continuously monitor providers puts organizations at significant regulatory risk. This article explains why exclusion monitoring matters and how technology simplifies ongoing screening to reduce administrative burden and maintain compliance.

What Is A Healthcare Exclusion? 

A healthcare exclusion is an administrative action taken against an individual or entity by the Department of Health and Human Services (HHS), Office of Inspector General (OIG), or a state Medicaid agency. An exclusion means that an individual or entity is excluded from receiving any money from federal or state healthcare programs. Healthcare exclusions apply to any items or services a provider may furnish, order, or prescribe.

Compliance Requirements for Healthcare Exclusions

In sections 1128 and 1156 of the Social Security Act HHS OIG mandates that healthcare organizations do not hire or do business with “excluded or sanctioned individuals or entities.” The OIG places exclusions into two categories: mandatory and permissive exclusions. If a provider is included on either list it prevents them from being reimbursed by federally-funded healthcare programs.

What is Exclusion Monitoring in Healthcare? 

Exclusion monitoring is the continuous monitoring of state and federal exclusion lists to verify that an employee or provider is in good standing. Hiring a provider in violation of exclusion lists may result in fines and civil monetary penalties (CMP) which start at $10,000 per item claimed or service provided by the excluded party. Implementing exclusion monitoring can be difficult because hundreds of lists are constantly being updated. Technology can ease this burden by automatically and continuously monitoring all new providers and current employees for sanctions and/or exclusions.

How Many Exclusion Lists Are There?

The most familiar safeguard for healthcare credentialing departments is the OIG’s List of Excluded Individuals and Entities, which identifies individuals and entities excluded from participation in Medicare, Medicaid, and all other federal healthcare programs. Providers are removed from the list only after reinstatement. In addition to the LEIE, exclusions may also appear on the General Services Administration (GSA) or System for Award Management (SAM) lists.

Most states (42 total) also maintain Medicaid exclusion lists that should be monitored regularly, as reporting delays to HHS OIG can take months. Failing to check state exclusion lists and hiring or retaining an excluded provider places healthcare organizations out of compliance and subject to enforcement actions.

How Verisys Catches Exclusions in Healthcare 

Continuously monitoring your staff and providers for exclusions and maintaining compliance can be a daunting task for healthcare administrators. However, with the appropriate technology for your organization, continuous monitoring of all federal and state exclusion lists can be automated.

Verisys offers the most comprehensive data set for screening and monitoring healthcare providers for exclusions and sanctions. With software from FACIS solutions to provider data management, that pulls data from more than 5,000 primary sources, Verisys will verify and monitor your provider’s credentials and notify you of exclusions or adverse actions affecting your staff. As the most trusted and nationally used database for screening and monitoring healthcare providers, Verisys is prepared to keep your patients and your organization safe from excluded providers.

What Is Pharmacy Compliance?

In essence, pharmacy compliance is an ongoing commitment to abide by all laws, regulations, and professional standards that guide how a pharmacy operates. The goal is to ensure that every prescription is filled accurately, every patient’s personal information remains confidential, and every process meets the highest safety and quality standards. 

Compliance in the pharmaceutical industry shouldn’t be thought of as merely a legal requirement; it also forms the foundation for patient trust and operational stability. A compliant pharmacy not only avoids steep fines but also demonstrates a dedication to the highest standards of care.

Pharmaceutical compliance spans several categories, each of which is important for conducting safe and lawful operations:

• Legal compliance: Meeting federal, state, and local laws that govern pharmacy practice.
• Safety compliance: Following proper storage, handling, and dispensing protocols to protect patients.
• Billing compliance: Ensuring claims are accurate, truthful, and in accordance with payer requirements.
• Data privacy compliance: Protecting patient health information in line with Health Insurance Portability and Accountability Act (HIPAA) regulations.

Multiple government agencies oversee pharmacy operations, each with its own focus and authority. They dictate how medications are prescribed, dispensed, billed, and documented, and together create a layered framework designed to protect patients, prevent medication misuse, and ensure that pharmacies are operating within the constraints of the law. Understanding who these key regulators are, as well as the scope of their oversight, is critical for maintaining good compliance practices.

• Drug Enforcement Administration (DEA): Regulates the handling, recordkeeping, and reporting of controlled substances. DEA verification and monitoring solutions help pharmacies stay compliant with DEA requirements.
• Food & Drug Administration (FDA): Oversees medication safety, labeling, and manufacturing standards.
• Centers for Medicare & Medicaid Services (CMS): Sets billing, reimbursement, and fraud prevention guidelines.
• Boards of pharmacy (state level): Establishes state-specific licensure and operational requirements.

Core Areas of Pharmacy Compliance

Maintaining safe operations and regulatory success depends on several interconnected areas of pharmacy success. One of the most visible areas is prescription accuracy and management of controlled substances. Every prescription must be reviewed, verified, and dispensed according to established protocols laid out by the FDA, DEA, and CMS. For controlled substances, the DEA has stringent requirements on ordering, storage, dispensing, and recordkeeping. These must be followed to a T, as even small violations can have serious consequences, such as civil fines, suspension of DEA registrations, or loss of professional licenses. 

Patient confidentiality represents another cornerstone of compliance. By nature, pharmacies handle highly sensitive health information every day, and HIPAA regulations require safeguards to protect this data from unauthorized access or disclosure. Digital and physical records must remain secure at all times, and all pharmacists and other staff should understand the gravity of maintaining patient privacy.

Compliance oversight also includes billing practices. All claims must be accurate, supported by proper documentation, and free from any form of misrepresentation. Errors, whether intentional or not, can trigger audits and fines, as well as risk reputation damage.

Additionally, effective inventory tracking and diligent recordkeeping are key to ensuring that medications are properly stored, dispensed, or disposed of before expiration, and reconciled regularly. A strong and compliant system reduces waste, prevents diversion, and protects patients by ensuring they receive only safe and effective medicines. 

Common Pharmacy Compliance Risks

Even the best-intentioned pharmacies aren’t immune to compliance challenges. Regulations are complex, requirements frequently change, and day-to-day operations move quickly, creating ample opportunities for mistakes to happen. However, most compliance issues stem from a few common problem areas, and with the right mitigation strategies, they can be addressed before escalating into violations.

Documentation Errors

Complete and accurate recordkeeping is arguably one of the most fundamental aspects of pharmacy compliance. Every prescription, billing entry, and inventory record must be logged in a way that complies with legal and regulatory standards. Incomplete logs, missing signatures, or inconsistent entries can raise red flags during audits or inspections. These kinds of issues can lead to denied insurance claims, fines, or even disciplinary action from federal agencies or state boards. A good compliance program should implement standardized documentation procedures and routine quality checks to prevent errors from slipping through the cracks.

Controlled Substance Violations

Handling controlled substances carries heightened scrutiny from the DEA and state regulators. Improper storage, incomplete or inconsistent inventory counts, or dispensing without proper documents can lead to serious violations and trigger more frequent audits. Even seemingly minor oversights, such as failing to update records immediately, are taken seriously. These lapses not only jeopardize the pharmacy’s license but also put patient safety at risk. By having a well-enforced chain-of-custody protocol and performing frequent internal audits, pharmacies can ensure proper compliance.

Training Gaps

Preventing non-compliance consequences depends on the knowledge of all staff who are involved in day-to-day pharmacy operations. Without regular and comprehensive training, employees may be unaware of updated regulations, new security protocols, or changes in billing requirements. These knowledge gaps increase the likelihood of mistakes that could have easily been avoided. It can help to build a culture of continuous learning through scheduled training sessions, refresher courses, and easily accessible reference materials. 

By proactively addressing these common risk areas, pharmacies can significantly reduce the odds of encountering regulatory or legal trouble down the road. Unfortunately, compliance isn’t a one-time task but rather an ongoing process that requires vigilance, consistency, and a dedication to best practices.

How To Strengthen Your Pharmacy Compliance Program

A strong healthcare compliance program often starts with regular assessment. Conducting internal audits and mock inspections allows pharmacies to spot potential issues early — before they attract the attention of regulators. These reviews should cover critical areas, such as documentation, controlled substance handling, billing accuracy, and patient privacy safeguards. Treat these audits as learning exercises rather than punitive exercises, and encourage staff to view compliance as part of daily operations rather than a separate obligation.

Clear, well-documented protocols give staff the guidance they need to perform tasks correctly, every time. When every team member knows exactly how to perform key tasks, like filling prescriptions or securing patient records, there’s far less room for error. Consider appointing a dedicated compliance officer to ensure there is a dedicated point person responsible for oversight, training, and addressing concerns promptly.

Technology can also help mitigate non-compliance risks. AI-powered compliance software can track inventory, flag potential billing errors, and secure patient data in line with HIPAA requirements. Integrated systems can help eliminate information silos and make it easier to maintain accurate and up-to-date records.

By combining consistent compliance monitoring, detailed procedures, and smart technology, pharmacies can foster a culture where pharmacist guideline compliance is second nature, protecting patients, fostering trust, and enabling regulatory success.

Conclusion: Prioritizing Pharmacy Compliance

Strong pharmacy compliance not only protects patient safety and your license but also preserves the trust your community places in your business. By regularly reviewing the process, investing in staff training, and leveraging technology, pharmacies can stay ahead of regulatory changes and reduce the risk of burdensome and costly violations.

Verisys empowers pharmacies to take this proactive approach with confidence. Our pharmacy compliance and credentialing solutions deliver real-time monitoring, automated documentation support, and robust regulatory resources to help you navigate DEA, FDA, CMS, and state board requirements with ease. 

With Verisys as your compliance partner, you can focus on delivering safe, effective care—knowing your regulatory obligations are met, your risks are minimized, and your reputation is protected.

Sources: 

1. U.S. Food & Drug Administration. Pharmaceutical Inspections and Compliance. https://www.fda.gov/drugs/guidance-compliance-regulatory-information/pharmaceutical-inspections-and-compliance
2. U.S. Centers for Disease Control and Prevention. Health Insurance Portability and Accountability Act of 1996 (HIPAA). https://www.cdc.gov/phlp/php/resources/health-insurance-portability-and-accountability-act-of-1996-hipaa.html
3. American Journal of Health Systems Pharmacy. ASHP Guidelines on Preventing Diversion of Controlled Substances. https://www.ashp.org/-/media/assets/policy-guidelines/docs/guidelines/preventing-diversion-of-controlled-substances.ashx
4. U.S. Drug Enforcement Administration Diversion Control Division. Administrative Actions. https://www.deadiversion.usdoj.gov/administrative_actions.html
5. CMS. Pharmacy Toolkits. https://www.cms.gov/medicare/medicaid-coordination/states/pharmacy-toolkits#prescribing-and-billing
6. Wolters Kluwer. The Critical Role of Effective Record-keeping for DEA Compliance. https://www.wolterskluwer.com/en/expert-insights/the-critical-role-of-effective-record-keeping-for-dea-compliance

Choosing the right credentialing verification vendor directly affects whether your healthcare organization can maintain compliance, protect patient safety, and operate efficiently. This is especially important when credentialing fails, organizations face delays in onboarding, missed exclusions, audit exposure, and legal and financial risk. 

The vendor you select directly impacts your ability to verify provider credentials accurately, monitor sanctions in real time, and protect patients from unqualified or excluded providers.

This complete guide explains what to look for in a credentialing partner or verification vendor and outlines the key factors to consider when choosing a credentialing service provider. Here, we will focus on accuracy, regulatory adherence, automation, and scalability within the credentialing process, helping healthcare leaders select the right credentialing service provider to support long-term operational performance.

Why Choosing the Right Credentialing Vendor Matters

In the healthcare industry, vendor credentialing is the process of validating that individuals and companies meet required standards before they can access facilities, systems, or patients. The vendor credentialing process supports safe and effective patient care by confirming licenses and certifications, conducting background checks, validating qualifications, and verifying adherence to laws and regulations that underpin vendor credentialing compliance.

At a minimum, the credentialing process ensures that vendors and providers meet specific requirements, including:

• Valid licenses and certifications 
• Appropriate qualifications and training 
• Completed background checks 
• Proof of liability insurance 
• Adherence to laws and regulations

For healthcare facilities, this process is critical in healthcare operations and directly supports healthcare compliance audit preparation by ensuring documentation, monitoring, and verification are consistently maintained. Credentialing ensures that only qualified vendors can provide goods and services, particularly when they require access to sensitive systems, clinical spaces, or patient information.

When credentialing is handled poorly, provider onboarding gets delayed and healthcare organizations face compliance risks that can result in regulatory penalties from the OIG, CMS, and state boards.

Additionally, healthcare organizations must maintain strict oversight, as NCQA requires organizations to conduct monthly monitoring of sanctions, exclusions, and limitations¹.

Key Factors to Consider When Evaluating Credentialing Vendors

Selecting the right credentialing service provider requires careful evaluation of their expertise, technology, data quality, and scalability. These core factors ultimately determine whether your vendor can streamline operations while maintaining the compliance standards your organization requires.

Compliance Expertise and Regulatory Knowledge

Compliance is the foundation of any effective credentialing service.

Your credentialing service must demonstrate a deep understanding of regulatory requirements and the ability to apply those standards consistently across healthcare environments.

A credentialing service provider should be able to ensure compliance with oversight from key regulatory bodies, including:

• Office of Inspector General (OIG) exclusion lists 
• Centers for Medicare and Medicaid Services (CMS) requirements 
• National Practitioner Data Bank (NPDB) reporting 
• State licensing boards and accrediting organizations 

For hospital vendor access, credentialing must also account for vendor credentialing requirements that go beyond licensure. These often include:

• Verification of vendor credentials and qualifications 
• Proof of liability insurance 
• Completion of required training and education 
• Ongoing OIG exclusion monitoring to support continuous compliance and protect the organization from regulatory penalties.

Effective credentialing solutions ensure that providers and vendors remain compliant over time, not just at onboarding. This level of oversight protects healthcare organizations from regulatory violations, supports audit readiness, and helps address any issues before they escalate.

Technology and Automation Capabilities

Modern credentialing relies on automation to reduce manual workload, minimize human error, and accelerate review cycles through dashboards, workflow tools, and automated alerts. In practice, credentialing involves coordinating data, documentation, and approvals across teams, systems, and external parties. What automation does is simplify these processes while improving efficiency and accuracy.

For healthcare organizations, the impact is material. The industry demonstrates significant cost savings potential, with $222 billion avoided² annually through automation initiatives that streamline the process of administrative work tied to credentialing, provider enrollment, and compliance oversight.

Your credentialing platforms should offer configurable workflows that adapt to different operational realities, including:

• Supporting healthcare systems, health plans, and specialty providers 
• Managing vendor relationships and credentialing activities across state lines 
• Maintaining audit readiness for a facility’s network

A modern portal also plays an important role by making credentialing data more transparent and easily accessible to internal teams and external partners.

Data Accuracy and Primary Source Verification Quality

Primary source verification validates a credentialing provider’s qualifications directly with issuing authorities, such as state boards and certification bodies. This step is essential for meeting standards and regulations, maintaining quality and compliance, and supporting strong data security across credentialing and provider enrollment workflows.

When evaluating a vendor’s methods, organizations should confirm what is required for vendor credentialing, including sources, refresh frequency, match logic, jurisdictional coverage, error rates, and how third-party data is validated and protected. Verification operates at a significant scale, with NPDB processing 12.5 million queries³ in 2023, making accuracy and infrastructure critical.

High-quality healthcare provider data verification solutions deliver real-time, verified data with proven accuracy by consolidating licensure, sanctions, and exclusions from primary sources. 

Use these questions to evaluate verification quality:

Key Questions to Evaluate PSV Quality

Scalability and Customization

Credentialing workflows must adapt as organizations grow, whether supporting a single-site practice or a national health plan. In many organizations, vendor credentialing is typically managed separately from clinical credentialing, even though both rely on consistent data and oversight.

Scalable solutions should support:

• Multi-entity and delegated credentialing models 
• Alignment with broader supply chain and network governance requirements 
• State-specific rules, specialty requirements, and evolving vendor needs

The right vendor credentialing system helps organizations simplify expansion by ensuring vendors are qualified to provide services without disrupting care delivery or operations.

Customer Support and Service Reliability

Of course, technology alone isn’t enough. Strong customer support, onboarding assistance, and responsive account management are critical resources for healthcare organizations navigating complex credentialing requirements. Medical groups consistently emphasize the importance of holding vendors to written SLAs and defined turnaround targets⁴.

Organizations should ask about:

• Implementation timelines and onboarding support 
• SLAs for uptime and request turnaround 
• Escalation paths for urgent issues 

Dedicated account managers and comprehensive training resources help with vendor credentialing, helping staff remain confident as requirements evolve.

Common Mistakes Healthcare Organizations Make When Choosing a Vendor

Selecting a credentialing partner without adequate due diligence can introduce legal, financial, and operational risk, including broader healthcare legal issues tied to improper access, billing, or compliance failures. Industry research continues to point to a $20 billion opportunity² to reduce waste through better credentialing and compliance processes.

Here are the most critical mistakes to avoid:

• Prioritizing cost over quality or compliance – Choosing the lowest-cost vendor credentialing service often leads to incomplete verification, missed exclusions, and audit failures that cost significantly more long-term.
• Overlooking integration requirements – Failing to evaluate how credentialing platforms integrate with existing systems creates duplicative work and fragmented data across departments.
• Failing to evaluate reporting capabilities – Lack of audit trails, performance tracking dashboards, and compliance reports limits visibility into vendor quality and regulatory adherence.

These missteps often affect credentialing organizations across both clinical and vendor domains, increasing exposure and slowing onboarding.

Questions to Ask When Comparing Credentialing Vendors

To discover what vendor credentialing capabilities truly support compliance, focus on questions that reveal data quality and operational maturity.

Ask how the platform validates data, how exclusions are monitored, and how updates are delivered to ensure that the provider remains eligible over time. Comprehensive healthcare exclusion screening provides monitoring across federal and state exclusion lists with continuous updates. Confirm alignment with NCQA, URAC, TJC, HIPAA requirements, and payer delegation rules.

Finally, request examples of audit-ready reports, compliance dashboards, expiration alerts, and performance metrics that streamline regulatory reviews. Automated healthcare license verification helps organizations maintain compliance without manual tracking, particularly for vendors and providers operating across state lines.

Choosing a Vendor That Strengthens Compliance and Efficiency

The right credentialing service ensures long-term value over short-term cost savings by investing in proven accuracy, regulatory expertise, and automation capabilities that reduce administrative burden and mitigate risk. This strategic approach helps align vendor capabilities with organizational goals, whether for health plans managing provider networks, healthcare systems credentialing medical staff, or specialty providers ensuring regulatory compliance.

Verisys stands as the trusted partner for healthcare credentialing, offering real-time verified data, continuous monitoring, and seamless integration to help healthcare organizations optimize credentialing procedures and maintain industry standards. By choosing the right vendor, you can focus on what matters most: delivering quality patient care while protecting your organization from legal and financial exposure.

Sources

1. NCQA. FAQ Directory: Health Plan Accreditation. https://www.ncqa.org/programs/health-plans/health-plan-accreditation-hpa/faqs/all/?faq=000025418
2. CAQH. The CAQH Index Report. https://www.caqh.org/insights/caqh-index-report
3. U.S. Department of Health & Human Services, HRSA, NPDB. NPDB Insights – March 2024. https://www.npdb.hrsa.gov/enews/March2024Insights.jsp
4. MGMA. Confronting Credentialing, Reappointment Crunch Time in Your Medical Practice. https://www.mgma.com/mgma-stat/confronting-credentialing-reappointment-crunch-time

For healthcare organizations, exclusion screening is not a one-time task, it is an ongoing compliance obligation. The question is not whether you should screen against the OIG exclusion list, but how often you should do it to protect your organization, your patients, and your participation in federal healthcare programs.

Many organizations struggle to balance regulatory expectations with operational realities. Manual screening processes, large or constantly changing workforces, and fragmented data systems make it challenging to maintain consistent supervision. When routine checks fall out of alignment, organizations can face penalties, repayment obligations, and broader compliance risk.

This guide explains how often you should check the OIG exclusion list, why monthly screening is widely considered the standard, and how healthcare organizations can build a defensible, sustainable exclusion monitoring approach.

What Is the OIG Exclusion List?

The OIG exclusion list, formally known as the List of Excluded Individuals and Entities (LEIE), is maintained by the HHS OIG under the Department of Health and Human Services. The Office of Inspector General uses the LEIE to identify individuals or entities that are excluded from participating in Medicare, Medicaid, and other federal health care programs.

The LEIE is an online searchable database that includes:

• Individuals convicted of felony offenses related to healthcare fraud or financial misconduct

• Entities excluded due to patient abuse, neglect, or other unlawful activity

• Parties sanctioned for issues involving controlled substances or improper billing

When an excluded individual or entity appears on the exclusions list, federal healthcare programs may not pay for any item or service furnished by that person or organization, either directly or indirectly. This applies regardless of whether the individual is an employee, contractor, volunteer, or vendor providing goods or services.

Why Regular OIG Exclusion Screening Is Essential

Regular screening against the OIG exclusion list is a foundational element of healthcare compliance. If an organization employs or contracts with an excluded individual and submits claims to Medicare or Medicaid, it may be subject to penalties, repayment demands, or hefty fines, even if the exclusion was unintentional.

Beyond financial exposure, exclusion failures can create broader healthcare compliance issues, affecting audit readiness, payer trust, and patient confidence. Guidance from the Office of Inspector General makes clear that organizations are expected to understand the exclusion status of their workforce and vendors, not just at onboarding, but on an ongoing basis.

Routine exclusion screening supports:

• Compliance with federal healthcare program requirements

• Protection against healthcare non-compliance consequences

• Stronger governance across credentialing vs privileging workflows

For organizations managing provider credentialing, exclusion monitoring is closely tied to other screening activities, such as healthcare license verification and background checks. Gaps in one area often signal risk in others.

How Often Should You Check the OIG Exclusion List?

The short answer is monthly.

While regulations do not always prescribe a single frequency in statutory language, guidance from the Office of the Inspector General and industry practice consistently point to monthly exclusion screening as the standard. The LEIE is updated every month, and organizations are expected to list at least monthly checks as part of a reasonable compliance program.

Conducting an OIG exclusion check monthly helps organizations:

• Identify newly excluded individuals or entities soon after exclusions are imposed

• Detect changes in status, including parties removed from the list

• Maintain compliance across all workforce categories, not just licensed providers

From an operational standpoint, checking the OIG exclusion list monthly aligns with other recurring compliance activities, such as credentialing updates, contract reviews, and provider credentialing cycles. It also reduces the risk of missing name changes, aliases, or mismatches tied to social security number, date of birth, or NPI numbers.

Who Needs to Be Screened?

One of the most common misconceptions about exclusion list screening is that it applies only to physicians or licensed clinicians. In reality, OIG exclusions apply broadly to anyone involved in furnishing or supporting items or services billed to a federal healthcare program.

Healthcare organizations are expected to screen all individuals or entities whose work could affect claims submitted to Medicare and Medicaid.

Employees and Licensed Providers

All employees, clinical and non-clinical, should be included in routine exclusion checks. This includes physicians, nurse practitioners, physician assistants, medical assistants, billing staff, and administrative personnel.

If an excluded employee participates in patient care or supports billing activities for a healthcare program, the organization may face repayment obligations and penalty exposure. Screening licensed providers is also closely tied to provider credentialing, where exclusion monitoring complements license verification and other types of credentialing activities.

Contractors and Vendors

Contractors present a higher risk profile because they are often overlooked in workforce screening workflows. However, the OIG exclusion list applies equally to any contractor or vendor under contract who provides services connected to a federal health care program.

This includes:

• Staffing agencies and locum tenens providers

• Billing vendors and management services organizations

• Suppliers of clinical or administrative goods or services

Failure to screen vendors can result in liability if an excluded individual or entity contributes to claims, even indirectly. This is why exclusion screening is a critical part of vendor oversight and broader provider credentialing and compliance efforts.

Volunteers, Students, and Temporary Staff

Volunteers, students, interns, and temporary workers may not appear on payroll, but they can still create compliance risk. If these individuals support care delivery or access systems tied to billing, they should be included in the screening process.

Closing these gaps helps organizations demonstrate a comprehensive, defensible approach to OIG compliance.

Challenges in Maintaining Routine Screening

Maintaining consistent, monthly OIG screening is easier said than done. Many healthcare organizations struggle with operational barriers that increase the risk of missed exclusions.

Common challenges include:

• Manual searches against a limited exclusion database

• Managing large or frequently changing workforce rosters

• Missing name variations, aliases, or incomplete identifiers

Manual processes make it difficult to reliably search the OIG exclusion list using identifiers like social security, date of birth, or social security number. These gaps can delay detection and increase exposure to healthcare legal issues and repayment demands.

As workforce size and complexity grow, so does the need for more scalable approaches to exclusion monitoring.

Best Practices for Effective OIG Exclusion Monitoring

Mature compliance programs treat exclusion screening as an ongoing, documented process—not a point-in-time task. Industry best practices align around three core principles.

• Conducting screening monthly in alignment with LEIE updates

• Including employees, contractors, and vendors in the process

• Documenting each screening activity for audits and investigations

Automated healthcare background screening tools help organizations maintain this cadence at scale, reducing administrative burden while supporting consistent oversight

Consistent Screening Protects Compliance and Reduces Risk

Checking the OIG exclusion list regularly is one of the most effective ways healthcare organizations can protect themselves from avoidable compliance failures. Monthly screening reflects regulatory expectations, aligns with how the LEIE list is maintained, and helps organizations respond quickly when exclusions are imposed.

By screening all employees, contractors, and vendors, and by documenting those efforts, organizations can reduce exposure to fines, repayment obligations, and broader healthcare non-compliance consequences. Just as importantly, consistent exclusion monitoring supports patient trust and safeguards participation in government healthcare programs.

This is where provider data compliance solutions from Verisys support healthcare organizations. Through automated healthcare background screening, ongoing exclusion monitoring solutions, and integrated verification workflows, Verisys helps organizations maintain defensible compliance programs without adding operational strain. With continuously monitored data and clear audit trails, organizations can approach exclusion screening with greater confidence and control.