Most billing and coding professionals are familiar with the No Surprises Act as a payer-side compliance obligation. What is less commonly understood is how the NSA requirements create upstream data quality obligations that directly affect billing operations.
The 48-hour update requirement, mandating that provider directory information be updated within 48 hours of a change, is the most operationally demanding element of NSA compliance. It is also one of the most direct drivers of the data quality gap that billing teams encounter when provider information has changed but has not yet propagated through the systems billing organizations depend on.
The Gap Between Regulatory Requirement and Operational Reality
Health plans are required to update their provider directories within 48 hours of receiving notice that a provider’s information has changed. That requirement creates a compliance obligation for payers. It also creates a practical reality for billing organizations: when a provider’s information changes (when they move, when they leave a network, when they update their specialty or practice location), the billing system may not reflect that change for days, weeks, or longer.
The gap between when a change happens and when it appears in the billing system is where preventable denials originate. A billing firm submitting claims for a provider who changed their billing address last week is submitting claims based on information that may already be generating rejections, even if the payer’s directory updated within 48 hours as required.
What This Looks Like for Billing Teams
The practical billing consequence of the 48-hour requirement is that provider data must be validated continuously, not periodically. A quarterly roster verification cycle, common across the industry, creates a window of up to 90 days during which provider data changes can generate denials without being caught and corrected.
The REAL Health Providers Act, currently advancing through Congress with bipartisan support, would extend a 90-day verification requirement broadly across the industry. For billing organizations, this regulatory trajectory means the standard is moving toward continuous verification as a baseline expectation, not a premium practice reserved for the most sophisticated organizations.
The Datagence Situation Analysis describes this dynamic directly: “Verification cadence is moving toward continuous validation, which cannot be achieved through manual processes.” That assessment reflects the regulatory direction and its operational implication for every organization that depends on accurate provider data.
The Compliance Exposure for Billing Firms
Billing and coding organizations face compliance exposure that parallels the payer-side enforcement activity described in the Q1 series. While direct NSA penalties have been focused on health plans to date, billing firms that submit claims with provider data that does not comply with current enrollment and credentialing requirements face audit risk, recoupment demands, and, in cases where patterns of billing with incorrect provider information are identified, potential OIG scrutiny.
The risk is not hypothetical. MDaudit’s 2025 analysis found a 30% year-over-year increase in external payer audit volume, with coding errors and billing errors among the most common triggers. Billing firms operating on provider data that has not been validated against current credentialing and enrollment records are submitting claims that carry that audit risk on behalf of their clients.
For submission staff: When you receive notice that a provider has changed information (address, group affiliation, specialty, payer enrollment), escalate that update immediately rather than queuing it for the next roster review cycle. The 48-hour window that regulatory standards are moving toward is not just a payer obligation. It is the operational cadence that prevents billing disruptions from provider data that has changed but has not been updated.
Ready to See What Provider Data Accuracy Can Do for Your Bottom Line?
If any of this resonates with what your team is dealing with, the next step is a conversation. Schedule a Strategy Session. You’ll get no sales pitch, just a working discussion about your current data posture and the revenue you’re leaving on the table.
We invite you to take a deeper dive with these third-party and Datagence resources:
- Datagence: The Revenue Cycle Consequence
- Datagence: Provider Data Enforcement Reckoning