Verification cadence is now the compliance battleground
For decades, provider data management followed a familiar rhythm: quarterly file reviews, annual directory refreshes, periodic audits triggered by regulatory cycles. In a slower enforcement environment, that cadence was considered reasonable, and often sufficient.
Federal law now sets a different standard.
Under the No Surprises Act and related regulations, health plans are required to verify provider directory information at least every 90 days and to update material changes within two business days. This is not advisory guidance. It is an explicit statutory requirement reinforced through regulatory oversight and enforcement actions.
(Source: American Medical Association – No Surprises Act Guide)
What has changed is not only the rule, but how compliance is evaluated.
Courts assessing ghost network cases are no longer focused on whether organizations performed periodic cleanups. The question has shifted to whether plans can demonstrate ongoing verification and timely correction of inaccuracies. In ERISA contexts, directory errors are increasingly framed as fiduciary failures, not administrative lapses.
(Source: American Bar Association – ERISA and Ghost Networks)
This distinction is critical. A quarterly or annual review process, by definition, allows provider data to drift out of accuracy for extended periods of time. In a regulatory environment that expects 90-day verification and near-real-time updates, that drift itself becomes evidence of non-compliance.
The practical implication is uncomfortable but unavoidable: point-in-time accuracy is no longer a defensible position.
Even if a directory was accurate on the day it was published, organizations are now expected to answer a more demanding question: how was accuracy maintained between verification events?
For many payer organizations, this is where existing processes fail. Provider data changes continuously, addresses, phone numbers, participation status, accepting-new-patients indicators. Static reviews cannot keep pace with a dynamic system. Manual workflows, even when well documented, do not scale to the cadence regulators now expect.
Compliance is no longer about snapshots. It is about proving a process that never stops.
Learn how payer operations teams can leverage Polus™ HCP to replace point-in-time directory checks with continuous provider data verification to reduce manual reconciliation, compliance risk, and audit exposure.