KEY FINDING 3
Too Often, Credentials Quietly Expire
Exclusions draw the most attention, but they're not the largest gap in this data. The largest gap is administrative: licenses, registrations, and certifications that lapse quietly between credentialing cycles, with no one catching them due to a lack of continuous monitoring processes and tools.
NPI Accuracy
Every provider in a payer network should carry a valid National Provider Identifier (NPI) — the ten-digit number used to identify healthcare providers industry-wide. ProviderTrust cross-referenced every NPI in this dataset against NPPES, the federal registry that maintains these numbers, and against the Medicare Opt Out list. Providers listed as active in payer directories but flagged as inactive, suspended, or opted out in the federal registry represent a basic data quality failure.
Licensing
License status issues are the single largest gap uncovered in this analysis. Roughly 1 in 5 providers industry-wide (almost 20%) have a license status issue — expired, inactive, or surrendered licenses — filtered to exclude stale placeholder data. License board actions, which are confirmed disciplinary actions, are far less common. That distinction matters: the story here is not about widespread misconduct but rather about human and administrative issues. These gaps add up over time because the scale of manually keeping up with ongoing checks just isn’t manageable.
Controlled Substance Registration
Providers who prescribe controlled substances must maintain active, valid registration with the DEA or a state equivalent. Registration status issues, like lapsed or expired registrations, appeared across the majority of networks in this dataset. Given that these providers are authorized to prescribe medications with real abuse and diversion potential, a lapsed registration here is a meaningful gap, not a technicality.
Board Certification
A similar pattern is starkest in board certification data. Disciplinary board actions against a certification are almost nonexistent: 42 total across all 144 networks, appearing in only 14% of them. Lapsed or expired board certification status, by contrast, affects 402,918 providers across 96.5% of networks — a gap of roughly 9,600 to 1 between disciplinary actions and simple lapses.
Across all four categories, the systems built to catch serious misconduct are largely working. The systems built to catch quiet, administrative lapses between credentialing cycles are not. That gap closes only with continuous monitoring, not on a fixed schedule.
KEY FINDING 3
Too Often, Credentials Quietly Expire
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