Two Systems You Must Manage: Medicare vs. Commercial Payers
One of the most common sources of confusion in 2026 is the difference between:
1. Medicare Enrollment (PECOS 2.0 / PDM)
Governs billing privileges
Tracks ownership, accreditation, and enrollment data
Managed through CMS systems
2. Commercial Payer Directories (No Surprises Act Compliance)
Governs provider visibility in insurance networks
Requires 90-day attestations
Managed through payer portals and third-party systems
These systems operate independently.
You can be:
Fully enrolled and compliant with Medicare
But still invisible to patients if you are removed from commercial directories.
The 90-Day Attestation Requirement Explained
Under the No Surprises Act, providers must verify their directory information every 90 days.
This includes confirming:
Practice name and location
Contact information
Services offered
Network participation status
This process is typically completed through platforms such as:
CAQH ProView
Availity Essentials
Individual payer portals
Failure to complete this attestation results in:
Your practice being marked as “unverified”
Automated removal from payer directories
Loss of visibility in “Find Care” tools
Why This Responsibility Cannot Be Delegated
A critical detail many providers overlook:
The 90-day attestation must be completed by the provider or authorized owner/manager.
Third-party billing companies:
Do not have legal authority to attest
Cannot certify the accuracy of internal business data
Cannot prevent removal if the provider does not respond
Even if your billing is outsourced, directory compliance remains your responsibility.
What Happens When You’re Removed from Directories
Directory removal has immediate and measurable consequences.
1. You Appear Out-of-Network
Even if your contract is active, patients and providers will see:
“Out-of-network” status
Missing or outdated listings
2. Referral Volume Drops
Referring physicians rely on directory tools to:
Identify in-network providers
Send orders for equipment or services
If you are not listed, referrals are often redirected to:
Competitors
Larger network providers
3. Claims and Patient Experience Issues Increase
Directory inaccuracies can lead to:
Claim delays or confusion
Patient complaints about coverage
Compliance risks tied to directory accuracy standards
In 2026, payers are enforcing these standards more aggressively, making visibility a compliance issue—not just a marketing issue.
The Hidden Risk: Missed Notifications
One of the biggest challenges providers face is simply missing attestation requests.
Common causes include:
Emails sent to outdated addresses
Notifications buried in administrative inboxes
Lack of centralized tracking across multiple payer portals
Because enforcement is automated, missing a notification often leads directly to removal without warning.
How to Stay Visible: A Proactive Compliance Process
To avoid directory removal, providers need a structured internal process.
Recommended approach:
Monthly Review Cycle
Log into all major payer portals
Check for pending verification requests
Confirm contact information is current
Dedicated Responsibility
Assign a staff member to:
Track attestation deadlines
Monitor payer communications
Ensure timely responses
Data Alignment
Keep information consistent across:
NPPES (NPI Registry)
PECOS 2.0
Payer systems
Synchronize with CMS Requirements
Align directory updates with:
30-day reporting requirements for changes
Practice location updates
Ownership or contact changes
This ensures consistency across all regulatory systems.
A Shift from Reactive to Continuous Visibility Management
In 2026, provider visibility is no longer passive.
It requires:
Ongoing monitoring
Regular verification
Active participation in payer systems
The shift is clear:
From “set it and forget it” → continuous verification
From manual updates → automated enforcement
Providers who adapt will maintain:
Network visibility
Referral flow
Revenue stability
Those who do not risk becoming invisible despite being contracted.
Why Directory Accuracy Is Now a Business-Critical Function
Directory accuracy directly impacts:
Patient access to your services
Referral volume from physicians
Claims processing efficiency
Compliance with federal regulations
Maintaining accurate listings is not just administrative—it is essential to:
Protect revenue
Preserve reputation
Ensure continuity of care
How PACCS Helps Maintain Network Visibility & Compliance
Managing multiple payer portals, attestation cycles, and data systems can be time-consuming and error-prone.
PACCS (Pharmacy Administrative Credentialing & Compliance Services) helps pharmacies and DMEPOS providers stay visible and compliant by offering:
Commercial payer credentialing and directory management
90-day attestation tracking and completion support
CAQH, Availity, and payer portal monitoring
NPI, PECOS, and payer data alignment
Ongoing compliance oversight and deadline management
Issue resolution for directory removal and reinstatement
By ensuring your provider data is consistently verified and up to date, PACCS helps protect your network presence, referral flow, and revenue continuity.
To learn more, visit our Services page or contact PACCS to discuss how we can support your organization.
Sources
https://pecos.cms.hhs.gov/pecos/help-main/useraccounts.jsp
https://www.cms.gov/nosurprises/notices
https://proview.caqh.org/
https://www.availity.com/directory-information-verification-for-providers/
https://www.federalregister.gov/documents/2025/09/19/2025-18236/medicare-and-medicaid-programs-contract-year-2026-policy-and-technical-changes-to-the-medicare
https://www.federalregister.gov/documents/2025/09/19/2025-18236/medicare-and-medicaid-programs-contract-year-2026-policy-and-technical-changes-to-the-medicare
Investigative Dispatch — PACCS Editorial Series
Insights on regulatory developments affecting pharmacy credentialing, Medicare enrollment, and compliance.
Sterling Bly | Investigative Healthcare Blogger
