The Joint Commission Just Changed Everything: Why Annual License Checks Are Dead

Read time: 3-4 minutes

In summer 2025, The Joint Commission fundamentally changed healthcare compliance. What was once an annual task—credential verification—became a monthly operational requirement. For most healthcare organizations, this shift represents the most significant compliance change in a decade.

If you’re still checking licenses once a year, you’re not just behind—you’re exposed to massive financial and regulatory risk.

What Changed and Why It Matters

The Joint Commission’s updated standards now require healthcare organizations to verify clinical credentials monthly, not annually. This isn’t a suggestion or best practice—it’s a mandatory accreditation requirement affecting thousands of hospitals, health systems, and healthcare facilities.

The reasoning is straightforward: licenses and certifications can lapse, be suspended, or be revoked at any time. A physician whose license was valid in January might face disciplinary action in March. Waiting until next January’s verification cycle to discover this creates months of exposure.

According to White & Case’s 2024 analysis of healthcare enforcement actions, organizations employing individuals with lapsed credentials face penalties calculated per patient interaction.

The Operational Reality Nobody Talks About

Here’s what monthly credential verification actually means operationally:

For a 500-bed hospital with 800 credentialed professionals, annual verification meant one intense period of checking licenses. Maybe 2-3 weeks of focused work by your credentialing team once per year.

Monthly verification means checking 800 professionals every 30 days, year-round. That’s nearly 10,000 verifications annually—versus 800 under the old standard.

The Association of Healthcare Internal Auditors (AHIA) 2024 audit findings report that without automated systems, healthcare organizations experience 3-7% annual credential lapses across their credentialed workforce. In a hospital with 800 providers, that’s 24-56 professionals practicing with expired or problematic credentials at any given time.

Most healthcare compliance teams weren’t built for this volume. KPMG’s 2024 Healthcare Compliance Outlook Survey found that credentialing specialists who previously balanced verification with other responsibilities now spend 60-75% of their time on manual verification tasks, leaving minimal capacity for strategic compliance work.

Why Manual Processes Cannot Scale

Healthcare organizations attempting monthly verification manually face predictable problems:

The Multi-State Complexity
Many healthcare organizations employ professionals licensed across multiple states. A physician might hold licenses in three states, have a DEA registration, board certification, and state-controlled substance permits. Each requires separate verification from different state boards with different systems and interfaces.

The National Council of State Boards of Nursing (NCSBN) reports that nurses increasingly hold multi-state licenses, but verification still requires checking multiple jurisdictions for many practitioners. Manual tracking of these complex credential portfolios at monthly frequency is overwhelming.

The False Positive Burden
How many “John Smith” physicians exist in your state’s medical board database? Manual checking requires distinguishing between your John Smith and the sanctioned John Smith two counties away—then documenting why you cleared the match.

According to Gartner’s 2024 research on healthcare compliance automation, organizations spend an average of 15-20 minutes investigating each false positive match. With common names appearing frequently, this investigation time compounds quickly across 800+ monthly verifications.

The Primary Source Requirement
Both The Joint Commission and CMS require primary source verification—confirmation must come directly from issuing authorities, not aggregator databases that may lag behind real-time status changes. This means visiting multiple government websites, navigating different interfaces, and manually recording results.

The Federation of State Medical Boards (FSMB) maintains that each state operates independent verification systems with varying user interfaces, search capabilities, and data presentation formats. There is no unified portal for multi-state verification.

The Documentation Nightmare
Where does verification documentation live? Some records exist in spreadsheets. Some are printouts from government websites. Some are emails confirming checks were completed. When Joint Commission surveyors arrive requesting credential verification documentation, compliance teams spend days compiling evidence rather than producing it instantly.

Healthcare Compliance Association (HCAA) 2024 benchmark data shows that organizations with manual processes require an average of 3-5 business days to compile comprehensive credential verification documentation for audits, compared to under one hour for organizations with automated systems.

The Real Cost: Beyond Penalties

Financial penalties for credential lapses represent only part of the risk:

Patient Safety Implications
ECRI Institute’s 2024 analysis found correlation between credential lapses and patient safety incidents. Professionals practicing with expired certifications may have missed required continuing education, potentially impacting clinical competency.

Reputational Damage
Public disclosure of credential violations damages organizational reputation. Local media frequently reports when hospitals employ unlicensed practitioners, eroding community trust.

Accreditation Risk
Systematic credential monitoring failures can jeopardize Joint Commission accreditation, affecting federal reimbursement eligibility and patient volume.

Staff Morale
When compliance teams spend 60-75% of their time on manual data entry and verification, burnout increases and strategic compliance work suffers. KPMG’s survey found that compliance professionals cite administrative burden as the primary factor limiting program effectiveness.

What Healthcare Organizations Need Now

The shift to monthly verification isn’t optional, and manual processes cannot sustainably meet the requirement. Healthcare organizations need:

Automated Primary Source Verification
Systems that check directly with state licensing boards, DEA, and certification bodies—eliminating manual website visits while ensuring primary source documentation that satisfies regulatory requirements.

Continuous Monitoring with Real-Time Alerts
Rather than monthly batch checks, leading organizations implement continuous monitoring that alerts immediately when credentials lapse or face sanctions—enabling action the same day, not weeks later during scheduled verification.

Intelligent Matching Technology
Algorithms using multiple data points (full name, date of birth, license numbers, addresses) to distinguish between your professionals and similarly named individuals, dramatically reducing false positive investigation time.

Comprehensive Audit Trail Documentation
Every verification automatically generates timestamped documentation showing what was checked, when, by whom, and what was found—creating immediately accessible audit trails that satisfy surveyor requests.

Scalable Batch Processing
The ability to monitor hundreds or thousands of professionals simultaneously with results in hours, not weeks, making monthly verification operationally feasible.

The Path Forward

Healthcare organizations have two choices: invest in automated credential monitoring systems that make monthly verification sustainable, or attempt to scale manual processes and face mounting operational burden, compliance risk, and regulatory exposure.

The Joint Commission’s requirement isn’t going away. If anything, regulatory expectations will continue tightening. Organizations that implement robust automated monitoring now will be positioned for whatever changes come next.

Those that defer, hoping to manage increased requirements with existing manual processes, will find themselves increasingly behind—both operationally and from a regulatory compliance perspective.

Key Takeaways

• Monthly credential verification is now mandatory, increasing annual verifications from 800 to 10,000 for typical 500-bed hospitals
• Manual processes require 60-75% of credentialing staff time, leaving minimal capacity for strategic work
• Without automation, 3-7% of credentialed professionals have credential issues at any given time
• Primary source verification from state boards is mandatory but operationally complex across multiple jurisdictions

In our next post, we’ll explore the specific technology capabilities and implementation strategies that make monthly credential monitoring operationally sustainable while strengthening audit readiness.