ncqa accreditation ncqa standards Oct 12, 2022
MHR NCQA Survey Tips

Leading an organization through an NCQA Survey can be daunting, especially if it’s your first time. Even if you’ve led an organization through a survey in the past, you are well aware of the preparation needed. Among the strategies for a successful survey are uniting around common goals, planning ahead, supporting subject matter experts, training, and having your files and systems in order.  

Heed these tips to help you stay on course.

  • Common goals: Executive leadership must communicate to all employees that their ongoing contributions are needed, important, and valued. Some organizations may be undergoing review for more than one type of accreditation program or may have multiple product lines under review. Having stated goals for each should prompt management to align their budgets and staffing. For example, a clearly stated goal could include achieving the maximum points allowable for each program and each product line. 
  • Plan Ahead: A plan begins with an assessment of the standards to identify gaps, prioritize work, and assign risk. MHR Consultants use our proprietary Gap/Readiness Assessment/Project Management Tool to assess high-risk areas such as must-pass elements, critical factors, documents within the look-back period, file reviews, delegation worksheets, and system controls.  Critical to your plan is that it is done before the start of your look-back period.
  • Subject Matter Experts (SMEs):
  • SMEs, including backups, are designated for each standard set under review. Having multiple SMEs for each business area helps the organization plan for unexpected absences and business disruptions.   Multiple SMEs are essential in areas with file reviews:  appeals, denials, case management, credentialing, and recredentialing.  Included in your SMEs are your medical directors or physician advisors involved with utilization management and credentialing.    
  • Coaching and training: Achieving high quality in any organization is not a one-time event. In MHR Blog "6 Common Ways Organizations can lose points in an NCQA Survey", you read how organizations can lose points when high-risk work is not prioritized. Achieving excellence takes people that consistently use the NCQA standards as best practices and integrate the processes throughout their organization. But this doesn’t occur “overnight" or just by reading the standards alone.

    Our consultants work side-by-side with you and address your individual needs. We help you anticipate questions that NCQA surveyors may ask and coach you on how to respond. We advise on additional training sessions to help you gain confidence and the skill and knowledge needed for ongoing success. Individuals benefit the most when Training is conducted before the start of your look-back period.

    Organizations that invest in their people may increase their value by having more knowledgeable employees who are confident in their roles, better utilize critical thinking skills, are adaptable in various environments, and are team players . Additionally, they feel valued that the organization invests the money to improve their skills and confidence, which can lead to employee retention.
  • Files and Systems: All file reviews and system controls audits for utilization management and credentialing are high-risk. Holding mock file reviews with an MHR consultant and SMEs is especially helpful for staff to see how their files look through a surveyor’s eyes.  Auditing your systems along with your IT systems analysts helps identify any issues with data fields, workflows, letter generation, and recording critical dates.  Validate the preparedness of your delegated entities to ensure that their files and system auditing will support your accreditation process.

See how MHR worked with one organization that benefited from additional training.

The organization was new to NCQA.  After assessing their readiness for Health Plan Accreditation, MHR found that most individuals in the organization, including the Project Lead, had never experienced an NCQA survey.  Support for NCQA “at the top” was not strong, but the executive team knew their state required the accreditation for their line of business.

MHR recommended the following Training sessions:

  • Basics of Accreditation
  • Health Plan Accreditation standards sets
  • Analysis
  • Delegation

As a result of the Training sessions, the organization learned:

  • NCQA standards are best practices that have evolved over time
  • How Standards, elements, factors, and scope are interrelated
  • Explanation is where required details are found
  • Nuances of specific standards are found in PCS questions and FAQs
  • Prioritizing what is most challenging and worth the highest points helps with scoring
  • Knowing the look-back period is essential to all standards
  • Using a tracking tool at a corporate level is needed
  • Using standard templates for analysis and delegation drives consistency
  • Periodic mock audits, including file reviews, help detect gaps for prompt remedy

Consider these Calls to Action.

  • Validate your organization’s goals
  • Seek expert assistance on a readiness assessment
  • Check all dates, determine gaps, and assess risks
  • Develop your plan
  • Arrange for training before your look-back period

Heed these tips from the experts.  Let us know how we can partner with you as you take the lead.     


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