How We Work


While consulting agreements are between organizations, MHR knows it’s the people who make the organizations work.  No matter where you sit on the organization chart, each person has a role in the accreditation process.  Described here are general groups, their roles, and how MHR works with them. 

C-suite executives

C-suite executives include the chief executive officer, the chief operating officer, the chief finance officer, and the chief medical officer, or equivalent titles. 

Responsibilities of C-suite executives for NCQA accreditation commonly include:

  • approving corporate goals
  • assuring budgetary resources are available
  • approving the corporate quality plan
  • resolving conflict impacting corporate goals
  • keeping the organization’s Board apprised of accreditation statuses

MHR communicates directly with the C-suite executives in:

  • negotiating and securing contracts
  • providing periodic status updates on accreditation
  • providing alerts that may impact corporate goals or any unethical behaviors

The perspective of NCQA accreditation by C-suite executives may be mixed.  Some who have had positive experiences may view NCQA as a set of best practices to improve quality, member experience, and costs.

Others, more cynical, may view NCQA as an unnecessary administrative overhead expense, which negatively impacts setting goals, establishing budgets, not prioritizing the work or allocating the budget, demeaning staff, minimizing the level of work effort, not attending status overviews, and “hiding” unethical behaviors.

Management/Executive Leadership

Management of organizations seeking NCQA accreditation includes vice presidents, directors, managers, supervisors, or equivalent titles.  Individuals may have oversight of one or multiple departments. For example, a VP may be responsible for provider contracting, provider relations, network management, and value-based agreements.

Primary responsibilities of management for NCQA accreditation commonly include:

  • establishing departmental goals to align with corporate goals on accreditation
  • monitoring ongoing accreditation readiness
  • securing resources aligned with budget
  • assigning staff to complete the work of accreditation
  • communicating up and down the organization on any pertinent issues or conflict
  • attending training and keeping current with NCQA requirements
  • reviewing and assuring delegate and vendor contracts meet requirements and prioritizing and removing barriers to compliance
  • scheduling celebrations regardless of outcomes

MHR works directly with management in:

  • assisting with defining deliverables of the contract
  • executing deliverables per the contract
  • arranging for training, coaching, and mentoring
  • alerting to and resolving any issues or conflicts impacting goals
  • escalating issues at critical points in the process
  • providing regular status reports

The perspective of NCQA accreditation by management is like that of the C-suite executives and is often influenced by them as well.  If disagreements or unethical behaviors occur, some in management will not bring issues to the C-suite executives for assistance in resolving them for fear of their own position.


The staff of organizations seeking NCQA accreditation is vast. They include individuals from areas such as quality, accreditation, credentialing, provider contracting, member experience, network management, marketing, pharmacy, case management, utilization management, population health, etc. Individuals may be nurses, specialists, pharmacists, physicians, therapists, administrative assistants, information technology professionals, analysts, accountants, and others.

Primary responsibilities of staff for NCQA accreditation include:

  • completing the work as assigned
  • alerting management of issues or conflict
  • collaborating with cross-functional departments
  • attending training and keeping current with NCQA requirements
  • offering suggestions and ideas

MHR works directly with staff in:

  • reviewing and scoring all work per contract
  • coaching and mentoring staff on standards and messaging needs to executive leadership
  • proactively identifying needed activities for best practices
  • conducting work groups for analysis depending on multiple departments
  • collaborating on status updates and timelines
  • identifying areas needing escalation due to risk
  • identifying “stars”

The perspective of NCQA accreditation by staff is mixed.  Like management, which is influenced by C-suite executives, the staff is influenced by management.  Staff who receive training, coaching, and mentoring to do their best work for the good of the organization and its members, have a positive experience.  Staff who do not receive the needed training, coaching, and mentoring and are assigned the work of accreditation in addition to their already full workload often have a negative experience.   Many staff feel like they’re alone in this accreditation journey that truly takes a well-functioning village to meet requirements. 


MHR is dedicated to providing consultation to organizations for NCQA preparation. NCQA is all we do. Because of this, our processes, or how we work with you and your organization, benefit from the years of experience of MHR’s President, Susan K. Moore, and her team of diverse expert consultants.

While our processes may be like those of other firms that also consult on NCQA accreditation, MHR is unique.  Since MHR has been in business since 1991, we have honed how we work with our clients and continue working towards the most efficient and effective ways that are based on best practices that we have seen work successfully over and over again. 

We are highly flexible and committed to meeting your needs, whether this is your first time approaching a survey, you have multiple corporate entities, you have just delegated a large part of your business, or perhaps you are now about to add Health Equity Accreditation along with another accreditation. Whatever it is, we likely have done that!  And more than once!

Know that we always have our finger on the pulse of NCQA requirements since Susan and many of the MHR consultants are also NCQA surveyors.  We continually update our knowledge and skills to provide the most up-to-date information and advice on your NCQA accreditation preparation. As a team, we discuss annual standards changes, triennial Policy Changes, Clarifications and Corrections, FAQs published each month, and the myriad of Policy Clarification Support (PCS) answers that we submit and receive every month and place in our PCS catalog, along with any training updates from NCQA provided to surveyors. The discussions help memorialize the requirements and assure consistency across the consultants with all clients.

Here is a general overview of what you can expect from us. Of course, we tailor this according to your specific needs.

Discovery Call

When you schedule a Discovery Call with us, you will be scheduled to speak with Susan. We will ask you about:

  • The type of accreditation you seek
  • Why are you seeking accreditation?
  • Your organization’s products – Commercial, Medicare, Medicaid, Exchange, or FEHP if a health plan, or the accreditation you are seeking if one of the derivative products (such as Population Health Program (PHP), Credentialing or Utilization Management Accreditation, Health Equity, among others)
  • Your organization’s program if a health plan– HMO, PPO, POS, HMO/POS. If a derivative product, where do you operate-local, regional, or national?
  • Where in the accreditation cycle you are, i.e., at the start and just obtained the standards, somewhere in the middle, or getting ready to submit and need some urgent help
  • Your survey dates, if known
  • If your Survey Application has been submitted
  • What is important in a consulting relationship and whether you have worked with a consultant in the past
  • How much of the work in the scope of the standards do you delegate and whether any are NCQA accredited
  • Whether you have internal or external barriers that would hamper the accreditation process, such as staffing, lack of budget or leadership support
  • How MHR can best help you
  • Your needs for additional templates, tools, or training

We also discuss our Values to ensure that our companies are a good fit for a working relationship. MHR’s philosophy is to teach our clients to “fish” and we do not work with organizations that want to “buy” their accreditation. We do work with smaller products (such as CVOs) to perform outsourcing of accreditation in lieu of organizations hiring accreditation staff.

Proposal/Statement of Work (SOW)

Once we mutually agree that our companies are a good fit, MHR will develop a brief proposal and SOW for review by the organization.


Once the proposal and SOW are accepted, we proceed to an Agreement.  The Agreement is for our consultants to help your organization prepare you for your accreditation survey(s).  Any additional purchases, such as our proprietary templates, tools, or training, can be done at this time or decided on in the future.


When talking with the organization, Susan determines which consultants would be a good fit with the organization due to their knowledge, experience, and bandwidth. After the Discovery Call Susan talks with the consultant to discuss the potential client and whether there is a goodness of fit and availability. Based on that, she sends the consultants’ bios and/or resumes to the client when the proposal and agreement are executed.

Afterward, Susan formally assigns a consultant or team with the requisite knowledge and skills to meet your specific needs. These can be both clinical and non-clinical team members, depending on the accreditation product. Clinicians support the UM standards and case management in health plans, along with the standalone UM, CM, and PHP standards. Non-clinicians cover the other standards. The MHR consultants create a detailed Plan based on your needs as expressed in the Discovery Call and according to our Agreement. 

At the same time, you are asked to identify your organization’s executive responsible for NCQA accreditation, your project lead, and individuals who are your subject matter experts (SMEs) for the various standards.

Documents and File

MHR initiates a kick-off meeting with your team where both sides introduce themselves. The MHR President talks about the roles of each side and standards assignments to begin after the call. The SOW and timelines are discussed along with how we work with clients. We discuss a cadence of calls and make recommendations for what we have found is a best practice frequency. Additionally, we ask to schedule file reviews, as frequently the gaps require additional training for staff or system modifications, in the worst-case scenario. Both take time but need to be scheduled so look-back periods for file review can be met successfully. Certainly, credentialing files, with an ongoing look-back period (except for Initial surveys) are a priority.

We will ask you to send us a series of Documents beginning with the ones that are higher risk, such as:

  • Delegation worksheet (if you have submitted a survey previously) or a listing of delegates
  • Documented processes specified by the standards, such as program documents or P&Ps
  • Screenshots for Elements that require processes to be in place throughout the look-back period
  • Must-pass Elements
  • Critical Factors
  • Included in your look-back period
  • High points or complex
  • We do not accept any documentation with PHI included. If a document with PHI is needed to confirm that a letter was sent, you must redact it. We do view PHI when conducting file reviews, but consultants are prohibited by MHR contract and principles of practice from taking any screenshots of files.

As you provide us with these documents, we check them according to the standards and determine any gaps that would prevent you from attaining the maximum points possible.  MHR tracks all documents in our proprietary Gap/Readiness Assessment/Project Management Tool.

Next, we check a sample of your files within your look-back period, including medical, behavioral health, pharmacy, credentialing, and re-credentialing, and case management, as appropriate to your survey.  Our sample review requires limited system access that enables MHR to examine the fields necessary to score the files.  We conduct these virtually with organization staff to move through files efficiently and we are always evaluating the ease with which file review would be done for a survey using the system.

Also under review by MHR are your delegates, from pre-delegation assessment to ongoing oversight, including minutes from collaborative meetings.

Once our assessment is complete, MHR estimates how prepared your organization is to undergo its survey. 

Ongoing Support

Throughout the engagement, MHR guides you on utilizing the Gap/Readiness Assessment/Project Management Tool to identify priorities, track your project, and gauge your organization’s preparedness. If you are not on target according to the plan, MHR will work with you to mitigate risk and guide you on critical action steps.

As you update documents where gaps were identified, you will send them to the MHR consultant for re-evaluation.  Feedback and coaching are provided along the way.

A focus on people is critical. As we work with you, we help assess the readiness of your SMEs to complete assignments and assume accountability for tasks.  We also coach individuals in presenting files to NCQA during the survey.  As MHR coaches individuals on preparing for the survey, more formal Training on the standards for larger groups may be desired.  

After you finalize your collective document preparation, you are ready to submit to NCQA according to your scheduled survey time.  After submission, MHR may hold a virtual closing conference (as a best practice) with all stakeholders. At this time, we summarize your organizational accomplishments, note any potential issues that may arise during the survey, and explain the next steps. It is important for representatives of the executive, management, and staff teams to be present to hear the status.

Survey Support

MHR remains available by phone during your virtual survey with NCQA as you may have questions or want immediate advice on responding to a question from the NCQA surveyor.

At your scheduled time, NCQA sends the organization a list of outstanding issues, ranging from nothing to simple clarifications or requests for additional supporting documentation. MHR is there to help you craft your response, check your other documentation, and identify which standards should be discussed on the conference call.  

The consultants also are available for file review support when you receive your listing two weeks prior to the survey. We can assist you from as little as reviewing files you have identified as problematic to assist in framing responses, reviewing all the files selected or assisting in developing PDFs of files for presentation when the system is not efficient for file review. Many surveyors have come to expect PDFs of files as it assists them in moving more quickly through the file reviews. We are also on call and available to problem solve any issues identified by the surveyors during the survey to coach staff on addressing the situation ethically and respectfully.

Post Survey Support

You have an additional opportunity to address areas that you believe were inaccurately scored down during the survey. This process typically starts the last working day prior to the file review portion of the survey when you receive your listing from the Accreditation Survey Coordinator (ASC). We coach you on documents that can be submitted to support your position. No documents can be developed after the submission of the survey. Sometimes the surveyor did not understand the context and framework of the organization, and documents that provide additional information may be needed to overturn decisions. This information can be provided when you receive your survey results, and you have 10 days to submit additional documentation. You’re ready because you planned ahead from the time of receiving the “Not Met” requirements!

Unfortunately, there are times that you may be placed on a Corrective Action Plan (CAP) because you either did not retain MHR prior to the necessary look-back period or did not respond quickly enough to consultation to change or develop documentation to mitigate your risk. In these circumstances, MHR consultants assist you in responding to the CAP in a way that NCQA would understand that you know what you need to do to meet the standards along with the timeframe in which you will do it.

We await your final scores according to the timeframe that NCQA has outlined for your organization.  Once your organization has received the final scores, NCQA posts them to the Report Cards site on

If not already done, it’s time for your organization to celebrate your accomplishments.   Preparing for an NCQA survey takes significant effort from many individuals.  Your team has increased its knowledge and skills, your leaders have grown in their abilities, you have increased value to your organization, and you have likely set in place new processes or activities to improve the quality and service to your members! We also celebrate your achievements as we are partners in your company and your success!

End with a Start in Mind  

You usually hear the saying, “Start with the End in Mind.” MHR likes to think that after all the dust has settled with your survey, you are back to collecting everyone’s notes, comments, action plans, etc., and start your organization’s project plan for the following survey. It isn’t long before your next look-back period begins! For CVO certification, the process never stops. For accreditation, there is a brief time period for taking a breath but preparing for the next cycle. Remember, credentialing has a look-back period that is ongoing – from one submission to the next. Continuity and Coordination within Medical Care and between Medical and Behavioral needs three data points. You can’t take a breath for too long! MHR is ready to help you take your organization to the next level.

What is Needed from Your Organization

When you partner with MHR for NCQA preparation, we request the following:

  • Commit to supply resources necessary for the success of our engagement
  • Maintain open communication at all levels
  • Be available for scheduled status briefs
  • Identify your executive accountable for NCQA
  • Assign a project lead and SMEs who work in tandem with the MHR consultant(s)
  • Your organization’s administrative support for facilitating document flows
  • Access to your IT systems with organization staff facilitation that is limited to what is necessary for sample file reviews