CVO and CR NCQA Surveys - From Those Who Have Been There

CVO and CR NCQA Surveys - From Those Who Have Been There

Oct 17, 2018
  • Author:
    Renee Dengler, RN, MS, CPMSM, CPCS, FMSP
    Before she joined VerityStream Client Success and Consulting Services, Renee was director of medical and professional affairs for Advocate Health Care. In previous positions, Renee was responsible for medical staff office management, risk management, quality management, continuing medical education, graduate medical education and utilization review. Recently, Renee was one of the first sixteen people to receive the NAMSS Fellow designation which is the pinnacle of achievement and acknowledgment for the Medical Services Professional (MSP).

Four organizations who recently became certified/accredited by NCQA have offered to share some survey experiences with our readers. 

  • Kettering Health NetworkMandy R. Addison, CPCS; Manager, Central Credentialing Office; Kettering Health Network, Dayton, OH – Accredited in CR
  • VerityStreamCVOPamela A. Butler, CPCS; Director, VerityStream CVO; San Diego, CA – Certified CVO
  • Allina HealthMary Heller, MBA, CPMSM, CPCS; Director, Credentials Verification Organization; Allina Health, Minneapolis, MN – Certified CVO
  • Franciscan Missionaries of Our Lady Health SystemRenee Zimmerman, RN, MSN, MBA, CPCS, CPMSM; Assistant Vice President, Franciscan Physician Group, Franciscan Missionaries of Our Lady Health System, Baton Rouge, LA – Accredited in CR

To assist with the experience sharing, questions were sent to each participant. Below is a summary of responses which have been edited for clarity and space considerations.  Responses are in no particular order


Why did you apply for accreditation/certification from NCQA?

  • The short-term goal was so that we wouldn’t have to continue full annual audits with the health plans with which we held delegation. Long term, we hope to grow our CVO services with clients externally from the health system and this certification is a great way to let others know of our superior services in credentialing.
  • Part of our Clinical Integration Network initiative is to enter into delegated agreements with payers. We understand that NCQA Accreditation demonstrated a high quality and efficient process that our health plans can count on. In addition, we were already doing PSV and while trying to do more with less, entering into a delegated agreement with payers should elevate the burden of managing multiple databases for payers and helps get our providers into practice sooner.
  • Our ultimate goal is to enter into delegated agreements with payers and the CVO certification was one of the steps toward that goal. We wanted to ensure our process was high quality, not just according to our own standards, but according to experts and a nationally recognized accrediting body.
  • It is an important validation to our business. Certification is a report card to inform clients that we adhere to NCQA credentialing standards. It also demonstrates that we have confidentiality protection in place with ensure data integrity. These are important features that clients consider when using CVO services.

Did you find that the surveyors interpreted any standard or element differently than you did?

  • No
  • No. But my advice is to be sure you’re using the most recent set of standards. I would also invest in an NCQA expert. Someone that has been there and done that and can share what has worked in the past.
  • Yes. Our organization had designated the CVO Director the authority to grant final approval of credentialing policies and procedures. At survey, it was deemed that this did not meet criteria because the governing body had not reviewed or approved the policies and procedures.
  • There were two instances where the surveyor made recommendations for things that were a “good practice” but were not a standard. In addition, we use our client’s applications. One of the clients has a question on their application relative to “lack of drug use” that NCQA determined did not meet the intent of the standard. Therefore, several applications were scored “no” for this element.

What part of the survey process did you find the most difficult/stressful and why?

Choices given were:
  1. Submission of survey documents in the IRT (Interactive Review Tool)
  2. Offsite conference calls with surveyors
  3. Onsite file review
  4. Other

  • Submission of survey documents in the IRT – This was the most time consuming and stressful part of the survey. I didn’t realize how much time it would take to find the most appropriate “proof of compliance” document to submit for each standard.
  • Submission of survey documents in the IRT and Offsite conference calls with surveyors – Both of these were difficult because they were new to me. I, personally, didn’t enter data in the IRT, but the organization of your data is important at this point. We ended being “spot on” with this piece. My advice is to have one person in charge of submitting the documents in the IRT.
  • Other – We found the entire process to be stressful, but not difficult. We knew what we did and that we met the standards, but there is always that nagging thought that THEY might not know what we meant by our policies and procedures.
  • Onsite file review and Other – During the survey we were asked in depth questions about backups, backup success, who had oversight of the process, etc. We went back and forth throughout the day. When the surveyor left, I did not feel that we would score well in this area based on the questions that were asked, but we scored 100%. Waiting for the final decision from the Review Oversight Committee was stressful. We also had issues with final payment (finance/corporate office/approval) and barely made the final payment on time. We also moved to a new location 2 weeks prior to survey submission which created extra anxiety leading up to survey time.

Which part of the survey process did your find the least difficult/stressful and why?

Choices given were:
  1. Submission of survey documents in the IRT
  2. Offsite conference calls with surveyors
  3. Onsite file review
  4. Other

  • Onsite file review – This was the easy part. If you’ve got a great process with internal audits, this should be the easiest part for the team.
  • Onsite file review – I felt comfortable with the file review. There is no reason to have issues with file review and you should always achieve 100%.
  • Onsite file review – We were confident that we had everything ready and in logical order. The surveyor was pleasant, friendly and explained things as she went along. Fortunately, we were able to answer all her questions.
  • Submission of survey documents in the IRT – It was easy to upload information. The NCQA survey support team responded to question very quickly and the Tip Sheets were very helpful. Completing the hotel recommendation form was easy, but a waste of time considering the surveyor did not use any of the recommendations.

What was the single, most significant/important thing you did to prepare for the survey that contributed to your success?

  • Going through each standard with a consultant surveyor before we applied for the survey.
  • Have good “wayfinding” for the surveyors and easy to follow policies and procedures. Make it easy for your surveyor to find exactly where and how you speak to the standards.
  • We hired a consultant to conduct an onsite audit of our files and policies and procedures.This helped tremendously!
  • Policies and procedures were cross-referenced to every standard and element. We audit 10-20% of closed files throughout the year. Once we received the list of files to be audited by NCQA, we reviewed the files in advance to determine if there were any areas of concern or missed elements. Even with that prep, the surveyor cited areas that she felt were not in total compliance.

If you had to do it over again, what would you do differently?

  • I’d give myself more time with the IRT. This is the most labor-intensive part and requires much more time than I designated the first go-round.
  • Nothing – We achieved a 100% on policy review and 100% on file review. The offsite part of the survey was the most successful as we had no clarifications to provide or explanations of what we meant.
  • We would review and re-check our policies and procedures and try to interpret them in a variety of ways and ask for further clarification from NCQA if we are unsure of anything – though we did ask a lot of questions.
  • I made my document submission for one of the standards and its elements too complicated. I would condense the number of documents that I uploaded to the IRT. I would have named the documents submitted by the Standard/Element rather than our policy number. It would have made it much easier for the surveyor and for us to find and cross-check.

What advice would you have for others who are contemplating applying for NCQA Accreditation/Certification?

  • Decide what your organization’s goals are for applying. What does your organization benefit from this? Apply the cost/reward analysis.
  • Work with someone from your organization that is not “med staff” trained. I found myself going into my “medical staff lane” and sometimes got off track to what the standards were asking for. Internally I worked with someone that didn’t know NCQA or medical staff services and found their “strategic planning” valuable while I kept to the details of the standards and elements. Engage leadership in the beginning so they understand the purpose and the value of collecting information for both of our accrediting bodies (TJC and NCQA) at the beginning of the provider application process.
  • Create policies and procedures that align directly with NCQA Standards. I would also strongly recommend investing in hiring an outside expert (ideally someone who is or was an NCQA surveyor) to come and perform a mock audit prior to submission so you have an objection review and have time to make any changes or clarifications.
  • Write your policies and procedures simple and to the point aligning with NCQA Standards. Definitely use an expert if it is your first survey or even if your have gone through multiple surveys. Conduct a mock survey. Our mock survey gave us a laundry list of changes which we were able to make in advance. It definitely helped us. Keep your policies and procedures updated and keep informed of any new or changes to NCQA standards.

Anything else?

  • The NCQA survey is very similar to an annual health plan audit, just more intense. If you regularly pass those with flying colors, I have no doubt that you can do the same with NCQA.
  • No.
  • All in all, it was a great experience. Very nerve wracking, but what a great sense of accomplishment and pride after we became certified. It encouraged us to move forward with NCQA CR Accreditation.
  • I cannot think of any additional points.

Take-Aways and Recurring Themes from the participants:

  • Understand the requirements and intent for each standard/element.
  • Make it easy for someone outside of your organization (who does not know your processes/procedures/policies) to understand what each document you are submitting is intended to show and how it complies with the standard.
  • Consider a mock survey.
  • And always celebrate your success!