Case Study · Accreditation & Compliance
Strengthening NCQA audit readiness for a regional Medicaid health plan
An independent, surveyor's-eye assessment of accreditation readiness — followed by two years of gap remediation, mock audits, and file review — culminating in NCQA Health Plan Accreditation.
Business Challenge
A regional Medicaid health plan was preparing for an upcoming NCQA accreditation review and sought an independent assessment of its operational readiness. Leadership recognized the importance of ensuring that documentation, business processes, delegated oversight activities, and operational controls aligned with NCQA standards and state Medicaid requirements.
The organization engaged C Suite Assets to evaluate current-state operations, identify potential compliance gaps in a gap analysis, remediate those gaps, and provide an objective assessment of audit readiness prior to the formal NCQA review — for NCQA Accreditation for Complex Case Management and Health Plan.
Scope of Engagement
C Suite Assets partnered with cross-functional business and operational leaders to assess organizational readiness across multiple NCQA domains:
Activities included:
- Executive and operational stakeholder interviews
- Review of NCQA-required documentation
- Process walkthroughs
- Data collection — Year One
- Gap analysis — Year One
- Gap remediation — Year One
- Data collection — Year Two
- Gap analysis — Year Two
- Gap remediation — Year Two
- Risk assessment
- End-to-end collateral review
- File preparation / mock audit
- IRT submission
- NCQA file review
- NCQA Accreditation
Our Unique Approach
Our consultants utilized a structured audit readiness methodology designed to simulate the perspective of an NCQA surveyor. Working collaboratively with business owners, we evaluated documented policies, operational workflows, supporting evidence, and governance processes to determine whether current practices aligned with accreditation requirements.
Rather than waiting for deficiencies to be identified during the accreditation survey, the assessment proactively highlighted opportunities to strengthen compliance, improve documentation consistency, and enhance operational readiness.
Key Findings
The assessment identified opportunities to improve:
- Standardization of policies and procedures across business units
- Consistency of supporting documentation and evidence retention
- Documentation of delegated oversight activities
- Tracking and monitoring of corrective action plans
- Operational process documentation and ownership
- Governance reporting and committee documentation
- Cross-functional coordination for NCQA evidence collection
- Audit trail documentation supporting compliance activities
Each observation was prioritized based on potential accreditation impact, operational risk, and implementation effort.
Outcomes & Business Impact
The engagement provided executive leadership with a comprehensive Audit Readiness Gap Identification Report that enabled the organization to:
- Gain an objective assessment of NCQA readiness
- Identify compliance risks before the accreditation survey
- Prioritize remediation efforts based on business impact
- Strengthen documentation and evidence management practices
- Improve operational consistency across departments
- Increase confidence in organizational readiness for NCQA review
- Receive Health Plan Accreditation
Why C Suite Assets
C Suite Assets brings deep expertise in Medicaid managed care operations, regulatory compliance, and healthcare transformation. Our consultants combine strategic advisory capabilities with practical operational experience to help health plans prepare for accreditation, strengthen internal controls, and improve organizational performance.
By partnering closely with leadership and operational teams, we deliver actionable recommendations that enhance compliance while supporting long-term operational excellence.