How [CLIENT_TYPE] Built a Compliant Credentialing Program in [TOTAL_DURATION] — IHS Case Study

Last updated: April 2026

This case study documents how IHS designed and implemented a credentialing program for a [SIZE] [ORG_TYPE] in [STATE], achieving full compliance with NCQA CR standards and CMS 42 CFR 438.214 requirements without pursuing formal NCQA accreditation.

The Challenge

[CLIENT_TYPE] — a [SIZE] [ORG_TYPE] in [STATE] — needed a compliant credentialing program to [BUSINESS_DRIVER]. The organization [HAD/DID NOT HAVE] an existing credentialing infrastructure, and [SPECIFIC_CONTEXT — e.g., was entering the Medicaid managed care market for the first time / needed to satisfy health plan delegation audit requirements / faced an upcoming state Medicaid compliance review / was forming a Clinically Integrated Network across member FQHCs].

Key Obstacles

• [OBSTACLE_1 — e.g., No existing credentialing committee structure or charter]
• [OBSTACLE_2 — e.g., Legacy paper-based application forms missing mandatory demographic fields]
• [OBSTACLE_3 — e.g., No documented continuous monitoring process — OIG/SAM checks were ad hoc at best]
• [OBSTACLE_4 — e.g., Provider network of [X] providers with no standardized PSV protocol]
• [OBSTACLE_5 — e.g., Tight [X]-month deadline before state Medicaid contract start date]

Compliance Gaps Identified

IHS conducted a Standard-by-Standard Review against the NCQA CR standards rubric and identified [NUMBER] critical compliance gaps, including:

• [GAP_1 — e.g., No PSV protocol — verifications were not tracked against any timeline window]
• [GAP_2 — e.g., No credentialing committee — enrollment decisions made by administrative staff without clinical oversight]
• [GAP_3 — e.g., No Information Integrity controls — no audit trail for credentialing data changes]
• [GAP_4 — e.g., No delegation agreements — CVO relationship existed but without compliant contractual framework]
• [GAP_5 — e.g., No continuous monitoring — providers checked only at initial credentialing and 36-month recredentialing]

The IHS Approach

Thomas G. Goddard, JD, PhD, led the engagement, applying 25+ years of NCQA consulting experience to design a credentialing program calibrated to [CLIENT_TYPE]'s specific compliance requirements and organizational structure.

Phase 1: Standard-by-Standard Review ([PHASE_1_DURATION])

IHS conducted an exhaustive review of [CLIENT_TYPE]'s existing credentialing operations — [DESCRIPTION OF WHAT WAS REVIEWED — e.g., pulled [X] historical credentialing files, reviewed existing policies, interviewed credentialing staff and clinical leadership]. The deliverable was a gap assessment document with [NUMBER] prioritized remediation items mapped to NCQA CR standards and CMS 42 CFR 438.214 requirements.

• [KEY_FINDING_1]
• [KEY_FINDING_2]
• [KEY_FINDING_3]

Phase 2: Document Preparation — Policy Development and Templates ([PHASE_2_DURATION])

IHS provided customized policy templates and document frameworks for every required program component:

• [DELIVERABLE_1 — e.g., Credentialing committee charter with defined membership, quorum, and voting rules]
• [DELIVERABLE_2 — e.g., PSV protocol templates with 120-day timeline tracking]
• [DELIVERABLE_3 — e.g., Continuous monitoring SOPs for monthly OIG/SAM/NPDB batch checks]
• [DELIVERABLE_4 — e.g., Updated practitioner application templates with 2025 demographic fields]
• [DELIVERABLE_5 — e.g., Delegation agreement templates covering all 11 NCQA evaluation elements]
• [DELIVERABLE_6 — e.g., Information Integrity policy with audit trail requirements and annual training mandate]

Phase 3: Program Implementation Support ([PHASE_3_DURATION])

[CLIENT_TYPE] implemented the new policies into live operations with IHS guidance:

• [IMPLEMENTATION_1 — e.g., Credentialing committee formally established with [X] members including clinical representation]
• [IMPLEMENTATION_2 — e.g., First compliant committee meeting held and minuted on [DATE]]
• [IMPLEMENTATION_3 — e.g., Monthly monitoring protocols activated — first documented OIG/SAM/NPDB batch check completed]
• [IMPLEMENTATION_4 — e.g., Staff training on data integrity completed for [X] credentialing staff]
• [IMPLEMENTATION_5 — e.g., Internal FTE restructured to [X]:250 provider ratio with [PLATFORM] automation]

Phase 4: Mock Survey and Corrective Action ([PHASE_4_DURATION])

IHS simulated an external audit reviewing [NUMBER] randomly selected credentialing files processed under the new system:

• [MOCK_RESULT_1 — e.g., [X]% of files met 120-day PSV window requirement]
• [MOCK_RESULT_2 — e.g., [X] corrective action items identified and remediated within [TIMEFRAME]]
• [MOCK_RESULT_3 — e.g., Committee documentation met all NCQA CR 2 requirements]
• [MOCK_RESULT_4 — e.g., Information Integrity audit trail verified for all credentialing data changes]

Total engagement duration: [TOTAL_DURATION]

The Results

• [RESULT_1 — e.g., Fully compliant credentialing program operational within [X] months]
• [RESULT_2 — e.g., Passed state Medicaid compliance review with zero critical deficiencies]
• [RESULT_3 — e.g., Secured delegated credentialing agreements with [X] health plans]
• [RESULT_4 — e.g., Reduced provider onboarding time from [X] months to [Y] weeks]
• [RESULT_5 — e.g., Recovered approximately $[X] in previously deferred provider billing revenue]
• [RESULT_6 — e.g., Established 6-month compliance evidence trail positioning organization for future formal NCQA accreditation if desired]

Timeline Comparison

Key Takeaways

1. [TAKEAWAY_1_TITLE]: [TAKEAWAY_1_DETAIL — e.g., Starting with a Standard-by-Standard Review prevented the organization from investing in the wrong areas. The gap assessment identified that the most critical deficiency was not what leadership assumed — it was the absence of continuous monitoring, not outdated application forms.]
2. [TAKEAWAY_2_TITLE]: [TAKEAWAY_2_DETAIL — e.g., The shadow accreditation approach saved approximately $30,000 in NCQA survey fees while achieving the same operational compliance. The program is architecturally ready for formal accreditation if the organization decides to pursue it.]
3. [TAKEAWAY_3_TITLE]: [TAKEAWAY_3_DETAIL — e.g., Monthly monitoring implementation was the single most impactful change. Before IHS, the organization had no process for checking providers against OIG/SAM exclusion lists between 36-month recredentialing cycles. Under 2025 NCQA standards, this would have been an immediate critical deficiency.]
4. [TAKEAWAY_4_TITLE]: [TAKEAWAY_4_DETAIL — e.g., The delegation agreement with the external CVO was missing coverage for 4 of the 11 NCQA evaluation elements. Without IHS's review, the organization would have been cited for compliance gaps it assumed were the CVO's responsibility.]

About Integral Healthcare Solutions

IHS has provided credentialing and accreditation consulting since 1996. Thomas G. Goddard, JD, PhD, brings 25+ years of NCQA consulting experience and dual legal and academic credentials to every engagement. IHS designs credentialing programs for Medicaid MCOs, IPAs, state Primary Care Associations, FQHCs, and new health plan market entrants — providing templates, policy frameworks, and expert guidance that withstand state Medicaid audits and health plan delegation reviews.

Related Resources

• Credentialing Program Design Service Page — Complete overview of IHS credentialing program design consulting
• Credentialing Program Design FAQ — 16 detailed answers about building compliant programs
• Credentialing Program Design Cost Guide — Detailed cost breakdowns by organization type
• Internal Program vs. CVO Outsourcing Comparison — Build vs. buy analysis
• NCQA CVO Certification Consulting — For organizations ready to pursue formal certification

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