Case Study: Regional Qualified Health Plan Achieves URAC Marketplace Health Plan Accreditation

The Challenge

The health plan had been operating on a state-based ACA exchange for several years but had never pursued URAC accreditation. Several factors converged to make accreditation a priority:

• The state exchange began requiring or incentivizing URAC accreditation for QHP certification
• Competing plans on the exchange had already achieved accreditation, creating a competitive disadvantage
• The plan's compliance infrastructure had developed organically without a structured quality management framework
• Internal staff had limited experience with URAC standards and the accreditation process

The plan needed to achieve accreditation within 12 months to meet the exchange's timeline while continuing to serve approximately 85,000 enrolled members.

The IHS Approach

Phase 1: Gap Analysis (Weeks 1–4)

Dr. Goddard led a comprehensive gap analysis mapping the plan's existing operations against URAC Marketplace Health Plan standards, evaluating all major domains including consumer protection, network management, quality management, utilization management, and member rights.

• Reviewed 200+ existing policies, procedures, and operational documents
• Conducted interviews with department heads across compliance, medical management, network operations, and member services
• Identified 47 specific gaps requiring remediation before survey readiness

Phase 2: Remediation (Weeks 5–28)

• Developed a comprehensive quality management program aligned with URAC requirements
• Restructured the member grievance and appeal process to meet URAC standards
• Enhanced network adequacy monitoring and reporting capabilities
• Built a utilization management program with appropriate clinical oversight
• Created a consumer protection framework including health literacy and language access programs

Phase 3: Mock Review (Weeks 29–34)

IHS conducted a full mock desktop review simulating the actual URAC survey process. Identified 12 remaining deficiencies — all procedural documentation gaps — addressed within four weeks.

Phase 4: Survey Support (Weeks 35–42)

IHS provided pre-survey coaching, document organization, and consultation support throughout the survey period.

Results

• URAC Marketplace Health Plan Accreditation achieved on the first attempt
• Zero critical deficiencies identified during the URAC survey
• 42-week timeline from engagement start to accreditation award — ahead of the 12-month target
• Competitive positioning strengthened on the state exchange
• Quality infrastructure established supporting ongoing compliance and re-accreditation

About This Case Study

This case study is based on a composite of IHS engagements and is anonymized to protect client confidentiality. Specific details including organization size, timeline, and gap counts are representative of typical Marketplace Health Plan accreditation engagements.

Ready to Pursue URAC Marketplace Health Plan Accreditation?

Schedule a complimentary discovery call with Dr. Goddard to discuss your organization's accreditation goals and how IHS can support your path to accreditation.