Achieving Compliance with CMS's Appointment Wait Time Standards - Atlas Systems

For health plans with products on the federal exchange, there’s yet another hoop to jump through and another performance standard to satisfy. Adding to the ongoing struggle of maintaining accurate provider directory data, the Center for Medicare and Medicaid Services (CMS) will require health plans to conduct annual ‘secret shopper’ surveys to determine adequate provider access for consumers. In short, health plans on the exchange will now need to measure and document the timely availability of the providers in their network.

Published in April and updated in September 2024, the Appointment Wait Time Secret Shopper Survey Technical Guide provides extensive details regarding what this new requirement is meant to accomplish, how to conduct the surveys, the criteria for successful completion, and the very specific reporting necessary to satisfy this new requirement.

And while there’s no disputing this is yet another burden to manage and cost to incur, it doesn’t have to be insurmountable. Plus, there are even some potential benefits to this program if executed properly and creatively. But first, let’s cover some of the basic aspects of the CMS Appointment Wait Time (AWT) requirement. Here’s what you need to know:

• As indicated by the title, the program is designed to assess Appointment Wait Times for a new patient attempting to schedule an initial appointment within a defined time window.
• Notably, this process cannot be done in-house, but instead needs to be outsourced to an independent third-party partner not affiliated with the health plan.
• The wait time standard for primary care is 15 days or less, while a behavioral health appointment needs to be available within 10 days. Health plans will be required to survey specialists in future years, and the standard will be 30 days.
• The outreach effort will need to survey both in-person and telehealth visit options. And health plans will need to conduct the survey procedure for each unique provider network. On the plus side, provider data can be reused if/when the networks overlap.
• For the 2025 plan year, this applies to Qualified Health Plan (QHP) issuers, including stand-alone dental plan issuers, in the Federally-facilitated Exchanges.
• Starting in 2027, this will expand to include Medicaid Managed Care and Children’s Health Insurance Programs.
• Participating health plans are required to achieve a 90% compliance rate (with a confidence level of +/- 5%). Failure to achieve that threshold requires the plan to add providers to their network to eliminate identified gaps.
• CMS will be sending provider data file(s) in the September-October timeframe, and the health plan will need to complete this survey process between January and May of 2025, and then send the necessary reporting back to CMS.

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While this initially presents itself as an additional operational burden, the good news for network management and compliance teams is that all the heavy lifting will be borne by a vendor partner. And that IS good news given the non-trivial amount of detail, infrastructure, process and data crunching required to achieve a smooth, effective and ultimately beneficial outcome for the plan.

Simply put, the one real challenge facing your team is selecting a proven, experienced and capable survey partner. And Atlas, having conducted provider outreach for over 12 years, completed countless secret shopper surveys, and provided related data analysis and reporting for health plans, has the experience and proven track record to meet both your and CMS’ requirements.

While this may seem a tedious and burdensome exercise, we suggest this requirement presents at least two potential benefits to the plan. First, CMS is inadvertently providing you the opportunity to conduct a useful audit of your network, one that allows you to check your directory accuracy with a small but statistically valid sample. Given the constant scrutiny provider directories are under, having another ‘accuracy snapshot’ is good to have.

Second, this AWT ‘hurdle’ has an NCQA angle. With some design creativity and the addition of a few well-structured questions, the AWT survey process could contribute meaningfully to the health plan’s NCQA accreditation efforts. Of course, this requires close collaboration between plan and vendor partner, but the results have the potential to generate a positive ROI. And how often does that happen with CMS edicts?

Finally, CMS has done QHPs a favor by requiring a third-party to perform the surveys. The health plan simply contracts with a service provider skilled at outreach, system management, and data science (like Atlas.) By doing so, they 1) satisfy the CMS AWT requirement, 2) conduct a directory accuracy audit, and 3) contribute to one’s NCQA submission. All at once, and almost seamlessly.

Of course, there’s a lot more to the AWT requirement (which is spelled out in detail here) but the beauty is this: Find the right partner and your needs are easily fulfilled.

Need help with meeting CMS’s appointment wait time requirements?

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