Spotlight on Provider Access to Care Requirements

In light of the increased number of insured consumers, health plans with narrow networks, and consumer complaints about access to care, CMS and NCQA are expanding expectations and reporting requirements for ensuring network adequacy and timely access to care.

There is evidence of the expanding expectations and reporting requirements in the Notice of Proposed Rulemaking for the 2017 Benefit and Payment Parameters for issuers participating in Federally Facilitated Exchanges and in the Medicaid and Children’s Health Insurance Program (CHIP) managed care final rule (2016).

CMS Expectations and Requirements

In the recent Medicaid Final Rule, the Centers for Medicare and Medicaid Services (CMS) addressed the need to establish some consistency in access standards and reporting measures for Medicaid, Medicare, and QHPs while being mindful of existing standards at the State level.

CMS is looking at the option to “add a wait time standard as an option under the proposed permissible State standards” or to “apply a broad set of wait time standards.” 

NCQA Access to Care Requirements 

Similarly, the NCQA has expanded its health plan accreditation standards to include additional elements and reporting for member/patient access to care and appointment availability.

Following is a summary of the 2016 NCQA health plan accreditation standards requiring plans to perform either a member survey or provider office survey/audit to assess and/or measure availability and timeliness of provider appointments.  

NCQA Health Plan Accreditation
Category:  Network Management – Standard 2:  Accessibility of Services

The focus or intent of this standard is to hold the organization accountable for ensuring appropriate and timely access to providers and appointments for:

• Primary care
• Behavioral healthcare treatment/counselling
• High volume specialty care

NCQA is looking for the plan to show evidence of monitoring appointment availability through valid data collection and conducting an analysis of the data. NCQA suggests this can be done via a member survey or practitioner self-report feedback or information (i.e., Provider Access Survey/Audit).

Element A focuses on Access to Primary Care

NCQA specifies three primary care appointment types to be monitored.  However, NCQA does not specify the acceptable timeframe standard (to be specified by the plan):

1. Regular/Routine Appt. (Example of within 30 days is noted)
2. Urgent  (Example = 48 hours)
3. After Hours Care (Example = phone call from an appropriate practitioner within an hour of the member contacting the organization)

Element B focuses on Access to Behavioral Health

Similarly, NCQA is looking for confirmation of appointment availability by two types of behavioral health providers: 1) practitioners who prescribe medications (e.g., psychiatrists) and
2) behavioral healthcare practitioners who do not prescribe (e.g., psychologists)

Both the types of appointments and timeframe standards are specified by NCQA:

1. Regular/Routine within 10 business days
2. Urgent within 48 hours
3. Non-life threatening emergencies (within 6 hours)

Element C – Access to Specialty Care to include high volume and high impact

Element C is a new Element added in 2016. NCQA allows the plan to identify high volume and high impact specialty care providers. However, NCQA does specify that:

“… at a minimum, high-volume specialties include obstetrics/gynecology and high-impact specialties include oncology. If obstetricians are not appropriate for the population (i.e., Medicare), the organization may measure only gynecologists to meet the requirement.” 

Similar to Elements A and B, NCQA suggests data be collected via a member survey or provider self-report (i.e., Provider Access Survey/Audit).

Types of appointments and timeframe standards for this new element are not specified by NCQA; and, therefore, would be determined by the plan.

Support for Provider Access to Care Standards and Reporting Requirements

Not surprisingly, many health plans struggle to develop a comprehensive program or commit the resources needed to continually monitor compliance with access to care standards. That’s why healthcare organizations look to SPH Analytics to conduct and manage their access to care audits. We have been conducting Provider Provider Access Surveys/Audits and reporting for more than a decade.

We understand the importance of access to care performance measures to providers and health plans, as well as the complexity they face when capturing time sensitive data. In response, SPH Analytics has developed a standardized Provider Access Survey/Audit for contacting the provider office about access and appointment availability. By standardizing each point of data collection and survey execution, we are able to ensure the accuracy and reliability of data findings.

To support the NCQA standard (NET 2) noted above, clients may opt to conduct our Provider Access to Care Surveys/Audits or our Member Access to Care Survey. The Member Access to Care Survey is sent to members and asks about their most recent experience accessing care. Clients also have the option to conduct both surveys to get both the member and provider perspective for a defined period of time.

Resources and Guidance

SPH Analytics remains focused on supporting the multiple measurement and reporting needs of health plans seeking to achieve high scores/ratings and NCQA accreditation. Our teams work closely with our clients, industry influencers, and regulatory agencies to quickly respond to the needs of the healthcare community. We provide resources and step-by-step guidance to help our clients meet important healthcare requirements, improve scores and ratings, and provide enhanced patient care.

Contact us to learn how SPH Analytics can help you meet access to care requirements, improve performance, and deliver qua