According to data from the Congressional Research Service, more than 300 million Americans are insured through federally funded or state-licensed health plans. To ensure these plans meet operational expectations and provide satisfactory patient services, the federal government and state agencies require health plans to conduct healthcare surveys regularly.
However, the scope and scale of these surveys can create compliance challenges for health plans. Failure to meet regulatory requirements could lead to fines or sanctions, damaging the plan’s reputation and negatively impacting revenue. Forvis Mazars can help health plans navigate the evolving survey landscape, achieve compliance, and generate actionable insights from survey results. This article will examine current survey requirements, survey challenges, and ways to help streamline the process.
The Current State of Survey Requirements
Health surveys fall into two broad categories: regulatory and accreditation. State and federal agencies require regulatory surveys to ensure compliance with specific care standards, while accreditation surveys are mandated by organizations such as the National Committee for Quality Assurance (NCQA).
Health Plan Regulatory Surveys
These surveys focus on specific aspects of health plan service, such as timely access, provider satisfaction, and enrollee satisfaction. Plans may be subject to both federal and state level surveys.
Health plans that accept federal dollars are subject to federal survey requirements, such as those for timely access. According to the fact sheet for CMS-2439-F, managed care plans must ensure that wait times are no more than 15 business days for routine primary adult and pediatric care, and no more than 10 business days for outpatient mental health and substance use disorder services. States must conduct “secret shopper” evaluations and an annual enrollee experience survey, as well as submit annual payment analyses to evaluate compliance. While independent entities manage the secret shopper evaluations, states often offload the responsibility for experience surveys and payment analyses to health plans.
At the state level, three survey types are common:
- Provider Satisfaction – Provider satisfaction surveys measure provider satisfaction with plan processes and administration. These surveys typically involve contacting the provider via physical letter, phone call, or email and asking predetermined questions. States may set a minimum requirement for the percentage of providers that plans must contact to meet survey requirements.
- Enrollee Satisfaction – Enrollee surveys speak directly to plan members: What do they like about the plan? Where do they believe it could improve? Are they satisfied with the plan overall? These surveys are conducted similarly to provider surveys, where plans must query a minimum number of enrollees to meet state requirements.
- Timely Access – States also may require health plans to demonstrate they can meet timely access requirements. Depending on the state, plan administrators may have more or less freedom in survey processes.
For example, health plans in Colorado are responsible for creating and applying their own approach to survey data collection—as long as the end results satisfy state requirements and meet CMS standards, if applicable. In California, the Knox-Keene Health Care Service Plan Act of 1975 lays out stricter timely access reporting guidelines applicable to all state-licensed full-service health plans and specialized plans that provide mental health services. Under the act, health plans must directly contact a sampling of their network providers and identify each provider’s next urgent and non-urgent appointment. As of 2023, plans must demonstrate a 70% rate of compliance for both urgent and non-urgent care timelines. While California health plans have the option to add additional questions to their timely access survey, they must gain approval from the California Department of Managed Health Care (DMHC) before implementation. California health plans do have greater leeway in how they develop and execute enrollee and provider satisfaction surveys.
Health Plan Accreditation Surveys
In addition to regulatory surveys, health plans may need to complete accreditation surveys, such as those required by NCQA.1 Currently, 26 states require plans to be accredited by NCQA and another five states accept NCQA accreditation as part of a broader accreditation requirement, with more likely to adopt this standard moving forward. Key aspects of NCQA Health Plan Accreditation include consistent monitoring of practitioner availability and accessibility of services, practitioner directory usability and information accuracy, and efficient collection and analysis of member experience data.2 Moreover, plans must demonstrate their ability to perform multiple functions in alignment with NCQA standards, including quality management and improvement, population health management, network management, utilization management, credentialing and recredentialing, member rights and responsibilities, member connections, and the provision of benefits.
Four Survey Challenges for Health Plans
While it is possible for health plans to take on the task of creating surveys, obtaining responses, and keeping survey methods up to date, those who take an in-house approach often experience four common challenges:
- Diversion of Internal Resources – Managing multiple federal and state survey requirements simultaneously requires a significant resource investment. In practice, this means diverting internal resources away from mission-critical projects to create survey templates, draft compliance questions, contact providers, and record their answers.
- Difficulty in Obtaining Responses – Due to the demands on providers’ time and attention, it can be challenging for health plans to connect with providers and obtain survey responses. Furthermore, while health plans are required to conduct surveys, it is not mandatory for healthcare providers to complete them. Even with incentives for completing surveys or returning messages, providers may simply ignore plan requests, hindering the ability to meet minimum reporting requirements.
- New Regulatory Requirements – Regulatory requirements are constantly changing, making it difficult for health plans to keep pace. For example, the California DMHC completely changed its reporting process in 2016 and required health plans to use a new framework.
- Delivering Compliant Data – After recording survey data, health plans need to convert it into approved regulatory formats. This can be challenging if survey results are dispersed between telephone calls, email responses, and replies to physical documents. Failure to properly convert and report data may result in corrective action plans, sanctions, and fines.
Streamlining the Process With Forvis Mazars’ Survey Services
Forvis Mazars has the experience to help health plans achieve survey compliance and leverage survey data to inform operational improvements. Benefits of our survey services include:
- Customizable Collaboration – Health plans can choose their level of involvement with the survey process. For example, some plans prefer to build their own provider contact list, while others prefer a full-service approach. Forvis Mazars can meet health plans where they are in the survey process to help fill in missing pieces and address the biggest pain points, providing ongoing support and consistent communication from start to finish.
- Connecting the Dots on Data – Survey results not only satisfy compliance requirements, but also make it possible for health plans to connect the dots on data. For example, analysis of timely access survey data might reveal a provider pattern of low compliance, in turn prompting plans to investigate the root cause. Surveys might indicate falling enrollee satisfaction rates, leading to more in-depth inquiries to identify key issues. Forvis Mazars has developed proprietary tools tailored to the reporting process, allowing us to create detailed dashboards, progress reports, and key at-a-glance metrics to help health plans gain actionable operational insights.
- Transformational Experience – The introduction of timely access periods is transforming care standards—and will continue to do so over the next few years. Consider that along with access time requirements for routine care and certain specialist services, CMS also is allowing states to set maximum wait times for one additional service of their choice. With nearly a decade of experience helping health plans conduct surveys, Forvis Mazars can help companies navigate current requirements and prepare for ongoing transformation.
Our experienced Payor Services team can help health plans reduce regulatory stress, improve survey compliance, and leverage collected data to connect the dots for actionable insights. If you have questions or want to learn more, please reach out to one of our professionals.