In California, the Knox-Keene Act requires state-licensed health plans to follow timely access reporting guidelines to help ensure that plan members can access urgent and non-urgent appointments with covered providers within prescribed time-elapsed standards. While the goal is to support better health for Californians, frequently changing regulations and strict provider survey requirements present compliance challenges for health plans.
For example, over the past two years, the California Department of Managed Health Care (DMHC) has made a series of changes to timely access requirements that have been a source of frustration for health plans. In measurement year 2023, DMHC removed weekends and holidays from the urgent appointment calculation, which led to an increase in health plans meeting the standard for compliance. However, DMHC has once again included those days in the calculation for measurement year 2024, resulting in a drop in compliance to pre-2023 levels.
This moving of the compliance goal posts has been difficult for health plans to make sense of, and it fails to account for underlying issues like the shortage of providers compared to the number of Californians who need care. However, there are proactive steps plans can take to make inroads to compliance and mitigate the loss of productivity and capital.
Proactive Steps to Improve Timely Access Compliance
Timely access compliance challenges are often related to two factors: low provider availability and low response rate to the Provider Appointment Availability Survey (PAAS). These challenges apply across a wide range of providers, but they are especially prevalent among mental health specialties, which tend to be single-provider offices that lack staff to answer phones and respond to survey outreach.
Health plans should consider the following strategies to help improve provider appointment availability and response rates:
- Adding telehealth provider groups to your network – DMHC recently updated PAAS requirements to collect data on in-person versus telehealth appointments. Telehealth providers can help ease the burden on the network of in-person providers, and our professionals have seen an increase in timely access compliance among health plans that have added large telehealth groups. Some plan members are hesitant to seek care virtually, but health plans can help make members feel comfortable with telehealth visits through communication and education.
- Using past years’ data to prepare for the current year’s provider outreach – When Forvis Mazars assists health plans with timely access surveys, we use multiple years of past data to identify provider groups with low response rates and work with leadership to develop an outreach strategy to help increase eligible responses.
- Coordinating provider outreach with other health plans – This can help ease the burden on providers during survey season by reducing the number of phone calls or emails they receive.
- Prioritizing email outreach – Email is often more convenient for providers than phone outreach, as it allows for more flexibility and a longer time frame to respond—up to 15 business days after receiving the email compared to two days after receiving a phone call. The initial credentialing process is an opportunity for health plans to collect email addresses from the appropriate contact—typically an office manager or administrative professional—at each in-network provider to help ensure surveys make it into the right hands.
- Educating providers about the survey process – In many cases, provider apprehension contributes to a low response rate. A proactive strategy for provider relations and education can help alleviate this apprehension by letting providers know in advance the purpose of the survey, when to expect survey outreach, how they will be contacted, e., phone or email, and from whom the outreach will come. Such an approach can help foster a sense of collaboration between health plans and their provider networks, which can in turn lead to greater cooperation in the survey process.
- Utilizing extraction via phone or web-based tools – Extraction—working directly with provider groups to schedule and complete multiple surveys at a single time—can help reduce fatigue for both health plans and providers and increase response rates. This strategy can be effective for groups as small as 10 providers, and it can be executed either over the phone or using web-based tools with individual encrypted links that allow providers to complete the survey online. Forvis Mazars has worked with health plans to monitor survey outreach in real time and identify opportunities to utilize extraction and facilitate bulk completion of surveys.
- Reviewing provider comments and addressing concerns – While PAAS is not part of the standard grievance or provider dispute resolution process, some respondents use it as a mechanism to voice concerns with the health plan. It is important to dedicate time to review provider comments and identify any that should be forwarded to your provider relations team. For example, some providers may indicate that they are dissatisfied with your plan’s billing protocols, or that they don’t believe they are part of your network. When your plan is aware of such concerns, you can work to address them and improve provider relations, which in turn can increase cooperation and survey participation in the future.
Addressing Structural Obstacles to Provider Availability & Compliance
The above strategies can help improve compliance among existing providers. Addressing provider shortages is a more difficult challenge, but there are things health plans can do to help drive change. These approaches may not yield immediate results, but they can help foster improvement in the long run.
For example, plans can collaborate with colleges, universities, and the larger community to develop grassroots strategies for recruiting students for medical programs, especially in areas of high need such as mental health services. Encouraging academic institutions to revisit the curriculum and administrative requirements for mental health programs can also be an effective strategy.
Health plans can also work to educate DMHC on their pain points when it comes to timely access compliance. Raising awareness about provider shortages and related challenges may lead to more collaborative approaches to compliance, instead of regulatory changes that plans often find frustrating or arbitrary.
How Forvis Mazars Can Help
Our Payor Services team at Forvis Mazars has extensive experience with helping health plans achieve regulatory excellence as they navigate timely access surveys and other requirements for compliance. We work with plans in California to support the PAAS process, as well as plans across the U.S. that are subject to evolving federal timely access regulations. If you have questions or need assistance with regulatory compliance at your health plan, please reach out to our professionals today.