20-790 2019 Provider Appointment Availability and After-Hours Access Survey Results
Date: 10/02/20
This information applies to Physicians, Participating Physician Groups (PPGs) and Ancillary providers.
Summary
See how results compared to the previous year
The Department of Managed Health Care (DMHC), Centers for Medicare & Medicaid Services (CMS) and California Department of Insurance (CDI) have requirements to ensure health care services are provided to patients in a timely manner appropriate for the nature of the patients’ conditions and consistent with good professional practice. The surveys measure how well providers comply with DMHC, CMS and CDI availability and access requirements.
The complete provider update, 20-790, 2019 Provider Appointment Availability and After-Hours Access Survey Results covers the below content in detail:
- Corrective action plan (CAP) when timely access to care standards are not met.
- Tips to help maintain appointment access standards and after-hours messaging.
- Resources to help comply with appointment availability and after-hours access standards.
- Complete 2019 Provider Appointment Availability Survey (PAAS) and Provider After-Hours Access Survey (PAHAS) results.
The complete update is available in the Provider Library under Updates and Letters, then search for provider update 20-790. Providers who do not have access to the Internet may request a print copy of update 20-790 by contacting the Provider Communications Department by email.
Areas for improvement
Based on 2019 PAAS survey results, the below appointment access metrics did not meet the performance goal as indicated:
HMO/POS (DMHC-regulated) results (80% performance goal)
- Urgent care appointment with PCP within 48 hours.
- Urgent care appointment with a specialist within 96 hours.
- Non-urgent care appointment with a specialist within 15 business days.
Medicare Advantage (CMS-regulated) results (80% performance goal)
- Urgent care appointment with PCP within 48 hours.
- Urgent care appointment with a specialist within 96 hours.
- Non-urgent care appointment with a specialist within 15 business days.
PPO/EPO (CDI-regulated) results (90% performance goal)
- Urgent care appointment with PCP within 48 hours.
- Urgent care appointment with a specialist within 96 hours.
- Non-urgent care appointment with a specialist within 15 business days.
Complete
See how results compared to the previous year
The 2019 annual Provider Appointment Availability Survey (PAAS) and Provider After-Hours Access Survey (PAHAS) results are in. The results are from a random sample of participating primary care physicians (PCPs), specialty care providers (SCPs), ancillary providers, and non-physician mental health providers (NPMH) surveyed from August 2019 through December 2019.
The surveys comply with the Department of Managed Health Care (DMHC), the Centers for Medicare & Medicaid Services (CMS) and the California Department of Insurance (CDI) timely access regulations. The survey results are used to monitor provider compliance with timely appointment availability and after-hours access standards, and evaluate the effectiveness of the network to meet the needs and preferences of Health Net members.
Failure to meet one or more timely appointment and after-hours access standards, as indicated, will result in a corrective action plan (CAP).
2019 Provider Appointment Availability Survey results
Availability and access requirements are designed to ensure that health care appointments are provided to patients in a timely manner appropriate for the nature of the patient’s condition and consistent with good professional practice.
The results of the 2019 PAAS survey reflect a need for improvement in several areas. The following appointment access metrics did not meet the performance goal as indicated:
HMO/POS (DMHC-regulated) results (80% performance goal)
- Urgent care appointment with PCP within 48 hours.
- Urgent care appointment with a specialist within 96 hours.
- Non-urgent care appointment with a specialist within 15 business days.
Medicare Advantage (CMS-regulated) results (80% performance goal)
- Urgent care appointment with PCP within 48 hours.
- Urgent care appointment with a specialist within 96 hours.
- Non-urgent care appointment with a specialist within 15 business days.
PPO/EPO (CDI-regulated) results (90% performance goal)
- Urgent care appointment with PCP within 48 hours.
- Urgent care appointment with a specialist within 96 hours.
- Non-urgent care appointment with a specialist within 15 business days.
Refer to the tables on pages 2–4 for the appointment availability results overall.
Measurement year (MY) 2019 and MY 2018 provider appointment availability results summary – overall
| Access measure | Appointment standard (wait time) | Performance goal | MY2019 rate (%) | MY2018 rate (%) |
|---|---|---|---|---|
| Urgent care appointment with PCP that does not require authorization | 48 hours of request | 80% | 71.0^ | 62.5 |
| Urgent care appointment with specialist that requires prior authorization | 96 hours of request | 80% | 60.6^ | 59.1 |
| Non-urgent appointment with PCP | 10 business days of request | 80% | 87.0^ | 81.1 |
| Non-urgent appointment with specialist | 15 business days of request | 80% | 73.7^ | 70.9 |
| Non-urgent ancillary appointment for magnetic resonance imaging (MRI), mammogram, physical therapy | 15 business days of request | 80% | 97.1↓ | 98.8 |
| Access measure | Appointment standard (wait time) | Performance goal | MY2019 rate (%) | MY2018 rate (%) |
|---|---|---|---|---|
| Urgent care appointment with PCP or specialist | 48 or 96 hours of request | 80% | 66.0 | N/A |
| Non-urgent appointment with PCP or specialist | 10 or 15 business days of request | 80% | 82.0 | N/A |
| Access measure | Appointment standard (wait time) | Performance goal | MY2019 rate (%) | MY2018 rate (%) |
|---|---|---|---|---|
| Urgent care appointment with psychiatrist | 96 hours of request | 90% | 51.2↑ | 46.2 |
| Non-urgent appointment with psychiatrist | 15 business days of request | 90% | 76.3↓ | 83.6 |
| Urgent care appointment with non-physician mental health provider (NPMH) | 96 hours of request | 90% | 61.5↓ | 71.5 |
| Non-urgent appointment with NPMH provider | 10 business days of request | 90% | 74.1↓ | 89.3 |
| Access measure | Appointment standard (wait time) | Performance goal | MY2019 rate (%) | MY2018 rate (%) |
|---|---|---|---|---|
| Urgent care appointment with PCP that does not require authorization | Within 48 hours of request | 80% | 63.2^ | 58.3 |
| Urgent care appointment with specialist1 that requires prior authorization | Within 96 hours of request | 80% | 56.1^ | 60.6 |
| Non-urgent appointment with PCP | Within 10 business days of request | 80% | 87.5^ | 81.2 |
| Non-urgent appointment with specialist1 | Within 15 business days of request | 80% | 77.1^ | 72.7 |
| Non-urgent ancillary appointment for magnetic resonance imaging (MRI), mammogram, physical therapy | 15 business days of request | 80% | 97.1^ | 98.4 |
| Access measure | Appointment standard (wait time) | Performance goal | MY2019 rate (%) | MY2018 rate (%) |
|---|---|---|---|---|
| Urgent care appointment with PCP or specialist | 48 or 96 hours of request | 80% | 60.0 | N/A |
| Non-urgent appointment with PCP or specialist | 10 or 15 business days of request | 80% | 82.0 | N/A |
| Access measure | Appointment standard (wait time) | Performance goal | MY2019 rate (%) | MY2018 rate (%) |
|---|---|---|---|---|
| Urgent care appointment with psychiatrist | 96 hours of request | 90% | 52.5 | 48.3 |
| Non-urgent appointment with psychiatrist | 15 business days of request | 90% | 76.4 | 82.4 |
| Urgent care appointment with non-physician mental health provider (NPMH) | 96 hours of request | 90% | 60.2¯ | 67.7 |
| Non-urgent appointment with NPMH provider | 10 business days of request | 90% | 71.3¯ | 85.5 |
| Access measure | Appointment standard (wait time) | Performance goal | MY2019 rate (%) | MY2018 rate (%) |
|---|---|---|---|---|
| Urgent care appointment with PCP that does not require authorization | Within 48 hours of request | 90% | 60.3^ | 62.0 |
| Urgent care appointment with specialist1 that requires prior authorization | Within 96 hours of request | 90% | 50.7^ | 55.0 |
| Non-urgent appointment with PCP | Within 10 business days of request | 90% | 85.5^ | 80.8 |
| Non-urgent appointment with specialist1 | Within 15 business days of request | 90% | 71.7^ | 67.7 |
| Non-urgent ancillary appointment for magnetic resonance imaging (MRI), mammogram, physical therapy | 15 business days of request | 90% | 97.5^ | 98.6 |
| Access measure | Appointment standard (wait time) | Performance goal | MY2019 rate (%) | MY2018 rate (%) |
|---|---|---|---|---|
| Urgent care appointment with PCP or specialist | 48 or 96 hours of request | 90% | 55.0 | N/A |
| Non-urgent appointment with PCP or specialist | 10 or 15 business days of request | 90% | 78.0 | N/A |
| Access measure | Appointment standard (wait time) | Performance goal | MY2019 rate (%) | MY2018 rate (%) |
|---|---|---|---|---|
| Urgent care appointment with psychiatrist | 96 hours of request | 90% | 40.4^ | 50.9 |
| Non-urgent appointment with psychiatrist | 15 business days of request | 90% | 76.3^ | 60.6 |
| Urgent care appointment with non-physician mental health provider (NPMH) | 96 hours of request | 90% | 49.5^ | 63.9 |
| Non-urgent appointment with NPMH provider | 10 business days of request | 90% | 74.1^ | 85.3 |
^Rates cannot be compared to MY2018 due to change in the survey methodology.
N/A – not applicable for the measurement year
2019 after-hours access survey results
A new survey vendor was used for the 2019 PAHAS. Performance guidelines require 90% compliance for after-hours access. Overall results for 2019 PAHAS indicate both metrics were met. The following tables display the after-hours results overall and by county. The results indicate there is a statistically significant increase in the performance score compared to the previous year for both measures.
MY 2019–MY 2018 Medi-Cal provider after-hours availability results – overall
| Access measure | Appointment standard (wait time) | Performance goal | MY2019 rate (%) | MY2018 rate (%) |
|---|---|---|---|---|
| After-hours emergency instructions | Give members clear and appropriate instructions for emergency issues | 80% | 93.4↑ | 87.5 |
| Contact on-call physician after hours (for urgent issues) | Callback within 30 minutes | 80% | 91.2↑ | 65.7 |
| Access measure | Appointment standard (wait time) | Performance goal | MY2019 rate (%) | MY2018 rate (%) |
|---|---|---|---|---|
| After-hours emergency instructions | Give members clear and appropriate instructions for emergency issues | 80% | 93.9↑ | 87.0 |
| Contact on-call physician after hours (for urgent issues) | Callback within 30 minutes | 80% | 92.4↑ | 62.9 |
| Access measure | Appointment standard (wait time) | Performance goal | MY2019 rate (%) | MY2018 rate (%) |
|---|---|---|---|---|
| After-hours emergency instructions | Give members clear and appropriate instructions for emergency issues | 90% | 90.7↑ | 83.3 |
| Contact on-call physician after hours (for urgent issues) | Callback within 30 minutes | 90% | 90.2↑ | 60.9 |
¯ Statistically significant difference between MY 2019 vs. MY 2018, p < 0.05.
Corrective action plan (CAP)
DMHC regulations (28 CCR §1300.67.2.2(d)(3)) require that Health Net investigate and request corrective action when timely access to care standards are not met. To comply with these requirements and meet the plan’s compliance requirements, as delineated by Health Net’s appointment accessibility policy and provider operations manual, a CAP will be issued to contracted participating physician groups (PPGs) and provider offices who fail any of the urgent or non-urgent metrics.
PPGs and providers who receive a CAP are required to:
- Submit a written improvement plan (IP) within 30 calendar days, including the actions taken to correct each deficiency.
- Attend an online provider training webinar, hosted online by Health Net, as part of their IP.
Providers with questions or concerns regarding their ability to meet these standards may contact Health Net via email.
Maintaining access standards
Providers should review current office scheduling practices and after-hours protocol periodically to ensure they are accurate and meet current guidelines. Orientation for new staff, office staff and answering service staff should include the appointment access standards and after-hours procedures and scripts. Providers can test their own appointment scheduling and after-hours practices by scheduling self-audits or secret shopper calls to verify appointment standards are met and after-hours outbound messaging is appropriate and take steps to correct any issues identified. The goal of reasonable access to care is essential for member safety and is monitored annually. After-hours script templates can be found online (see Resources) and are available in English, Spanish and other threshold languages.
Resources
Research shows that high patient satisfaction is linked to better health outcomes. For help in complying with appointment access standards, refer to the resources online in the Provider Library.
Included with the CAP packets is the Improve Health Outcomes: A Guide for Providers toolkit for participating providers. The toolkit includes information, support tools and resources that focus on drivers of patient satisfaction:
- Health Care Performance Measurement Systems
- QI Activities
- Timely Appointment Access
- Advance Access
Implementing just one practice intervention can make a big difference to an organization and a patient’s experience. The brochure is available electronically through Health Net's Provider Portal. Select QI Corner > Working with Health Net > Quality. Under Provider Resources, select Improve Health Outcomes: A Guide for Providers.pdf.
Additional information
Providers are encouraged to access the provider portal online at provider.healthnet.com for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact the applicable Health Net Provider Services Center within 60 days at:
| Line of Business | Telephone Number | Provider Portal | Email Address |
|---|---|---|---|
| EnhancedCare PPO (IFP) | 1-844-463-8188 | provider.healthnetcalifornia.com | provider_services@healthnet.com |
| EnhancedCare PPO (SBG) | 1-844-463-8188 | provider.healthnet.com | provider_services@healthnet.com |
| Health Net Employer Group HMO, POS, HSP, PPO, & EPO | 1-800-641-7761 | provider.healthnet.com | provider_services@healthnet.com |
| IFP (CommunityCare HMO, PPO, PureCare HSP, PureCare One EPO) | 1-888-926-2164 | provider.healthnetcalifornia.com | provider_services@healthnet.com |
| Medicare (individual) | 1-800-929-9224 | provider.healthnetcalifornia.com | provider_services@healthnet.com |
| Medicare (employer group) | 1-800-929-9224 | provider.healthnet.com | provider_services@healthnet.com |