A new ruling by CMS regarding the Qualified Health Plan (QHP) requires issuers to ensure that patients can schedule appointments within the time frames listed below at least 90% of the time:
Behavioral Health: 10 business days
Primary Care: 15 business days
Specialty Care (Non-Urgent): 30 business days
“Secret shopper” calls will be made by third party entities to conduct assessments in order evaluate compliance with these wait time standards in the areas of primary care and behavioral health. As part of this process, your practice could be selected to participate in a secret shopper survey as well. These surveys will begin in January of 2025 and be completed by May 31, 2025.
As a best practice to prepare your clinic, review your scheduling processes to ensure new patients can be seen in the time frames required by this new ruling. Be sure your staff understands the need to comply with these new standards and is prepared for these calls.
For more information, please visit the CMS website.