How to achieve compliance with Centers for Medicare & Medicaid Services (CMS) wait time standards
The healthcare landscape just got more demanding. Starting January 1, 2025, Qualified Health Plan (QHP) issuers on the federal exchanges must meet strict new standards for initial appointment wait times. This means proving that 90% of the time, new patients can schedule primary care and behavioral health appointments within 15 and 10 days, respectively. Fail to comply? You’ll need to expand your network.
Decoding the New Appointment Wait Time Standards
CMS is tackling the growing problem of long wait times head-on. The new standards, which must be assessed by a third party unaffiliated with the health plan (more on that below), require QHPs to demonstrate timely access to care. Here’s a breakdown of the standards:
- Primary Care: Appointments within 15 days
- Behavioral Health: Appointments within 10 days
- 90% Compliance Target: Health plans must meet this target with a confidence level of +/- 5% or face mandatory network expansion.
Specialists will be surveyed in future years and that standard will be 30 days.
The Stakes Are High: Why CMS is Prioritizing Wait Times
Long wait times create barriers to care, frustrate patients, and can have serious consequences for health outcomes. As the media has reported, in some cases, patients are not able to schedule an appointment for 6-12 months from the first time they reach out for care.
CMS is “particularly concerned with the ability of new patients to schedule appointments with in-network providers” and secret shopper calls, from independent third-party entities, must take place from January to May of this year.
CMS is taking action to address this issue, recognizing the urgent need for timely access to both primary care and behavioral health services.
Navigating the CMS Assessment Process
The CMS wait time requirements will be assessed during annual secret shopper surveys conducted by independent third-party entities hired by the health plans. The standards are detailed in CMS’ Appointment Wait Time Secret Shopper Survey Technical Guidance for Qualified Health Plan (QHP) Issuers in the Federally-facilitated Exchanges (FFEs).
The completed surveys must be submitted to CMS with compliance rates, percentage of non-responsive providers, and contracts with third-party entities. Submissions are due in mid-June.
Veda: Your Partner in Achieving and Exceeding CMS Compliance
Veda’s proprietary provider data technology can help QHPs meet and exceed the wait time standards issued by CMS.
Meeting these new standards requires accurate, real-time data on provider availability. This is where Veda shines.
The first step in ensuring you can deliver on wait time requirements is auditing your directories for accurate provider-at-location data and keeping those records current.
Then, Veda can help you identify and strategically fill gaps in your network for known provider needs (from an adequacy perspective), particularly PCPs and Telehealth. This will ensure adequate access to care across all specialties and service areas.
Veda’s Dashboard: Your CMS Audit Command Center
Veda’s intuitive dashboard provides a clear, real-time view of your provider data accuracy. View your performance through a simulated CMS audit score, identify areas for improvement, and take proactive steps to ensure compliance.
Offering profiles on providers and roster automation, Veda offers true directory accuracy for providers, facilities, and groups. Veda’s solutions can help you not only meet the new CMS wait time standards but exceed them, all while enhancing your member satisfaction and solidifying your position in the market.
Don’t wait for secret shopper surveys to reveal gaps in your network. Request a demo from Veda today and ensure you are ready for this new era of provider data accuracy. By identifying and addressing gaps in your network with Veda’s powerful analytics, you are ensuring adequate access to care across all specialties and service areas.
