By March 31 of each year (until Measurement Year 2023 wherein the date changes to May 1), healthcare plans are required to submit a Timely Access compliance report that includes information related to monitoring network access and network rates of compliance to the California Department of Managed Health Care (DMHC). Over the years, this report, the Provider Appointment Availability Survey (PAAS), has evolved as the DMHC continues to incorporate feedback and make improvements.
Recently, California’s Office of Administrative Law approved new regulations related to Timely Access to health care, which will take effect on April 1, 2023. These additions include changes in the rate of compliance (ROC), survey scope/execution, telehealth, the Senate Bill 221 law, and remediation.
Additionally, the DMHC has expanded the types of specialist positions that are included in PAAS, including dermatology, neurology, oncology, ophthalmology, otolaryngology, pulmonology and urology.
As this new regulation unfolds, health plans should focus on the newly established Rate of Compliance and the subsequent compliance monitoring and CAP requirements.
The Rate of Compliance (ROC)
Health plans are required to report compliance rates, which are defined as the proportion of eligible survey respondents who had an appointment available within the time-elapsed standard. One of the most significant methodology changes for the measurement year (MY) 2023 is the establishment of a ROC. While the ROC has always been calculated and presumably reviewed by the DMHC, new regulations now set a specific threshold.
Starting in 2023, the ROC is 70% across each network for both appointment types, urgent and non-urgent. The thought is that if a user doesn’t get an appointment with the first provider or second provider, they should be able to get an appointment with the third provider about 98% of the time.
With ROC, healthcare organizations will be able to abide by all rules and regulations set by federal and state agencies. For health providers, having a high ROC ensures that patients are being treated properly, in accordance with the goals of providing high-quality and safe care to all.
As well as establishing a ROC, healthcare plans will need to develop corrective action frameworks for networks that do not meet the 70% threshold. After three months of implementation of the Corrective Action Plan, plans will have to submit an amendment to the department to demonstrate compliance.
Also, new regulations include additional details about the quality assurance processes that plans must follow to monitor their timely access and network adequacy on an ongoing basis.
Survey Scope and Execution
While survey sample sizes established in the MY of 2019 continue to be used, a new regulation requires plans to meet a minimum sample size for each county. If the plan does not survey sufficient providers to meet the required sample size, they must include it in the Quality Assurance Report. They also must explain why the health plan failed and what corrective actions will be taken to ensure meeting the requirements in the next year.
Another area where we see change is telehealth. While the telehealth county historically has included providers who offer both telehealth and in-person appointments, going forward the telehealth county will consist of providers who only offer telehealth. Providers who offer both telehealth and in-person appointments will only be surveyed in association with their physical offices. Providers are still able to respond with telehealth appointments, if available.
Additionally, when beginning surveys, plans must inform providers that they can respond with in-person or telehealth appointments. When giving appointment times and dates, if a provider does not specify the appointment type, surveyors should ask whether the appointment time/date is for an in-person or a telehealth appointment.
Finally, for providers listed as offering both telehealth and in-person appointments, the results should be recorded at the physical location of the provider.
All that said, given some of the confusion about the current language related to telehealth within the PAAS methodology, we anticipate the DMHC will likely provide more guidance. Users should keep an eye out for the DMHC FAQS.
Senate Bill 221
Now that Senate Bill 221 has been codified, a law that guarantees Californians the right to timely mental health and substance abuse disorder therapy sessions, health plans have several options. The additional follow-up appointment survey for non-physician mental health providers can be conducted separately from the rest of the PAAS survey. But it makes the most sense to ask additional questions regarding mental health provider follow-up appointments during the same time frame as an organization’s PAAS outreach.
The additional follow-up appointment questions only apply to non-physician health providers. These include Licensed professional clinical counselors, psychologists, marriage and family therapists and social workers.
For health plans licensed in California, the PAAS and related timely access reporting requirements can be complex and resource-intensive to complete. But adhering to the changes in the methodology of measurement for MY 2023, while tapping into experienced resources, can help your organization successfully perform PAAS.
By utilizing in-house programming and survey outreach, innovative data analytics and quality assurance techniques, as well as in-depth knowledge of the California managed care regulatory landscape, practices can perform PAAS in a way that suits any unique situation an organization may have.
Sunshine Strong is a Data Services Manager at Mazars in the US.