PROVIDER APPOINTMENT AVAILABILITY SURVEY SERVICES
By Laura Peth, MPA, CHC, CFE
For health plans licensed in the State of California, the provider appointment availability survey (PAAS) and related timely access reporting (TAR) requirements can be complex and resource-intensive to complete.
While the California Department of Managed Health Care (DMHC) requires the use of an outside vendor validator, many plans also use outside vendors to execute the PAAS itself as well as to review their timely access policies and processes to ensure compliance. As the DMHC works towards codification of the PAAS regulations in measurement year (MY) 2020, it is important to understand the current state of PAAS regulation and enforcement, as well as ask any potential vendor the right questions to ensure they will meet your needs.
The healthcare advisors from Mazars USA anticipate the MY 2020 methodology to be very similar to MY 2019; however, it is important to note that the current draft regulation still leaves room for the DMHC to modify the methodology from year-to-year. The following items were new in MY 2019 and we can anticipate their inclusion in MY 2020:
- Increased target sample sizes for multi-county plans
- Telehealth providers surveyed as their own county
- Inclusion of providers out on vacation or leave as eligible surveys
- Required inclusion of contracted providers located outside of a health plan’s service area
- Providers shall be surveyed only once with the response applied to the provider for all
relevant networks rather than “only once in a single county” as in MY 2018
- Shorter pause between waves – 3 weeks instead of 6 weeks as in MY 2018
- Exclusion of holidays from day counts
Timely access-related penalties can be costly and have ranged from as low as $1,000 to as much as $4 million. According to the DMHC, penalties include:
- 2014: $4 million penalty against a health plan in violation of behavioral health timely access requirements
- 2015: $600,000 combined penalty against health plans for inaccurate provider directories
- 2017: Dozens of plans received penalties from $3,000 and up for failure to report accurate PAAS data
- 2018: Dozens of plans received penalties from $2,500 and up for failure to report accurate PAAS data and/or properly file timely access reports
THE RIGHT APPROACH TO PAAS
There are many PAAS vendors in the marketplace, but very few check all the boxes and provide comprehensive and quality PAAS results. In the face of likely increasing and more costly enforcement actions, plans should ask the following questions regarding four main categories of service:
Any vendor you choose should provide collaborative and strategic project management with regular communication regarding the PAAS process – including issues related to provider directory accuracy, data anomalies, or outreach.
- Will you ensure timely milestone achievement through schedule setting?
- Is your team able to remain flexible and change the outreach schedule to accommodate unexpected issues?
- Will you regularly update us on all aspects of the PAAS project both through in-person meetings and written project status reports?
- Does your team have extensive California managed care regulatory and operational experience that enables you to provide advice on DMHC regulatory matters related to PAAS?
Your vendor’s data management team must be able to receive your provider data and develop your provider contact list (PCL), including performing all data cleaning and de-duplication, in-house. Strict adherence to the DMHC methodology and internal quality assurance standards are imperative during this step as mistakes within the PCL preparation and sampling processes affect the rest of the survey and can rarely be fixed retroactively.
Strict adherence to the DMHC methodology and internal quality assurance standards are imperative during this step as mistakes within the PCL preparation and sampling will affect the rest of the survey and can rarely be fixed retroactively.
- How knowledgeable is your team of the DMHC’s PAAS methodology and how it both relies on and impacts related DMHC-filings?
- How do you ensure all appropriate networks and lines of business are included?
- How do you ensure participating provider groups are correctly and completely identified?
- Will you clean, scrub, de-duplicate, and review provider categorization in-house?
- Do you have a superior de-duplication process that adheres to the DMHC methodology while also going beyond it to produce the most efficient survey process possible?
- Do you utilize an in-house programmer and an internal and secure server to ensure data integrity
- Can your team handle multiple, overlapping plan networks to most efficiently outreach to providers and decrease burn out?
- Does your team use innovative technology to perform constant data management and quality control tasks, such as robotic process automation (RPA)?
- Does your team perform extensive quality assurance and validation to ensure the PCL and sample selected is accurate and in compliance with the DMHC methodology?
Survey execution is the most resource-intensive portion of the PAAS process. Ensuring your vendor has a deep understanding of the DMHC methodology as well as appropriate processes in place to monitor and report on survey outreach progress and outcomes is an absolute necessity.
- Do you offer a customized survey tool that:
- Is compliant with DMHC methodology?
- Stores all survey data in one secure location with strong internal controls and data management?
- Allows for live monitoring of survey activity regardless of how outreach is performed?
- Houses all provider contact data and surveyor contact information to ensure timely completion of outreach in accordance with the Three Step Protocol?
- Includes additional and more specific outcome categories that allow for a deeper understanding of any access issues while still mapping to and adhering to DMHC requirements?
- Do you utilize and directly supervise survey staff with both customer service and healthcare experience in a local office to perform telephonic outreach?
- Do you monitor results throughout survey execution?
- Do you communicate regularly regarding any conclusions from the PAAS process including issues related to provider directory accuracy?
- Do you provide weekly reports on survey results throughout survey execution – not just at the end – that include details such as survey progress, outcomes summaries, outcomes details, and provider information updates?
To be effective, quality assurance and validation measures must be woven into the entire PAAS process, from start-to-finish. If your vendor only performs quality assurance and validation procedures at the end of its PAAS services, they are worthless.
- Do you complete a specifically-designed Quality Assurance Checklist Tool throughout the PAAS process to document and validate all PAAS-related tasks including sign-offs by the client and/or outside vendor validator at major milestones?
- Do you review and validate actions at certain key checkpoints, such as:
- Inclusion of appropriate network and provider type?
- Compilation of the PCLs using G data and mapping client fields to template fields?
- Providers within the PCLs are appropriately categorized and no provider is duplicated?
- Sampling is performed in accordance with DMHC’s survey methodology?
- Correctly designed survey tool the adheres to the DMHC methodology and records data in the necessary formats?
- Survey outreach data monitoring is performed live and issues are immediately investigated?
- Survey outreach staff training, monitoring, and observation is performed to ensure optimal experience for providers as well as accurate and complete recording of data?
- Survey raw data is validated and cleaned in accordance with DMHC requirements?
- DMHC Templates accurately reflect the data gathered?
- Rates of compliance reported on the Results Template are accurate and supported by data entered on Raw Data Template?
- If you are not selected as the outside vendor validator, will you work closely with another vendor selected as the outside vendor validator to produce a seamless process?
MAZARS USA’S APPROACH TO PAAS
Think twice before hiring any vendor that does not check all the boxes above that are applicable to your organization. Mazars USA’s Healthcare Consulting Practice offers these services and more as part of a holistic approach to PAAS. Our philosophy for PAAS is: excellence, expertise, and “no surprises.” For this reason, all our work includes an uncompromising commitment to strategic communication, project management, and customer care.
Our comprehensive support throughout the PAAS process extends from kick-off through submitting deliverables and responding to any DMHC questions. Our 360º approach is the result of years of direct experience performing PAAS as well as interacting with the DMHC on related matters, including health plan licensing. With in-house programming and survey outreach, innovative data analytics services, as well as an in-depth knowledge of the California managed care regulatory landscape, Mazars can perform PAAS in a way that suits your organization’s unique qualities. Whether you are a small health plan or a group of health plans with overlapping networks seeking to lessen provider burnout, Mazars can tailor its PAAS services to fit your needs. We are your nimble partner, offering a flexible range of options for our clients, to include for example:
- Comprehensive PAAS and Validation Services: Performing PAAS strategically from start-to-finish, to include communication and project management, provider contact list preparation, sampling, survey execution and management, validation and quality assurance reporting, template and raw data deliverables, and on-going consultation.
- PAAS Only: All the services above except for producing the quality assurance report. Instead, our team will liaise with your selected outside vendor validator.
- Supportive PAAS Services and Validation: Our team wraps around your internal resources to provide communication and project management, provider contact list preparation, sampling, survey tool development, survey outreach training to your own staff, survey outreach monitoring and reporting, validation and quality assurance reporting, template and raw data deliverables, and on-going consultation.
- Supportive PAAS Services Only: All the services above except for producing the quality assurance report. Instead, our team will liaise with your selected outside vendor validator.
As a leading change facilitator in this era of sweeping healthcare reform, the Mazars Healthcare Consulting Practice offers healthcare payors and providers a powerful combination of service and results-oriented strategy to help them meet their business goals, overcome challenges, and improve performance. Learn more about how Mazars USA is well-positioned to provide comprehensive support to plans in executing the survey, performing validation and quality assurance, as well as evaluation of timely access programs here.
Contact: Laura Peth, Principal – Healthcare Consulting Practice | Phone: 916.696.3675 | Email: Laura.Peth@MazarsUSA.com