Appointment Availability Access Standards for Primary Care-Type Providers, ObGyns and Specialists

Administrative Policy:
Appointment Availability Access Standards for Primary Care-Type Providers, ObGyns and Specialists

Effective Date:
June 2, 2017

Scope:
Practitioners that participate in Horizon BCBSNJ's Managed Care Network and/or PPO Network and provide care to fully insured and ASO members.

  • Primary care-type providers (e.g., family practitioners, internists and pediatricians)
  • Ob/Gyns
  • Specialists credentialed in: Cardiology, Dermatology, Endocrinology, Gastroenterology, General Surgery, Neurology, Oncology, Ophthalmology, Optometry, Orthopedic Surgery, and Pulmonology

For Medicare Advantage members, only internists and family practitioners may serve as primary care physicians.

Purpose:
To establish access standards for primary care-type practitioners, Ob/Gyns and specialists, define processes for evaluating a random sample of practices annually and for monitoring practices that did not meet our standards.

To identify high-volume and high-impact specialties.

Definitions:
High-Volume Specialties – Specialties that are expected to treat a large number of members within a geographic area.

High-Impact Specialties – Specialties that treat conditions that are high risk for mortality and morbidity or where treatment requires significant resources.

Practitioner Type

High-Volume

High-Impact

Family Practice

Yes

Yes

Internal Medicine

Yes

Yes

Pediatrics

Yes

Yes

Ob/Gyn

Yes

Yes

Cardiology

Yes

Yes

Dermatology

Yes

 

Endocrinology

Yes

 

Gastroenterology

Yes

 

General Surgery

Yes

 

Neurology

Yes

 

Oncology

Yes

Yes

Ophthalmology

Yes

 

Optometry

Yes

 

Orthopedic Surgery

Yes

 

Pulmonology

Yes

 

Appointment Availability Standards for Offering First Available Appointment:

Routine physical exam
The physician shall offer the member a scheduled appointment as soon as possible, but not to exceed four (4) months of the request.

Horizon BCBSNJ recognizes that CMS recommends a stricter guideline for preventive care and will monitor response rates to ensure that the majority of our physicians offer an appointment within a 30 day time period.

If we determine that wait times for routine physical exams are exceeding the guidelines, a barrier analysis will be conducted and an action plan will be implemented to improve the wait time.

Routine care
The physician shall offer the member a scheduled appointment as soon as possible, but not to exceed two (2) weeks of the request.

Urgent care
The physician shall offer the member a scheduled appointment within twenty-four (24) hours of the request.

Emergent care
The physician shall respond to the member’s call immediately and advise the best course of action. This may include sending the member to an emergency facility.

After-hours care
The Physician shall have a mechanism to respond to the members call for urgent or emergent care that ensures calls in these circumstances are returned within thirty (30) minutes.

Office waiting time
Members should not be expected to wait long after his/her scheduled appointment time to see a practitioner.

Horizon BCBSNJ Medicare Advantage members shall wait no more than fifteen (15) minutes from a scheduled appointment time to see a practitioner.

Other Horizon BCBSNJ members shall wait no more than thirty (30) minutes from a scheduled appointment time to see a practitioner.

If the waiting time is expected to exceed the above-noted time periods, the office shall offer the member the choice of rescheduling his /her appointment or continuing to wait.

If we determine that a practice is not in compliance with the above-noted wait time standards, a barrier analysis will be conducted and an action plan implemented.

Policy:
Horizon BCBSNJ maintains appointment availability standards for offering a first available appointment. The standards outlined in this policy for routine physical exams, routine care, urgent care and emergent care are based on common waiting times for care in the community. The standards for after-hours care and office waiting times are based on what Horizon BCBSNJ determined to be best practice.

These standards are not intended to direct the course of clinical care physicians provide to a Horizon BCBSNJ member. Nor do these standards replace the independent professional clinical judgment or the practitioner’s professional duty to exercise special knowledge and skill in the treatment of patients. As set forth in Horizon BCBSNJ’s Agreements, the practitioner remains responsible for the quality and type of health care services provided. A practitioner may need to see a patient earlier than the time frames listed based on the patient’s symptoms and/or health history.

The hours of operation for physicians should be convenient and not discriminate against members.

For practitioners that treat Medicare Advantage members: All first tier and downstream entities that contract with Horizon BCBSNJ, a Medicare Advantage Organization (MAO) must comply with our appointment availability standards.

Horizon BCBSNJ annually surveys a random sample of primary care, Ob/Gyn and specialist practices to determine if their first available appointments, after-hours care and office waiting times meet our standards. We expect that each practice meet all of the standards to be considered compliant with this policy. Each surveyed practice will receive a scorecard comparing their responses with the aggregate responses within the same survey type (i.e. primary care, Ob/Gyn and specialists). Practices that are not compliant will receive a highlighted scorecard noting the standards not met and will be re-evaluated again as part of the next annual survey to ensure compliance.

The Network Management Department will maintain a database of responses to the following questions and monitor practices that are non-compliant with any standard for two or more years to determine if personalized education is needed. Practices that are repeatedly non-compliant may be referred to the Director of Physician Contracting and Network Operations, who will determine next steps including referral to the Credentials Committee for appropriate action.

  1. When is your first available appointment for a routine physical exam? (primary care-type providers and Ob/Gyns only)
  2. When is your first available appointment for routine care?
  3. When is your first available appointment for urgent care?
  4. How quickly are members seen for emergent care?
  5. Does the practice have a mechanism in place to respond to after-hours phone calls for urgent or emergent care and how long does it generally take for calls to be returned?
  6. How many minutes beyond scheduled appointment times do patients wait to see a practitioner?

History:
6/3/2017: Administrative policies PCP, Ob/Gyn and Physician Access Standards (effective since 8/26/11), and Specialist Provider Access Standards (effective since 7/16/93) replaced with the posting of this policy.

References:

  • HMO Regulation N.J.A.C 11:24-6.2(d)(4) and HCQA Regulation N.J.A.C. 11:24A-4.10(b)(1)(iii)
  • NCQA - Current Standards and Guidelines for the Accreditation of Health Plans
  • Medicare Managed Care Manual, Chapter 4, Section 110.0 “Access and Availability Rules for Coordinated Care Plan
  • 2016 Medicare Part C & D Star Rating Technical Notes

HCM-PP-HCS-013-0617