Primary care appointment access and open panels

The annual PCP access studies performed by our vendor, North American Testing Organization based in California, were resumed and fielded in the third quarter of 2021. The purpose is to assess adequate appointment timeframes for our members with an urgent condition or for routine care.

 

The main challenges the vendor encounters while attempting to collect this required, essential data are related to inaccurate provider information in Anthem’s demographic database, i.e., incorrect or non-working phone numbers, practitioner moved, retired, or deceased; the practice has resigned their Anthem contract, accepts private pay only or is no longer in practice; as well as staff refusing to participate in the survey.  We ask that you update your office information using the online Provider Maintenance Form and that you participate in quality programs such as this critical survey as a condition of Anthem’s contract.

 

Another item captured in the survey is open panel status for new patients.  At the office level, we are capturing more closed panel data than is reflected in the provider directory for members. Please keep Anthem abreast of the open/close panel status of your practice. 

 

What does this mean for our members?  If the directory indicates “open” and the practitioner is not available for new patients, the member is making multiple calls to select a primary care physician. Their experience is reflected in the annual CAHPS® member survey of Anthem enrollees, which indicated “not open to new patients” as the number one reason throughout Anthem plans for not getting a personal doctor.

 

To be compliant, per the provider manual, participating providers agree to meet the following access standards, whether in person or a telehealth visit:

• Urgent – The patient must meet with their Practitioner, another Practitioner in the practice or a covering Practitioner within twenty-four (24) hours.

• Explanation – These callers are experiencing a non-emergent condition or injury with acute symptoms that require immediate attention (without prior authorization).

• Routine – The patient must meet with their Practitioner, another Practitioner in the practice or a covering Practitioner within 10 business days.

• Explanation – A regular routine appointment is a non-symptom related visit for existing patients, such as a check-up, including physicals and chronic monitoring.
• Routine follow-up – The patient must meet with their Practitioner, another Practitioner in the practice or a covering Practitioner within 30 calendar days.

• Explanation – This is for an evaluation of progress or services, including, but not limited to, medication management. This includes new or existing patients.

 

Note to staff: It is imperative that your office updates any changes to your practice using the online Provider Maintenance Form on anthem.com.

 

2149-0522-PN-CTME