The annual after-hours 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 phone messaging for our members with perceived emergency or urgent situations after regular office hours. Unfortunately, most of the Anthem Blue Cross and Blue Shield (Anthem) plans assessed fell short of the expectation of having a live person or a directive in place after hours.

 

The main challenges the vendor encounters while attempting to collect this required, essential data are related to an inability to reach the provider and/or the lack of after-hours messaging altogether. They include:

  • inaccurate provider information in Anthem’s demographic database to allow assessment of the after-hours messaging
  • no voicemail or messaging at all
  • voicemail not reflecting the practitioner’s name
  • calls being auto forwarded with no identification, no voicemail or messaging

 

Update your office information

To help both your patients’ and Anthem’s ability to reach your practice, we ask that you update your office information using the online Provider Maintenance Form. Also, review your after-hours messaging regarding connectivity for patients’ urgent accessibility.

 

What this means for our members and your patients

The annual member experience survey of Anthem enrollees indicated that of those needing advice, a sizable number sometimes, or never, reached the provider’s office for urgent instructions. To improve upon these instances of failing to meet our member’s needs, implement these steps:

  1. Have accessibility 24/7/365. Arrange to have your phone calls forwarded to a service or hospital, or have the appropriate messaging for the caller.
  2. Be sure to turn on the messaging mechanism when you leave the office.
  3. Be sure you are using the acceptable messaging for compliance with your contract.
  4. A live person or recording must express if there are prior arrangements with patients for after hour needs, to be compliant.

 

Be compliant

To be compliant, per the Provider Manual, have your messaging or answering service include appropriate instructions, specifically:

  • Emergency situations: Compliant response for an emergency instructs the caller/patient to hang up and call 911 or go to ER or connects the caller directly to the practitioner.
  • Emergent / Urgent situations: Compliant responses for urgent needs after hours:
    • Live person, via a service, advises their practitioner or on call practitioner is available and connects.
    • Live person or recording directs or directly connects caller/patient to Urgent Care, 24-hour crisis services, 911 or ER.
    • Mechanism connects the caller to their practitioner or the practitioner on call. (Must directly connect)

 

Non-compliant responses for urgent needs after hours include:

  • No provisions for after hour accessibility.
  • Live person or recording only directs the caller/patient to a mechanism for contacting their practitioner (via cell phone, pager, text, email, voicemail, etc.) or to get a call back for urgent questions or instructions. These scenarios are non-compliant because there is no direct connection to their practitioner. This prompt can be used in addition to, but not in place of instructions.

 

Is your practice compliant?

 

1311-0422-PN-CNT

 



Featured In:
April 2022 Anthem Provider News - Missouri