Primary care physician after-hours access requirements

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 2022. This was 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 and our affiliate HealthKeepers, Inc. plans assessed fell short of the expectation of having a live person or a directive in place after hours. We will resume the survey in the second quarter of 2023 and expect when your office is contacted, you will be able to accommodate a member’s urgent concerns after hours.

The main challenges the vendor has encountered 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. The challenges include:

• Inaccurate provider information in the Anthem 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 automatically forwarded with no identification, no voicemail, or messaging.

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

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

• Emergency situations:
  • The compliant response for an emergency instructs the caller/patient to hang up and call 911 or go to the emergency room (ER) or connects the caller directly to the physician.
• Urgent situations:
  • The compliant response for urgent needs would direct the caller to urgent care or ER, to call 911, or connect the caller to their physician or the physician on call.

Members must have access to care 24 hours a day, 7 days a week, 365 days a year. Primary care physicians (PCPs) must have arrangements for after-hours care to provide 24-hour coverage for members by a network provider during non-business office hours. Compliance requires that a recording or live person directs callers to urgent care, 911, the ER, or connects the call to the caller’s physician or physician on call.

In addition to these measures, but not in place of them, the messaging can give callers the option of contacting their healthcare practitioner (via transfer, cell phone, pager, text, email, or voicemail) or an opportunity to ask for a call back for urgent questions or instructions.

Is your practice compliant?