We have provided many articles advising providers of the compliant messaging when our members call your office during an urgent situation after regular business hours.

 

The annual after-hours access studies performed by our vendor, North American Testing Organization* based in California, assesses adequate phone messaging for our members with perceived emergency or urgent situations after office hours. Unfortunately, most of the Anthem Blue Cross and Blue Shield (Anthem) plans assessed still fall short of the expectation of having a live person or a directive in place for after-hours calls.

 

Members are experiencing this lack of ability to reach instructions and have voiced their opinions in the member experience surveys fielded annually for Commercial and Marketplace Exchange. An average of 16% of members have a need to contact their provider’s office after regular hours for urgent care. They are recalling, in the last 12 months, if they were able to reach the office via an appropriate message, a transfer directly to their doctor or service for instructions, or advice.

 

This chart represents the office level accessibility when contacted by the survey vendor compared to the CAHPS® (Commercial) and EES© (Marketplace Exchange) member satisfaction survey results of the member’s success getting their urgent needs meet after hours.

 

As shown, the office level results are barely meeting or are below the expected 90% access to members with urgent symptoms. More telling is members express getting advice as soon as needed less often than the office assessment captures. A sizable number of members sometimes or never reach the doctor’s office for urgent instructions.

After Hours Goals

After Hours

To help both your patients’ and Anthem’s ability to reach your practice, we ask that you verify or 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. 
  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 a messaging mechanism when you leave the office. 
  3. Be sure you are using the acceptable messaging for compliance with your contract.

Per the provider manual, have your messaging or answering service include appropriate instructions, specifically:
  • Emergency situations:
    • A compliant response for an emergency instructs the caller/patient to hang up and call 911 or go to the emergency room (ER) or live person connects the caller directly to the practitioner.
  • Urgent situations:
    • Compliant responses for urgent needs after hours:
      • Live person, via a service or hospital, advises their practitioner or on-call practitioner is available and connects.
      • Live person or recording directs caller/patient to urgent care, ER or call 911:
        • May also, but not instead of directing, suggest caller/patient contact their healthcare practitioner (via cell phone, pager, text, email, voicemail, etc.) or request a call back for further urgent instructions.
      • Mechanism connects the caller to their practitioner or the practitioner on call.  (Must directly connect.)
  • Non-compliant responses for urgent needs after hours:
    • No provision for after-hours 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, thus not ensuring a timely callback. This prompt can be used in addition to, but not in place of instructions.

Is your practice compliant?

MULTI-BCBS-CM-012546-22



Featured In:
December 2022 Anthem Provider News - Wisconsin