QHP secret shopper: Ensuring timely access to care
Starting January 1, 2025, the Centers for Medicare & Medicaid Services (CMS) will require qualified health plan (QHP) issuers in the Federally Facilitated Exchanges to comply with new appointment wait time (AWT) standards. This initiative aims to ensure timely access to care—particularly for new patients looking for appointments with in-network providers. The mandate requires QHP issuers to demonstrate that at least 90% of new patient appointments are scheduled within the standard time frames (shown below).
Appointments must be made available within:
- Primary care (routine): 15 business days
- Behavioral health: 10 business days
Methodology
Appointment wait times: For 2025, QHP issuers must ensure that at least 90% of new patient appointments are scheduled within the specified timeframes. CMS particularly wants to make sure new patients can see in-network providers quickly. To verify compliance, QHP issuers must contract with a third-party organization, like Press Ganey, to conduct a secret shopper survey. This program may expand in future years to include stand-alone dental plans (SADP) and other provider types.
Survey procedure: The secret shopper survey involves a sample of each provider type, including primary care and behavioral health. Secret shoppers will simulate the experience of a patient or family member trying to schedule a new patient appointment. CMS will check the compliance rate for each type of provider type to assess adherence to AWT standards.
Timing and reporting: The survey period runs annually from January 1 through May 31. QHP issuers must then submit survey results to CMS. For 2025, specialty care is not included in the requirements, but it’s expected to be in the future. SADP issuers are exempt from surveys for nonurgent specialty care for 2025.
Press Ganey's solution for QHP Secret Shopper regulations
Press Ganey’s QHP Secret Shopper Survey solution helps health plans meet CMS requirements. Our survey determines if network providers adhere to appointment wait time standards by measuring the number of business days between an appointment request and the first available appointment. This covers both in-person and telehealth visits, with compliance rates based on the shortest wait time available.
Our QHP Secret Shopper Survey includes a three-to-five-minute telephone script that Press Ganey interviewers use to validate if providers offer in-person and/or telehealth visits, as well as to request specific appointment types. The survey tool is standardized for all health plans. It also provides various introduction scenarios to minimize detection, ensuring objective and accurate results.
By partnering with Press Ganey, health plans can confidently navigate CMS regulations and improve patient access to care, demonstrating a commitment to health equity and compliance. To learn more about our QHP Secret Shopper Survey solution, reach out to a Press Ganey health plan expert.