Trends in Regulations and Enforcement

For health plans licensed in California, the Provider Appointment Availability Survey (PAAS) and related Timely Access Reporting (TAR) requirements can be daunting to understand and resource-intensive to fulfill. While the California Department of Managed Health Care (DMHC) requires the use of an outside vendor validator, many health plans utilize outside vendors to execute the PAAS itself. As the DMHC works towards codification of the revised PAAS regulations, it is important to not only understand the current state of PAAS regulation, but to know the right questions to ask any potential vendor to ensure they will meet your health plan’s needs in a compliant manner to help avoid enforcement action.

Pending Regulation

The healthcare advisors from Mazars USA anticipate the MY 2021 methodology to be very similar to MY 2020; however, it is important to note that the current draft regulation still leaves room for the DMHC to modify the methodology from year-to-year. The draft regulations encompass various changes including

• Defined rate of compliance
• Expanded list of specialties
• Staggering of waves must be coordinated by survey type and network rather than on county level
• Network data capture date shifted to January 15th

Enforcement

The amount of financial enforcement actions has levied, and the violation types targeted has varied from year to year. Timely access-related penalties can be costly and have ranged from as low as $1,000 to as much as $1.5 million. According to the DMHC, timely access-related penalties include:

• 2015: $1,627,000 – Fines from $12,000 to $1,500,000 for 6 plans
• 2016: $122,000 – Fines from $10,000 to $70,000 for 4 plans
• 2017: $776,500 – Fines from $1,000 to $500,000 for 32 plans
• 2018: $82,500 – Fines from $2,500 to $20,000 for 10 plans
• 2019: $257,500 – Fines from $2,500 to $17,500 for 34 plans
• 2020: $22,500 – Fines from $5,000 to $10,000 for 3 plans

Common timely access violations that have been assigned fines include:

• Failure to file a timely access report with the DMHC that contains the rate of compliance with time elapsed standards.
• Failure to report data accurately and/or in a manner consistent with the DMHC’s methodology.
• Failure to file, or to properly file, a timely access report that includes the plan’s enrollment in each product line; and/or a complete list of the plan’s contracted physicians, hospitals, and other contracted provider

The Right Approach to PAAS

Identifying the right PAAS vendor is increasingly important as the stabilization of the DMHC’s methodology will likely result in increased scrutiny and greater enforcement actions. There are several PAAS vendors in the marketplace, but few provide a combination of comprehensive, compliant, and reliable service. To select the best vendor, Plans should ask the following questions regarding four main categories of service:

Communication and Project Management

Any project manager you choose should work collaboratively with you and regularly communicate regarding the PAAS process – including issues related to provider directory accuracy, data anomalies, or outreach issues.

☑ Will you ensure timely milestone achievement through schedule setting?

☑ Will you share bi-weekly project status reports?

☑ Do you provide advice on communications with the DMHC regarding PAAS?

☑ Does your team have extensive California managed care regulatory and operational experience that enables them to provide advice on DMHC regulatory matters related to PAAS?

Provider Contact List Preparation and Data Analytics

Your vendor’s data management team should be well versed in DMHC requirements and be able to receive your provider data and develop your provider contact list (PCL), including performing all data cleaning and de-duplication, in-house.

Strict adherence to the DMHC methodology and internal quality assurance standards are imperative during this step as mistakes within the PCL preparation and sampling will affect the rest of the survey and can rarely be fixed retroactively.

☑ How knowledgeable is your team of the DMHC’s PAAS methodology and how it both relies on and impacts related DMHC-filings?

☑ Can you ensure all appropriate networks and lines of business are included?

☑ Can you ensure participating provider groups are correctly and completely identified?

☑ Can you clean, scrub, de-duplicate, and review provider categorization?

☑ Do you have a reliable de-duplication process that ensures adherence with the DMHC methodology and produces the most efficient survey process possible?

☑ Do you utilize an in-house programmer and an internal and secure SQL server database to ensure data integrity?

☑ Can your team handle multiple, overlapping plan networks to most efficiently outreach to providers and decrease burnout?

☑ Does your team perform extensive quality assurance and validation to ensure the PCL and sample selected is accurate and in compliance with the DMHC methodology?

Survey Execution and Reporting

Survey execution is the most resource-intensive portion of the PAAS process. Ensuring your vendor has a deep understanding of the DMHC methodology as well as appropriate processes in place to monitor and report on survey outreach progress is an absolute necessity.

☑ Do you offer a customized survey tool that is compliant with DMHC methodology?

☑ Does your survey tool store all survey data in one secure location with strong internal controls and data management?

☑ Does your survey tool allow for live monitoring of survey activity regardless of how outreach is performed?

☑ Does your survey tool all provider contact data and surveyor contact information to ensure timely completion of outreach in accordance with the Three Step Protocol?

☑ Does your survey tool capture additional outcome or categories that allow for a deeper understanding of any access issues while still mapping to and adhering to DMHC requirements?

☑ Do you ensure that survey results are collected in accordance with the three-step protocol and DMHC methodology?

☑ Do you utilize and directly supervise survey staff with both customer service and healthcare experience in a local office to perform telephonic outreach?

☑ Do you monitor results throughout survey execution?

☑ Do you communicate regularly regarding any conclusions from the PAAS process including issues related to provider directory accuracy?

☑ Do you provide weekly reports on survey results throughout survey execution – not just at the end – that include details such as survey progress, outcomes summaries, outcomes details, and provider information updates?

Quality Assurance and Validation

To be effective, quality assurance and validation measures must be woven into the entire PAAS process, from start-to-finish. If your vendor only performs quality assurance and validation procedures at the end of its PAAS services, they are worthless.

☑ Do you review and validate actions at certain key checkpoints including:

• Inclusion of appropriate network and provider type?
• Compilation of PCL’s using G data and mapping client fields to template fields?
• Preparation of PCL’s are appropriately categorized and that no provider is duplicated?
• Sampling performed in accordance with DMHC’s survey methodology?
• Correctly designed survey tool to follow DMHC methodology and record data in necessary format?
• Observe and monitor trained survey staff for excellent performance?
• Survey raw data is validated and cleaned in accordance with DMHC requirements?
• DMHC Templates accurately reflect data gathered?
• Rates of compliance reported on the Results Template are accurate and supported by data entered on Raw Data Template?

☑ If you are not selected as the outside vendor validator, will you work closely with another vendor selected as the outside vendor validator to produce a seamless process?

Our philosophy for PAAS is: excellence, expertise, and “no surprises.”

Mazars Approach to PAAS

Think twice before hiring any vendor that does not check all the boxes above. Mazars USA’s Healthcare Consulting Practice offers these services and more as part of a holistic approach to PAAS. Our philosophy for PAAS is: excellence, expertise, and “no surprises.” For this reason, all our work includes an uncompromising commitment to strategic communication and project management as well as ensuring data integrity, (i.e. in-house SQL programming, secure data hosting, robust survey tool).

Our comprehensive support throughout the PAAS process extends from kick-off through submitting deliverables and responding to any DMHC questions, as well as utilizing a 360º approach formed from years of experience performing PAAS as well as interacting with the DMHC. With in-house programming, superior data analytics services, and in-depth knowledge of the California regulatory landscape, Mazars can perform PAAS in a way that suits your needs – whether you are a small health plan or a group of health plans with overlapping networks seeking to lessen provider burnout, Mazars can tailor its PAAS services to fit your needs. We are your nimble partner, offering a flexible range of options for our clients, to include for example