2 Appointment accessibility statewide studies The Texas HHSC contracts with an external quality review organization (EQRO) to monitor all MCOs on appointment accessibility (i.e., how soon an appointment can be scheduled from the time of request). The 86th Legislative Session (SB 760), effective Sept. 1, 2019, mandates that the Texas HHSC monitor MCO networks and analyze compliance with appointment standards. MCOs are required to pay liquidated damages if performance thresholds are not met on these studies. The EQRO implements these studies for each MCO using secret shopper calls. The standards set by the HHSC and the Texas Department of Insurance for appointment accessibility are as follows: The necessity of self-audits We’ve all heard prevention is the best protection—but did you know that applies to audits as well? Here are 5 basic selfaudit tips from the Centers for Medicare & Medicaid Services to help your office reduce the chances of costly mistakes: 1. Develop and implement a solid medical record documentation policy if there is not one in place. If there is one in place, make sure the policy covers meeting federal and state Medicaid regulations. The policy should address what actually happens in everyday practice. 2. Develop or use one of the available standard medical audit tools. The tool should cover the documentation policy criteria and coding standards as part of the review. 3. Choose a staff member who understands documentation and coding principles to select a random sample of records for a specific time period. Decide how many records should be reviewed, then pull every “nth” chart for that time period. 4. Resist being the one to choose and audit your own charts. Most professionals can read their own writing and understand the meaning of records they wrote even if the documentation is not in the record. Removing bias is important. 5. Use the self-audit results for improving practice compliance. There is no real value in conducting a self-audit unless discovered issues are resolved. Review and analyze the audit findings. Identify the common documentation, coding, and billing problems, and solve the problems found. Then educate staff members and hold them accountable for making changes. If you suspect fraud, waste, or abuse, you can report it anonymously to the HHSC Office of Inspector General, toll-free, at 1-800-436-6184. resources Please note that all Providers designated as PCPs are also required to be available to our members 24 / 7. If you have any questions on the requirements, please contact the Provider Relations Department at 915-532-3778. Appointment type Standard (calendar days from time of request) Emergency ser vices Upon member presentation Urgent care Within 24 hours Routine primary care Within 14 days Specialty routine care Within 21 days Specialty therapy (PT / OT / ST) evaluations Within 21 days of signed referral Initial outpatient behavioral health Within 14 days Referrals for specialty care Within 5 days Prenatal care: low-risk pregnancy Within 14 days Prenatal care: high-risk pregnancy or new member in third trimester Within 5 days Preventive health: children (younger than 6 months) Within 14 days Preventive health: children (6 months to 20 years) Within 60 days Preventive health: adults (21 years and older) Within 90 days
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