Health Plan Secret Shopping

The contracted Mystery Shopping Agency must be fully independent of the commissioning QHP, and the surveys will have to be conducted according to CMS’s exacting standards regarding their execution and reporting.

Agreements must be in place by the end of 2024, with surveying due to start on or shortly after January 1st 2025. Survey results will be reported to CMS as part of the QHP issuer compliance and monitoring activities. CMS may require medical QHP issuers to provide documentation underlying the results of those surveys, for the regulator to review.

• Behavioral Health: 10 business days
• Primary care (routine): 15 business days
• Specialty Care (non-urgent): 30 business days

QHPs will be required to ensure new enrollees seeking an appointment are able to schedule one within the FFE-established wait time standards at least 90% of the time. This will pose a challenge to many issuers as the average wait time in 2022 for the 15 largest cities in the USA was recorded at 26 days.

For the 2025 plan year, only appointments for Behavioral Health and Primary Care will require secret shopper surveying and data collection, meaning SADP issuers are currently exempt. However, CMS expects the scope of surveying to expand to cover specialty care in future years.

The secret shopper survey will involve a representative sample across provider types. Mystery shopping agents will act as patients or family members seeking new appointments and record the earliest offered appointment.

QHPs found to be in non-compliance with regulations in the following situations will be required to add more in-network providers:

1. The QHP issuer fails to contract a secret shopping agency to conduct surveys.
2. The QHP issuer fails to report the survey results.
3. Survey results demonstrate that the QHP is failing to meet appointment wait time standards.