HomeMy WebLinkAboutIDHW 2025-6 Provider Appointment Access Survey Report MAGELLAN
Magellan Healthcare
Provider Access and Availability Survey
Audit of Medicaid Managed Care Provider Directory Information and
Appointment Availability
Survey Period: December 2025 – February 2026
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Table of Contents
Objectives ………………………………………………………………………………………………………………………………………………………………... 3
Technical Methods of Data Collection and Analysis …………………………………………………………………………………………………. 3
Summary Findings ……………………………………………………………………………………………………………………………………………………. 13
Recommendations …………………………………………………………………………………………………………………………………………………… 14
Appendix A ………………………………………………………………………………………………………………………………………………………………. 15
Table 1: Contract Standards Assessed …………………………………………………………………………………………….……….……………… 4
Table 2: Managed Care Plan Provider Participation Rate ………………………………………………………….………….…....….………. 5
Table 3: Provider Participation Failure Summary …………………………………………………………………………….…….………….……. 8
Table 4: Appointment Availability Disposition and Access Rates …………………………………………….………………………………… 9
Table 5: Appointment Failure Reasons ……………………………………………………………………………………………………………………. 12
Chart 1: Provider Survey Participation ……………………………………………………………………….…………………………………………… 6
Chart 2: Provider Survey Participation by Provider Type ……………………………………………………….………………………………. 7
Chart 3: Provider Participation Failure Reasons ……………………………………………………….…………………….……………….………. 8
Chart 4: Disposition and Access Survey Rates, All Provider Types 10
Chart 5: Disposition and Access Survey Rates by Provider Type 11
Chart 6: Appointment Failure Reasons ………………………………………………………………………….……………………….….……………. 12
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Objectives
Title 42 Code of Federal Regulations 438.356 State contract options for external quality review and Title 42 Code
of Federal Regulations 438.358 Activities related to external quality review establish that state agencies must
contract with an external quality review organization to perform the annual validation of network adequacy. To
meet these federal regulations, the Idaho Department of Health and Welfare (IDHW) contracted with IPRO to
perform an audit of Medicaid managed care provider directories, and surveys of appointment availability for
Magellan Healthcare (Magellan) in 2025.
These activities aimed to confirm provider participation in the managed care network through validating the
accuracy of provider directory information, and to determine appointment availability for providers who
positively confirmed their participation in the Medicaid network. IPRO’s methodology complies with Title 42 Code
of Federal Regulations 438.68(f)(4) standards for conducting secret shopper provider appointment access
surveys.
Technical Methods of Data Collection and Analysis
Data Acquisition
IPRO requested that Magellan provide a roster of all active participating network providers who were accepting
patients at that time of the request and the relevant corresponding data points required to conduct the survey
(descriptive characteristics and contact information) for the products under review. IPRO confirmed with
Magellan that providers offering exclusively telehealth services were excluded from the rosters as federal
regulations require that providers offering telehealth services must also offer in-person appointments to be
considered for the access survey. See for a list of the elements that IPRO requested that Magellan
include in the provider roster.
IPRO worked with the IDHW to determine an appropriate sampling method to support the objective of the survey
and sampled the provider roster files accordingly. Samples sizes for each provider type were set to target a
minimum of 30 responses in alignment with NCQA guidelines for reporting of quality measures that typically
require a minimum denominator size of at least 30. Additionally, IPRO applied a stratification to the sampling to
ensure appropriate geographic representation of sample in alignment with the general distribution of the Idaho
Medicaid beneficiary population across the State (33 percent rural, 67 percent urban). A 100 percent audit was
conducted on all sample files against Magellan’s online provider directory to validate the accuracy of the
information provided in their roster file. Any records in the sample that could not be matched to the online
directory were removed from the sample and replaced until the sample size, product and provider specialty was
satisfied and audited, or all records in the original roster were exhausted.
Once all samples were finalized, provider samples were loaded to a survey tool used to conduct the survey and
provider records were equally split across the two survey contract standard types being assessed (routine visits,
non-urgent “sick” visits). The contract standards and related survey groups are further defined as they pertain
to each managed care plan in Table 1 below.
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Table 1: Contract Standards Assessed
Managed
Care Plan
Contract Standard
Routine Non-Urgent “Sick”
(Dual-Eligible,
IMPlus and
MMCP producs )
member request for
appointment
member request for
appointment
(Molina only)
Outpatient Behavioral
Health2 (OP BH)
Outpatient Substance
Use3 (OP SUD)
member request for
appointment
member request for
appointment Dentist – Child5
member request for
appointment
Health2 (OP BH) – Adult4
Outpatient Behavioral
Health2 (OP BH) – Child5
Outpatient Substance
Use3 (OP SUD)
1Providers credentialed by the plan to practice as primary care practitioners typically include Internal Medicine,
Family Practice, General Practice, OB/GYN and physician extender nurse practitioner and physician assistants.
2Providers credentialed by the plan to provide outpatient mental health services typically include social workers,
clinical psychologists, psychiatrists and physician extenders such as psychiatric nurse practitioners.
3Providers credentialed by the plan to provide substance use counseling services typically include social workers,
clinical psychologists, psychiatrists, substance use counselors and physician extenders such as psychiatric nurse
practitioners.
4Providers credentialed by the plan to provide care to members ages 18 years of age and older.
5Providers credentialed by the plan to provide care to members less than 18 years of age.
IPRO team members trained in secret shopper survey techniques used the survey tool to place telephone calls to
provider offices and posed as a Medicaid member seeking an appointment using a script aligned with the
appointment type contract standard that was being assessed. During these calls, IPRO surveyors first validated
provider participation and provider directory information including managed care plan and product participation
status, practicing specialty, Medicaid panel status, physical location, and telephone number. Discrepancies in any
of this information obtained through the survey were reported to the managed care plan for correction.
Appointment availability was only assessed for those providers who confirmed participation in the Medicaid
network.
The determination of provider appointment availability includes the use of the secret shopper method, in which
IPRO surveyors act as managed care plan members seeking care. Using scripted scenarios with clinical
indicators, surveyors call providers and attempt to obtain appointments for routine or non-urgent “sick” care.
The validation of provider participation and the assessment of appointment availability are conducted during
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the same survey call to provider offices. IPRO surveyors placed calls Monday through Friday, 8:30 AM – 5:30
PM (MDT), excluding holidays; however, if there was an indication that a provider maintained alternative office
hours, surveyors attempted to recall the provider during these alternative office hours. IPRO made at least
three (3) attempts to reach a live voice at provider practice sites.
Upon completion of all provider contact attempts, IPRO concluded the survey and extracted and analyzed the
information collected and documented from the survey calls. The resulting analysis and Magellan results for
the Idaho 2025 Provider Directory Survey/Provider Access and Availability Survey follow in
and as follows:
• Table 2 provides the original sample size of providers contacted for Magellan, plan product and provider
specialty type and the number and percentage of providers that participated in the appointment access
survey (providers that were assessed for appointment availability). A statewide comparison including all
Idaho plans participating in the survey is also shown.
• Charts 1 and 2 visually display the data presented in Table 2.
• Table 3 provides the distribution of (failure) reasons for providers that were outreached and for which
contact was unable to be established, or the provider was deemed ineligible for the appointment access
survey (provider indicated not active with plan or not accepting patients, restricted practice).
• Chart 3 visually displays the data presented in Table 3.
• Table 4 provides the final disposition of each provider survey participant and the corresponding
appointment access rates for providers who were deemed to be eligible for participation in the survey.
• Charts 4 and 5 visually display the data presented in Table 4.
• Table 5 provides the distribution of (failure) reasons for providers who were deemed to be eligible for
participation in the survey, however, did not provide an appointment time for IPRO to assess against the
provider contract access standards.
• Chart 6 visually displays the data presented in Table 5.
IPRO’s summary findings and recommendations derived from the information presented in these tables and
charts are noted as the final section of this report.
1Total Providers Surveyed (or sample size) recommended by IPRO and approved by IDHW.
2 Total providers outreached and confirmed plan participation and open panel status.
3 Formula for Participation Rate = Total Providers Participated / Total Providers Outreached.
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Chart 1: Provider Survey Participation
1Participation Rate = Total Providers Participated / (Total Providers Participated + Total Providers Failed Provider Directory Audit )
361
92
226
41
38.5%
30.8%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
50.0%
0
100
200
300
400
500
600
700
800
900
State Magellan
Providers Participating in Access Survey
Total Providers Failed Provider Directory Audit Total Providers Participated Participation Rate1
Sample
n =133
Sample
n = 587
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Chart 2: Provider Survey Participation by Provider Type
1Participation Rate = Total Providers Participated / (Total Providers Participated + Total Providers Failed Provider Directory Audit )
36 33
23
14 17
10
28.00%
34.00%
30.30%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
0
10
20
30
40
50
60
70
80
90
100
Magellan
OP BH
Adult
Magellan
OP BH
Child
Magellan
OP SUD
Provider Participation -By Provider Type
Total Providers Failed Provider Directory Audit Total Providers Participated Participation Rate1
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Table 3: Provider Participation Failure Summary
Magellan State
Failure Reasons (n) (%) (n) (%)
Provider not at site 23 25.0% 154 42.7%
Answering machine/Voicemail system 33 35.9% 58 16.1%
Provider not a plan participant 2 2.2% 14 3.9%
Provider not accepting new patients (closed panel) 9 9.8% 52 14.4%
No Answer 4 4.3% 10 2.8%
Provider practice is restricted to specialty care 17 18.5% 52 14.4%
Constant busy signal 2 2.2% 8 2.2%
Telephone company message indicating phone out of order 1 1.1% 2 0.6%
Wrong number 0 0.0% 9 2.5%
Other 1 1.1% 2 0.6%
Total Failed 92 361
23
33
29
4
17
2 1
1
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Magellan
Other
Wrong number
Telephone company message
indicating phone out of orderConstant busy signal
Provider practice is restricted to
specialty careNo Answer
Provider not accepting new patients
(closed panel)Provider not a plan participant
Answering machine/Voicemail
system
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Table 4: Appointment Availability Disposition and Access Rates
1 Total number of providers that participated in the Appointment Availability Access Survey and did not provide the surveyor with an appointment
2 Total number of providers that provided an appointment within the contract standards noted in Table 1.
3 Total number of providers that provided an appointment NOT within the contract standards noted in Table 1.
4Formula for Appointment Rate = Timely Appointments / (Timely Appointments + Not Timely Appointments).
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Chart 4: Disposition and Access Survey Rates, All Provider Types
1Appointment Rate = Timely Appointments / (Not Timely Appointments + Timely Appointments)
88
30
42
3
96
8
69.60%
72.70%
68.00%
68.50%
69.00%
69.50%
70.00%
70.50%
71.00%
71.50%
72.00%
72.50%
73.00%
0
50
100
150
200
250
State Magellan
Disposition and Access Rates of Surveyed Providers -All Provider Types
Appointment Failures Not Timely Appointments Timely Appointments Appointment Rate1
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Chart 5: Disposition and Access Survey Rates by Provider Type
1Appointment Rate = Timely Appointments / (Not Timely Appointments + Timely Appointments)
11
13
6
1
2
0
2
2
4
66.70%
50.00%
100.00%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
0
2
4
6
8
10
12
14
16
18
Magellan
OP BH
Adult
Magellan
OP BH
Child
Magellan
OP SUD
Disposition and Access Rates of Surveyed Providers -Non-Urgent BH
Appointment Failures Not Timely Appointments Timely Appointments Appointment Rate1
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Table 5: Appointment Failure Reasons
Magellan State
Failure Reasons (n) (%) (n) (%)
Patient must complete a health form before an appointment can be made 5 13
0 1
6 23
15 42
4 6
0 3
5
6
15
4
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Magellan
Other
Provider practice required information that
surveyor could not provide
Provider practice is not scheduling
appointments at this time
Provider practice required referral
Provider practice required medical record
before an appointment can be made
Patient must complete a health form before
an appointment can be made
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Summary Findings
Statewide
IPRO outreached to each provider identified for the appointment access survey sample (n = 587). IPRO was
able to successfully validate provider directory information for only 38.5 percent (n = 226) of the outreached
providers, making them eligible for the appointment access survey (Table 2). Those provider offices deemed
ineligible for the appointment access survey most commonly indicated that the provider target did not practice
at the specific practice location as indicated by the MCP’s provider directory information (n = 154 or 42.7 percent
of all ineligible providers). Less common reasons for survey ineligibility included su rveyors encountering an
answering machine or voicemail system (n = 58 or 16.1 percent of all ineligible providers), the provider office
indicated that they were not accepting new patients (n = 52 or 14.4 percent of all ineligible providers) or the
provider office indicated that appointments were being restricted to specialty care (n = 52 or 14.4 percent of all
ineligible providers). Survey ineligibility information can be referenced in Table 3 and Chart 3.
Of the 226 providers deemed eligible for survey participation, 138 resulted in a surveyor being provided with
an appointment date to assess for access and 69.6 percent (n = 96) of these appointment dates were found to
meet the required access standards in the MCP provider contracts. The remaining 88 provider offices did not
provide a valid appointment time and are considered to be “appointment failures” (Table 4). The most common
appointment failure reasons were found to be provider practices indicating that they were not scheduling
appointments at that time of the survey call (n = 42 or 47.7 percent of all appointment failures), the provider
office indicated that a referral would be required prior to providing an appointment date (n = 23 or 26.1 percent
of all appointment failures) and provider offices indicating that the patie nt must complete a health screening
form before an appointment date would be provided (n = 13 or 14.8 percent of all appointment failures).
Appointment failure information can be referenced in Table 5.
Appointment access rates were found to be higher for routine (81.1 percent, n = 43) than for non -urgent (62.4
percent, n = 53) appointments (Table 4).
Magellan Healthcare
Magellan Healthcare was assessed for outpatient behavioral health (adult and child) and SUD for non-urgent
appointment types. Magellan had the second lowest participation rate of the four MCPs (30.8 percent) with
almost one quarter of the initial providers target ed for survey (33 of 133) found to be unreachable upon four
contact attempts (surveyors received answering machines upon all four attempts) (Table 2, Table 3).
Appointment access rates were found to be 66.7 percent for adult (n = 3), 50.0 percent for child (n = 4) and
100.0 percent for SUD (n = 4). These access rates should not be considered statistically reliable but rather
anecdotal given the final eligible sample sizes noted above. All Magellan access rates are noted in Table 4.
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Recommendations
IPRO’s paramount recommendation is that the survey be re-conducted with a larger initial sample size to attain
reliable access rates for MCP and provider/appointment type for specifically PCP and Dental providers . Though
statewide and some aggregate access rates were found to be statistically reliable enough to draw conclusions,
the access rates reported for Magellan provider/appointment type were not given final denominators were
always found to be less than 30. For the behavioral health providers, IPRO notes an exceptionally high rate of
participation failures many attributed to receipt of an answering machine on all four contact attempts (51 of all
58 answering machine contact failures were for behavioral health providers statewide). Due to this inherent
challenge with behavioral health provider contact, increasing initial sample sizes may not p rove an effective
strategy for improved reliability in behavioral health appointment accuracy rates for future surveys. IPRO also
recommends that for SUD providers, IDHW request that MCPs improve means for identification of relevant
providers or pursue network expansion as the population numbers that were provided to IPRO were
prohibitively small (population sizes were always less than 30).
Additionally, IPRO recommends that each MCP be provided with detailed information for the provider targets
that failed the initial provider directory accuracy audit making them ineligible for the appointment access survey
and be asked to remediate these specific directory inaccuracies (see file, “APPT SURVEY FAILURES – MAGELLAN”
for list of specific providers). IDHW could also consider asking the MCPs for root cause remediation plans to put
more proactive plans in place to prevent or lessen the likelihood of these inaccuracies from occurring in the
future. IPRO also recommends that the MCPs be provided with the appointment failure record details for
providers who passed the directory accuracy audit but did not provide an appointment date to the surveyor
specifically for those instances where provider offices indicated that they were not scheduling appointments for
providers that were indicated as accepting new patients (see file, “APPT SURVEY FAILURES – MAGELLAN” for list
of specific providers).
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Appendix A
Elements Requested for Managed Care Plan Provider Rosters
The provider’s legal last name Any
The provider’s legal first name Any
The provider’s National Provider Identification
(NPI) number
NPI format
The provider’s primary plan-credentialed
specialty
Any
The provider’s secondary plan-credentialed
specialty if applicable
Any
The provider’s specialty category PCP, Specialist, Both
The provider’s professional credential MD, NP, PA, LCSW,
etc.
The name of the practice location site Any
The 10-digit phone number of the practice
location site
Any
The street address of the practice location site Any
The city of the practice location site Any
The State of the practice location site Any
The five- or nine-digit ZIP code for the practice
location site
Any
The name of your managed care plan Any
An alternate phone number if applicable Any