Is 'Delay in Care, Deny in Care'? Californian Government to Enforce Stringent Response Time

  • Date: April 06, 2010
  • Source: Admin
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Access to healthcare is perhaps one of the most basic human rights today and to secure that human right, the California government is establishing limits for how long HMO’s and their doctors can make patients wait for appointments. 

What is the New Response Time

Sparked by the incessant numbers of patient complaints about long waiting period, Cindy Ehnes, director of the state Department of Managed Health Care, believes that the new regulation will improve the patient-physician relationship and will improve the quality of care.

The new rule states:

  • 24-7 screening by telephone
  • Waiting time for telephone screening must be no longer than 30 minutes.
  • During normal business hours, waiting time to speak to a plan's customer service representative must be no longer than 10 minutes.
  • 48 hours for urgent-care appointments that do not require prior authorization.
  • 96 hours for urgent-care appointments requiring prior authorization (including specialists)
  • 10 business days for non-urgent primary care appointments.
  • 15 business days for non-urgent appointments with specialists.
  • 10 business days for non-urgent appointments with a mental health care provider.
  • 15 business days for non-urgent appointments for ancillary services (X-rays, lab tests, etc.) for diagnosis or treatment of injury, illness or other health condition.
  • Dental plans: 72 hours for urgent care, 36 business days for non-urgent care, 40 business days for preventive care.

Other new rules include:

  • Waiting time for a phone response from a doctor's office can be no longer than 30 minutes.
  • During normal business hours, waiting time to speak to a health plan's customer service representative can be no longer than 10 minutes.
  • Urgent care appointments that do not require prior authorization must be granted within 48 hours.
  • Urgent care appointments requiring prior authorization, including specialists, must be within 96 hours.

Doctors’ Reaction to New Rule

The new rule, in general, has failed to please the major segment of the physicians. They believe failure to response early to patients’ calls or delayed appointments was the result of insufficient numbers of doctors on contract. The new rule, therefore, will strain the local doctors’ offices. Moreover, the physicians ascertain that meeting deadlines for response will not be an easy task for the physicians. However, they hope that the new rule will point out and resolve the issue of insufficient numbers of HMOs.

According to the insurance companies, people being asked to wait months for care are covered by existing laws that guarantee timely access and failing which can result inversely for the doctors and call for fines and negative performance ratings. And therefore, doctors may become forced to see patients who have insurance quicker than those who do not have insurance in order to avoid fines and other penalties.

Can the Rule Be Waived?

Yes, the rule can be waived in cases when doctors can document that the longer wait won't affect the patient's health. Though the clause seems to be a great escaping one but doctors or staff will still have to give an initial assessment over the phone and then provide a medical reason for why the appointment can be delayed, said Anthony Wright of the Health Access consumer advocacy group.


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