The Centers for Medicare & Medicaid Services now mandates annual Secret Shopper surveys for all QHP issuers. Non-compliance risks decertification, corrective action plans, and public penalties — all before your next open enrollment.
CMS has documented that a quarter of all insured adults encountered in-network providers who had no available appointments. Among Medicaid enrollees, that number jumps to 33%. The federal government is done waiting — and your plan can't afford to be caught without a compliant survey process.
Effective January 1, 2025, CMS requires all QHP issuers in Federally Facilitated Exchanges to satisfy six non-negotiable obligations — and the scope will only grow.
You cannot self-administer. CMS explicitly requires medical QHP issuers to contract with an independent third-party entity to conduct all secret shopper surveys.
MandatorySurvey calls must simulate a brand-new patient seeking their first-ever appointment — testing real-world access, not theoretical network participation.
Protocol RequiredSurveys must begin on or shortly after January 1st and be fully completed by May 31 of each plan year — a hard federal deadline with no extensions.
Annual DeadlineCMS provides a "provider population file" each fall. Your third-party vendor must draw a randomized, statistically valid oversample from that list.
CMS-Specified Methodology2025 requires Primary Care (routine) and Behavioral Health. CMS has signaled specialty care will be added in future plan years — prepare now.
Expanding ScopeSurvey results must be submitted to CMS as part of QHP issuer compliance monitoring. CMS can demand underlying documentation at any time for review.
Federal Submission| Provider Type | Visit Category | Max Wait Time |
|---|---|---|
| Primary Care | Routine / Non-urgent | 15 Business Days |
| Primary Care | Urgent Care | 4 Business Days |
| Behavioral Health / SUD | Non-urgent Outpatient | 10 Business Days |
| Behavioral Health / SUD | Urgent Outpatient | 4 Business Days |
| OB/GYN (Medicaid) | Routine | 15 Business Days |
| Specialty Care | Non-urgent (Future Years) | TBD by CMS |
Important: Telehealth appointments may count toward compliance only if the provider also offers in-person visits. Plans cannot satisfy wait time standards through telehealth alone. Both in-person and telehealth availability must be separately documented in survey results.
Failing to conduct surveys, missing reporting deadlines, or falling below the 90% threshold triggers a cascade of enforcement actions that threaten your plan's very existence on the Marketplace.
From the moment CMS delivers your provider population file each fall to the final submission of survey results, our team manages every step of the process — so your compliance team doesn't have to build infrastructure from scratch or risk a missed deadline.
We receive and process the CMS-issued provider population file on your behalf each fall, then design a statistically valid, randomized oversample that satisfies CMS methodology requirements — stratified by geography, specialty type, and network ID.
September – DecemberOur trained surveyors contact providers presenting as new patients, following CMS-compliant scripts. We document active network status, street address, phone number, new patient acceptance, and available appointment dates — both in-person and telehealth.
January 1 – May 31We calculate appointment wait times in business days per CMS's exact technical guidance — excluding federal holidays and weekends, applying correct disposition codes (A, B, J, K, S, T), and computing compliance rates per provider network ID.
Ongoing During Survey WindowBeyond appointment wait times, we verify four CMS-required data points for every provider contacted: active network status, accurate street address, correct telephone number, and new patient acceptance. All directory errors are flagged and reported within 3 business days of identification.
Real-Time Error ReportingWe compute your compliance rate numerator, denominator, and final percentage per provider type and per network ID. If results approach the 90% threshold, we immediately alert your team and provide actionable network gap analysis to support corrective hiring or contracting before the window closes.
Actionable AnalyticsWe prepare and submit your complete survey results to CMS in the required format as part of QHP issuer compliance and monitoring activities — and retain all underlying documentation required for potential CMS audit or request for supporting materials.
Before May 31 DeadlineWe don't adapt a generic mystery shopping program to healthcare. Our entire infrastructure is architected around CMS's technical guidance, HIPAA requirements, and the operational realities of provider network management.
Every call, every record, every data transfer is handled under strict HIPAA protocols. Our surveyors are trained on healthcare-specific compliance, not generic retail mystery shopping.
We follow CMS's Appointment Wait Time Secret Shopper Survey Technical Guide exactly — including disposition codes, business-day calculations, and required data fields in CMS submission format.
CMS requires provider directory errors to be reported within 3 business days of identification. Our real-time tracking system guarantees that timeline is never missed.
We don't just report compliance. We identify exactly where your network is failing — by county, specialty, and provider type — so you can act before results go to CMS.
We operate across all 50 states, supporting QHP issuers in all Federally Facilitated Exchanges and State-Based Exchanges — in-person, telehealth, and online visit modalities included.
CMS has signaled specialty care surveys are coming. Our platform is already built to add specialty care provider types seamlessly — no mid-year scramble when the mandate grows.
The survey window opens January 1st every year and closes May 31st. There are no extensions, no grace periods, and no second chances before CMS reviews your results. Contact us now to get your contract in place and your program ready.
Agreements must be in place before surveys begin. Contact us before Q4 to ensure a seamless January 1st launch.