Documenting an Access Gap: Wait Times, Distance and Closed Doors

Plans close panels on paper: a count of contracted providers by specialty and county, measured against a standard. If the paper is wrong where you practice, the way to show it is with a record of your own that is just as concrete. "Nobody in this town takes new patients" is a feeling. "Of the 22 providers listed in the plan's directory within 30 miles, 15 were reached, 4 offered a new-patient appointment and the earliest was 41 business days out" is evidence.

Here is the method we use, and the rules that decide what the record should measure.

Which providers count toward the plan's numbers?

Before counting anything, know what the regulator counts, because it is narrower than the directory.

• Medicare Advantage. Providers "contracted with the organization only for its commercial, Medicaid, or other products" do not count toward Medicare Advantage network adequacy (42 CFR 422.116(a)(4)(i)(C)). Telehealth-only providers do not count toward the minimum-number standard (422.116(e)(1)(ii)), although a plan can earn a 10 percentage point credit toward the time and distance percentage for certain specialties when it contracts with telehealth providers (422.116(d)(5)).
• Medicaid managed care. Under the new secret shopper rules, a telehealth appointment counts toward the wait-time standard only if the surveyed provider also offers in-person appointments to the plan's enrollees, and it must be reported separately (42 CFR 438.68(f)(2)(ii)).

So a directory full of commercial-only contracts or telehealth-only clinicians can look adequate and still miss the standard for a Medicare Advantage or Medicaid product. Record the product for every listing.

How do you build the directory sample?

1. Pick the product. Medicare Advantage HMO, Medicaid plan, commercial PPO. One audit per product; mixing them makes the result easy to dismiss.
2. Pick the specialty the way the regulator names it. Medicare Advantage uses its 29 named provider types, such as "Clinical Social Work" and "Psychiatry" (422.116(b)(1)). States name their own Medicaid types under 438.68(b).
3. Pick the radius from the standard. Use the maximum distance for your county type, not an arbitrary number. See time and distance standards.
4. Pull every listing in that radius from the plan's public directory, and save a dated copy or screenshot of the search.

What should the call log record?

For each listing, one row:

• date and time of the call, and who called;
• whether the number reached the listed provider's office;
• whether the provider is still at that location and still in network for that product;
• whether the provider is accepting new patients with that plan;
• the first available new-patient appointment offered, if any, and whether it was in person or telehealth;
• any language, age group or service the office said it does not offer.

Use the same short script for every call, ask as a prospective new patient with that plan would, and do not invent a patient or give false details. Two callers on different days make the result harder to wave away. The point is a sample the plan could reproduce.

Directory accuracy rules give the log extra weight. Medicaid plan directories must say whether a provider "will accept new enrollees" (42 CFR 438.10(h)(1)(vi)), and Texas PPO insurers must list which preferred providers continue to be available to new patients and update the listing at least quarterly (Tex. Ins. Code 1301.1591). A listing that says "accepting new patients" next to a call log that says otherwise is a fact the plan has to answer. See provider directory accuracy rules.

How do you measure wait time and distance?

Wait time: count business days from the date of the call to the first offered appointment, which matches how the federal Medicaid rule states its limits ("no longer than 10 business days from the date of request" for outpatient mental health and substance use disorder, for example, under 438.68(e)(1)(i)). Medicare Advantage states its primary care and behavioral health limits in business days as well (422.112(a)(6)(i)). Texas states its PPO limits in weeks (Tex. Ins. Code 1301.00555).

Distance: measure driving distance and time from the ZIP codes where the plan's members actually live, not from your office. Texas defines "maximum distance" as "the miles calculated to drive by automobile" (Tex. Ins. Code 1301.00553(a)). For Medicaid, the state must consider "the means of transportation ordinarily used by Medicaid enrollees" (438.68(c)(1)(vi)), so note public transit time where that is how people get to care.

What about demand from your own patients?

It helps, and it needs care. Count inquiries from members of that plan and product by month, and record the outcome (referred elsewhere, paid out of pocket, waited). Keep names and diagnoses out of anything sent to the plan. If you want to include a patient's own account, ask a healthcare attorney about the authorization you would need. Referral letters from primary care physicians who cannot find an in-network specialist are strong, and do not need patient detail to make the point.

Where can you find published data?

• State Medicaid secret shopper results. States must contract with an independent entity for annual secret shopper surveys of directory accuracy and appointment wait times, and post the results within 30 calendar days of submitting them to CMS (438.68(f)). That requirement applies from the first rating period beginning on or after July 9, 2028 (438.68(h)), so many states will not have these reports yet. Where a state already publishes access studies, use them.
• Published state standards. States must publish their Medicaid network adequacy standards (438.68(g)).
• Texas waiver filings. The Texas Department of Insurance posts waiver requests and decisions, including the specialty types and counties affected, on its network adequacy pages and the Texas Open Data Portal. A granted waiver for your specialty and county is the plan admitting a gap.

How do you present it?

One summary table (listings found, reached, accepting new patients, median and earliest first appointment, number beyond the distance standard), followed by the full call log as an exhibit, a simple map, and the plan's own denial letter. Then a two-page letter that ties the numbers to the standard. See how to write a network adequacy letter.

Can we run the audit?

Yes. The directory pull, call audit, distance analysis and evidence package are part of every Payer Network Dispute ($799 per payer; $1,999 for three). We prepare the package and the letter, and you review, sign and send them. We do not contact plans in your name without your instruction, and we never present the audit as anything other than what it is. See pricing. We are not a law firm; questions about patient authorizations or your legal rights go to a healthcare attorney.