The launch of CMS’s Secret Shopper Survey mandate in January 2025 marked a significant shift for Qualified Health Plan (QHP) issuers. For the first time on a broad scale, plans were required to prove timely access to care through independent appointment-availability surveys, with strict thresholds: 15 business days for primary care and 10 for behavioral health.
The goal was clear: to ensure that patients can get care when they need it. But the first year showed just how difficult it is to turn that policy into an operational reality.
The Reality of 2025
Most health plans followed an implementation guide to execute the Secret Shopper Survey. But, during the execution, feedback from across the market paints a consistent picture of year one:
- Compliance was achieved, but often at a cost. Many health plans scrambled to staff up or repurpose internal teams, driving expenses higher than anticipated.
- Execution was uneven. Directory inaccuracies and nonresponsive healthcare providers made survey completion more challenging and compliance targets harder to meet .
- Visibility was limited. Without real-time dashboards, many leaders waited for static reports instead of acting on issues as they arose.
- Competing priorities stretched teams thin. Plans were already balancing multiple new compliance mandates in 2025, along with normal workloads and cost-reduction pressures.
The result: surveys were completed, but in many cases the process was reactive, expensive, and difficult to sustain.
Lessons Learned
The first year highlighted several essential takeaways:
- In-house models are resource-intensive. Standing up for new processes, training staff, and managing call quality added significant administrative overhead.
- Data accuracy matters. Secret Shopper surveys exposed weaknesses in provider directories and highlighted the impact of non-responsive practices.
- Member experience must remain central. CMS’s (Centers for Medicare & Medicaid Services) intent was not just compliance—it was to ensure real patients can access care. Plans that treated surveys only as a checkbox missed the broader opportunity for improvement.
The 2026 Challenge
As the second cycle begins, QHPs face a chance to reset and address the challenges faced in 2025. The key questions for health plans now are:
- How can surveys be executed more efficiently and sustainably?
- What models balance compliance with cost-effectiveness?
- How can survey results be used not just for compliance, but for continuous improvement in patient access?
The plans that succeed in 2026 will be those that build on the lessons learned in year one: embedding automation, leveraging analytics for real-time visibility, and focusing on surveys as a tool for transparency and improvement—not just regulation.
Conclusion
Secret Shopper Surveys are here to stay. Compliance is non-negotiable, but the way plans approach these programs can evolve. By learning from the challenges of the first year, QHPs can transition from reactive compliance to sustainable, efficient models that meet CMS standards and enhance the patient experience. Partnering with the right experts can make all the difference. If you’re interested in exploring more about how outsourced and technology-enabled models can support this shift, click here to learn about Sutherland’s Secret Shopper Solutions.
