After-hours blind spots: Assessing and improving reliable access

For many health care organizations, after-hours strategies are often synonymous with having coverage for incoming calls. Health care leaders turn to a call center service or develop a schedule for on-call professionals, checking the box for 24/7 needs and equipping teams with guidance for appropriate escalation paths.

Yet variables exist at every juncture that impact the efficacy of an after-hours strategy. Imagine a regional health system that rolls its phones to an answering service at 5 p.m. One night, this call center is effective in routing a concerned parent to the on-call pediatrician. But the next night, issues mount: One call gets routed to the wrong provider. In another instance, the answering service pages an appropriate physician, but the contact number is out-of-date. When hiccups occur, the likelihood that patients will become anxious and simply head to the emergency department (ED) increases.

Breakdowns in after-hours access rarely show up as performance metrics, but they do impact clinical outcomes and the bottom line through inappropriate ED utilization, unnecessary readmissions and patient leakage. A better approach is "reliable access," where a consistent operating model exists that is measured, manageable and transparent.

Foundationally, after-hours access is one area where a nurse-first triage strategy can markedly improve consistency across the enterprise and improve the outlook on physician burnout. American Medical Association data suggests a 43.2% burnout rate with high stress among emergency medicine, family medicine and OB-GYN physicians, where heavy on-call workload environments exist. A nurse-first model ensures patients promptly reach trained clinicians who use evidence-based protocols to assess acuity and provide guidance.

Reliable access: A deeper look

More comprehensive than coverage, reliable after-hours access means patients consistently reach clinical support every time. In contrast, coverage means someone is scheduled to receive phone calls.

Reliability breaks down when health care leaders treat after-hours coverage as a staffing exercise instead of a system performance strategy. In many organizations, ownership of this area is fragmented, and there is no clear line of accountability. Without system-wide oversight, small behaviors that can impact reliability go unnoticed and unchanged.

For example, it would be easy for executives of a large multispecialty group to believe their after-hours model is working because they rarely receive complaints. What leaders might be missing is the variance between clinics once the doors close. In one primary care office, calls may roll to an answering service that texts the on-call physician directly. In another, calls are held in a queue until enough accumulate to justify paging the provider.

With the latter, patients may have already waited more than 30 minutes before the messages are sent to the physician. This model isn't designed to deliver timely clinical triage. It is instead designed to collect messages. Without oversight into routing times, escalation intervals and callback performance, patients can quickly learn that after-hours means "go to the ED."

With nurse triage, patients have timely access to a licensed professional who can listen and direct them to the appropriate level of care, whether that's home management, next-day follow-up, urgent care or the ED. Notably, up to 60% of all ED visits remain non-urgent and potentially unnecessary.
Seven steps assessing after-hours reliability

Understanding after-hours blind spots starts with a thorough analysis. Health leaders can start the process by evaluating seven areas of after-hours access to determine how reliable systems are across the enterprise.

1. System level ownership Who is in charge of after-hours strategies? Is access governed centrally for visibility and accountability, or is it a collection of departmental decisions?
2. Consistency under variability Change is the only constant in health care. The real test of reliability is consistency — whether the patient experience remains predictable regardless of changes in demand, acuity or staffing. How does an after-hours access model respond to variability?
3. Continuity of care In time-sensitive situations, delayed guidance can increase clinical risk. Can patients reliably reach timely clinical guidance after hours, or are decisions pushed into the ED or deferred until morning?
4. Consistency of documentation quality Accurate documentation is critical to optimal next steps with a patient. Are after-hours interactions documented consistently, visible to the appropriate teams and reinforced by closed-loop escalation and clear follow-up accountability?
5. Downstream operational impact When gaps exist in after-hours access, pressures are compounded during the day. This can look like increased ED traffic, additional follow-up work and care coordination delays. Where are after-hours access gaps showing up operationally?
6. Clinician strain Increased work becomes a driver of burnout and retention risk. Is after-hours on-call work placing undue strain on providers when issues could be resolved without a provider callback?
7. Executive visibility Does leadership know if after-hours access is unreliable and the downstream impact it is producing?

A more reliable way forward

Going forward, it is important for health care leaders to devise after-hours access strategies that go beyond the concept of staffing coverage. Many organizations reinforce reliability with a nurse-first triage model that connects patients to a licensed clinician for timely clinical guidance and appropriate escalation. With clear standards and follow-through, this approach reduces delayed callbacks and protects provider capacity. The real question isn't whether someone is on call; it's whether performance is consistent, measurable and manageable across the enterprise.

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When to bill CHI, PIN or CCM: A practical framework for independent practices

When CMS introduced Chronic Care Management codes in 2015, primary care practices spent years figuring out how to operationalize them. A decade later, many practices that did the work are still running care coordination programs under that same CCM-only mental model, even though the reimbursement landscape has shifted.

In January 2024, CMS introduced two new sets of codes under the Physician Fee Schedule: Community Health Integration (CHI), using HCPCS codes G0019 and G0022, and Principal Illness Navigation (PIN), using G0023, G0024, G0140 and G0146. Both expand what Medicare reimburses for between-visit coordination. Both have specific qualifying conditions and documentation requirements. And both are currently uncaptured in most independent practices I encounter.

The gap is rarely about willingness. It is about decision-making. When a practice manager is asked which code to bill for a given patient, the honest answer is often “I don’t know,” and so they default to billing nothing, billing CCM for everyone or running an informal coordination program off the books. None of those serve the patient or the practice.

A simple decision framework can clarify the choice.

Question 1: Does the patient have two or more chronic conditions expected to last at least 12 months?

If yes, CCM is in play. The patient qualifies for ongoing chronic care management: care coordination, medication management and between-visit support. The practice can bill the corresponding CCM codes for the time spent. CCM is the workhorse. Most patients with multiple chronic conditions in a primary care panel qualify, and most practices have at least started billing it.

Question 2: Does the patient have unmet health-related social needs that affect their care?

If yes, Community Health Integration enters the picture. CHI was designed to reimburse for the coordination work that addresses social drivers of health: transportation barriers, food insecurity, housing instability and social isolation, when those barriers are documented as affecting the patient's clinical condition. G0019 covers the first 60 minutes per calendar month; G0022 covers each additional 30 minutes.

CHI is not a replacement for CCM. A patient may qualify for both, with the practice billing each for distinct services on different days. The key is documentation. The social need must be identified, the intervention must be tied to a clinical concern, and the time must be tracked under the appropriate code.

Question 3: Does the patient have a serious, high-risk illness requiring active navigation?

If yes, Principal Illness Navigation may be the right code. PIN was created for patients with serious, high-risk conditions expected to last at least three months, including cancer, COPD, congestive heart failure, dementia, HIV/AIDS, severe mental illness and substance use disorder, where the patient is at risk of hospitalization, nursing home placement, acute exacerbation or functional decline. PIN reimburses for the navigation work that helps these patients move through the health care system, manage symptom burden and execute their treatment plan. G0023 covers the first 60 minutes per calendar month; G0024 covers each additional 30 minutes.

PIN doesn't apply to every patient with a chronic condition. It's specifically for serious illness with high navigation need. But for the patients it does fit, the reimbursement is meaningful and the clinical benefit is real.

Putting the framework into practice

The framework above is simple in concept and harder in execution. Capturing the right code for the right patient requires three things working together: clear identification of which patients qualify for which programs, documentation that meets each code's specific requirements and time-tracking that holds up under audit.

That infrastructure is where most practices stall. The codes exist. The patients exist. What's missing is the operational layer that connects them: the workflows, the documentation templates, the staff time and the EHR integration to make sure that what's clinically happening is also what's getting billed.

Related content from Medical Economics: New Medicare codes could transform how physicians serve their most vulnerable patients: here's how to use them

Bottom line

The codes have been live since January 2024, with federal reimbursement authorized. The patients these codes were designed for are sitting in independent primary care panels right now, often receiving the coordination work informally and unbilled. Practices that operationalize CHI and PIN now will be ahead of the value-based care curve. Practices that don't will keep leaving Medicare revenue uncaptured and, more importantly, will keep leaving their most complex patients without the coordinated care those codes were designed to fund.

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Hidden costs, unmanaged denials drain practice revenue

Medical practices are losing money in places most administrators never think to look, from aging shredding contracts to appeals that never get filed, and the gap between what practices spend and what they collect is only widening.

Shawntea Gordon, MBA, FACMPE, CEO of Atlas & Perpetua Healthcare, said the pressure on practices has intensified in recent years as technology costs, staffing shortages and stagnant reimbursement converge. She works with practices across the country to identify revenue leakage and build sustainable cost-management frameworks.

“The disparity between the costs we’re putting out and the reimbursement we’re getting in has gotten so much larger,” Gordon said. “I think the tech stacks with our organizations have gone from maybe two or three main software systems to upwards of 15.”

That assessment tracks with data from MGMA, which has documented steady increases in operating costs per physician even as collections have remained relatively flat for many specialties. The AMA’s Physician Practice Benchmark Survey has similarly flagged rising administrative overhead as a top financial stressor for independent practices.

Gordon said the most common source of revenue loss she encounters is unmanaged denials, followed by charges sitting untouched in accounts receivable. But she said leakage often starts much earlier in the revenue cycle, with front desk data entry errors that miss coordination of benefits or patient responsibilities, undocumented in-office services and down coded claims that go unchallenged.

“We have denials that aren’t appealed. We have down coding happening. There’s kind of a ton of places where I find leakage typically,” she said.

For administrators who have never formally benchmarked their expenses, Gordon’s advice is to start with historical data before making any changes.

“If you are not starting from an evidence-based perspective, you’re at a high risk of going off in the wrong direction,” she said. “Go dig into your own historical data.”

She recommends using established associations, including MGMA, HFMA and relevant medical specialty societies, as benchmarking references rather than newer online tools that may lack the historical depth to produce meaningful comparisons. She also cautioned that practices must be honest about their own characteristics, including size, location, community type and payer mix, before concluding they are over- or understaffed.

“A lot of groups that I come into say staffing is the highest cost, we need to get rid of staffing,” Gordon said. “Then we do an analysis and find out they’re already vastly understaffed, and the reason they don’t have more revenue is because the staff is burnt out.”

Beyond the expected line items of supplies and technology, Gordon flagged one cost that often goes unnoticed: outdated shredding service contracts.

“So many people kept their shredding services on the same rotation” after transitioning from paper to electronic records, she said. “If you weren’t paying by weight, or you’re paying like a monthly minimum fee, and you’re not really dumping a lot into the shredder bin anymore because you’re putting everything online, that’s one place that I see people just have these monthly contracts that they’ve had since ’92.”

She acknowledged shredding costs are relatively small individually but said they illustrate a broader pattern of practices paying for services that no longer match their operational reality.

Before making any significant change, Gordon said leaders should run through a standard set of questions: Will this create a compliance risk? Will it hurt the patient experience? Will it affect revenue collection? She described a case in which a practice switched medical supply vendors to cut costs, only to discover the new vendor had a history of back-ordering a critical surgical item.

“You have to dig into those things ahead of time,” she said. “Really make sure you’re looking holistically and not just making a decision based on your gut.”

For the longer term, Gordon recommends building a structured improvement cycle rather than conducting one-time audits. That means doing a full organizational review, building a 90-day improvement plan and then converting that review cadence into a standing monthly process.

“This is something you look at every single month,” she said. “How can we do better than we did last month? How can we improve, even if it’s just by 1% every single month?”

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