Medicare
Communications with Physicians Can Be Improved Gao ID: GAO-02-249 February 27, 2002Unlike other federal programs that make expenditures under the direct control of the government, Medicare constitutes a promise to pay for covered medical services provided to its beneficiaries by about one million providers. Given this open-ended entitlement, it is essential that appropriate and effective rules and policies be specified so that only necessary services are provided and reimbursed. Congress and the Centers for Medicare and Medicaid Services (CMS) have promulgated an extensive body of statutes, regulations, policies, and procedures on what shall be paid for and under what circumstances. Information that carriers give to physicians is often difficult to use, out of date, inaccurate, and incomplete. Medicare bulletins that carriers use to communicate with physicians are often poorly organized and contain dense legal language. Similarly, other means of communicating with physicians, such as toll-free provider assistance lines and websites, have problems with accuracy and completeness. Although all carriers issue bulletins, operate call centers, and maintain websites, each carrier develops its own communications policies and strategies. This approach results in a duplication of effort as well as variations in the quality of carrier communications. CMS provides little technical assistance to help carriers develop effective communication strategies. Neither CMS carrier oversight nor self-monitoring by the carriers is comprehensive enough to provide sufficiently detailed information that could either pinpoint specific communication problems or identify poorly performing carriers. CMS is working to improve its physician communications by consolidating new instructions and regulations and issuing them on a more predictable schedule to lessen the burden of frequent policy changes that physicians cannot anticipate. CMS is also enhancing its education programs for both physicians and carrier staffs and expanding its efforts to obtain physician feedback. Finally, CMS is improving its national website and intends to develop a single web-based source of information for physicians.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-02-249, Medicare: Communications with Physicians Can Be Improved
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United States General Accounting Office:
GAO:
Report to Congressional Requesters:
February 2002:
Medicare:
Communications With Physicians Can Be Improved:
GAO-02-249:
Contents:
Letter:
Results in Brief:
Background:
Carrier Communications Are Often Difficult to Use, Out of Date,
Inaccurate, and Incomplete:
CMS's Management and Oversight of Communications With Physicians Are
Insufficient:
CMS is Making Efforts to Improve Physician Communications:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Call Center Accuracy Test Questions:
Appendix III: Results of Communications Collection from Seven
Physician Practices:
Appendix IV: Comments from the Centers for Medicare and Medicaid
Services:
Appendix V: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Timeliness of 10 Carriers' Publication of Program Memorandums
(PMs):
Table 2: Summary of the Accuracy of Responses by Question:
Table 3: Compliance with Fiscal Year 2001 BPR Content Requirements by
10 Carrier Web Sites:
Table 4: Questions and Answers for Test of Carrier Call Centers:
Table 5: Summary of Communications Included and Excluded by Physician
Practices:
Table 6: Percentages of Medicare Communication Subjects and Sources
Collected by Seven Physician Practices from February 1, 2001 through
April 30, 2001:
Abbreviations:
BFE: business function expert:
BPR: budget and performance requirement:
CMS: Centers for Medicare and Medicaid Services:
CPE: contractor performance evaluation:
CSR: customer service representative:
FAQ: frequently asked questions:
HCFA: Health Care Financing Administration:
HHS: Department of Health and Human Services:
LMRP: local medical review policy:
PM: program memorandum:
PRIT: Physicians' Regulatory Issues Team:
[End of section]
United States General Accounting Office:
Washington, DC 20548:
February 27, 2002:
The Honorable Jim Nussle:
Chairman:
Committee on the Budget:
House of Representatives:
The Honorable Nancy L. Johnson:
Chairman:
Subcommittee on Health:
Committee on Ways and Means:
House of Representatives:
The Honorable Saxby Chambliss:
House of Representatives:
Medicare, serving nearly 40 million beneficiaries, is the nation's
largest health insurer and second largest federal program. Unlike
other federal programs that make expenditures under the direct control
of the government, Medicare constitutes a promise to pay for covered
medical services provided to its beneficiaries by about 1 million
providers. Given this open-ended entitlement, it is essential that
appropriate and effective rules and policies be specified so that only
necessary services are provided and reimbursed. To accomplish this,
the Congress and the Centers for Medicare and Medicaid Services (CMS)
[Footnote 1]-”the federal agency within the Department of Health and
Human Services (HHS) that administers Medicare-”have promulgated an
extensive body of statutes, regulations, policies, and procedures
regarding what shall be paid for and under what circumstances. CMS,
which relies on the assistance of about 50 claims administration
contractors[Footnote 2] to operate the Medicare program, is charged
with communicating this information to medical providers, including
physicians, so that they can bill the program properly.
Recently, physicians and their representatives testified at
congressional hearings that their participation in Medicare is
becoming increasingly burdensome. Among other things, they reported
being inundated with large volumes of complicated, unclear, and
inconsistent information from the Health Care Financing Administration
(HCFA) and its carriers about Medicare program requirements. They also
expressed concern that, because rules change frequently, their
understanding of billing rules may be obsolete and incorrect, which
could lead to inadvertent billing errors.
This report responds to your request, which recognized both the need
for HHS, and particularly CMS, to routinely communicate regulations,
instructions, and guidance to physicians, and the concerns of
physicians regarding the quality of the materials they receive.
Specifically, you asked us to examine several aspects of Medicare
communications, including (1) the quality of Medicare information
provided to physicians by IRIS, and CMS and its carriers, (2) the
quality of CMS's management and oversight of carrier communications,
and (3) current CMS efforts to enhance the communication process.
To understand physicians' concerns regarding Medicare communications,
we first solicited the views of individual physicians from several
specialties and representatives from relevant professional
organizations. As part of this effort, we obtained the cooperation of
seven physician practices of varying sizes that provided us with
information on the volume and type of Medicare communications they
received during a 3-month period. These practices were located in
different areas of the country and received information from different
carriers. They also provided us with excerpts from documents they
received and shared their views on the usefulness of the information
they received during that time frame. In addition, we interviewed
officials at several carriers and HCFA. We also met with officials at
other HHS agencies to discuss their communications with physicians
participating in the Medicare program.[Footnote 3]
On the basis of this information, and because the vast majority of
Medicare communications are issued by carriers on behalf of CMS, we
focused on the information carriers provide to physicians. We then
conducted an evaluation of the quality of the three main methods
carriers use to provide information to physicians”bulletins they
publish and mail to physicians, telephone call centers that respond to
physician questions, and Internet Web sites to serve participating
physicians. Specifically, to assess bulletins we reviewed recently
issued bulletins from 10 carriers to determine whether they organized
material in ways that would help readers locate information. We
evaluated the timeliness and completeness of these bulletins by
examining them to determine when certain CMS-issued memorandums, which
were relevant to physicians, were included. To assess the quality of
information provided to physicians calling carriers with questions, we
telephoned 5 of the 37 provider assistance call centers with
frequently asked questions (FAQ) taken from carrier Web sites. With
CMS's assistance, we scored the completeness and accuracy of these
responses. We also visited 3 carrier call centers to observe their
operations and to study the carriers' approaches to monitoring the
performance of the customer service representatives who are
responsible for responding to physician inquiries. To assess carrier
Web sites we examined 10 such sites to determine if they complied with
requirements established by CMS, as well as to assess whether the
information presented on those Web sites was accurate, complete, and
timely. We did not evaluate communications issued by all Medicare
carriers; our findings are limited to those carriers we reviewed and
cannot be projected to other carriers.
To evaluate the quality of CMS's management and oversight of carriers'
communications activities, we identified relevant requirements that
CMS imposes on carriers regarding their communications with
physicians. We also examined CMS's allocation of key resources devoted
to communication activities. In addition, we observed CMS officials
conduct an on-site performance evaluation of one carrier's call
center. To identify CMS's efforts to improve Medicare communication to
physicians, we spoke with officials from CMS, carriers, medical
associations, physicians and their practice administrators, and
reviewed related documentation. We identified recent initiatives CMS
has undertaken to improve physician communications and also explored
its plans for future enhancements.
Appendix I contains more information regarding the scope and
methodology of our work. A more detailed description of our review of
carrier call centers is contained in appendix II. Appendix In
summarizes the amount and types of information the seven physician
practices received from both governmental and nongovernmental sources
from February 1, 2001, through April 30, 2001. CMS provided comments
on a draft of this report. These comments are reproduced in appendix
IV.
Our work was conducted from December 2000 through January 2002 in
accordance with generally accepted government auditing standards.
Results in Brief:
Information given to physicians by carriers is often difficult to use,
out of date, inaccurate, and incomplete. Medicare bulletins that
carriers use as the primary means of communicating with physicians are
often poorly organized and contain dense legal language. They are
sometimes incomplete, failing to include information about upcoming
program changes, and are not always timely in communicating CMS-issued
information. Similarly, carriers' other principal means of
communicating information to physicians”toll-free provider assistance
lines and Web sites”also proved to be problematic in terms of accuracy
and completeness. Customer service representatives rarely provided
appropriate answers to questions, answering only 15 percent of our
test calls completely and accurately. In addition, only 20 percent of
the carrier Web sites we reviewed contained all of the information
required by CMS, and many lacked common features that allow Web sites
to be used effectively, such as site maps and search functions.
Although all carriers issue bulletins, operate call centers, and
maintain Web sites, each carrier develops its own communications
policies and strategies. This approach results in a duplication of
effort as well as variations in the quality of carrier communications.
Although CMS is tasked with assuring that carriers are responsive to
physicians, the agency has established few standards for carriers to
meet in their physician communications activities. CMS provides little
technical assistance to help carriers develop effective communication
strategies.
CMS officials told us that they do not have enough staff to
effectively monitor and assist carriers in their communications with
physicians. Neither CMS carrier oversight nor self-monitoring by the
carriers is comprehensive enough to provide sufficiently detailed
information that could either pinpoint specific communications
problems or identify poorly performing carriers.
CMS is working to improve its physician communications in a number of
ways. For example, the agency announced that it would consolidate new
instructions and regulations and issue them on a more predictable
schedule to help lessen the burden of frequent policy changes that
physicians have no way to anticipate. CMS is also enhancing its
education programs for both physicians and carrier staffs and
expanding its efforts to obtain physician feedback. In addition, CMS
is improving its national Web site and intends to develop a single Web-
based source of information for physicians. These and other
improvements are potentially valuable; however, many are in the early
stages of planning or implementation, and we could not assess their
ultimate effectiveness.
We are making recommendations to the CMS administrator to further
improve the timeliness, consistency, and quality of Medicare
communications to physicians. CMS agreed that it needs to improve
these communications and described some of its ongoing and planned
improvements.
Background:
The complexity of the environment in which CMS operates the Medicare
program cannot be overstated. CMS manages Medicare, the nation's
largest health insurer, in a challenging and complex environment in
which medical providers and beneficiaries form a vast network of
stakeholders with differing priorities. The agency is charged with
developing regulations and policies that implement the statutory
provisions of the Medicare program. The program is operated by CMS
with the assistance of approximately 50 carriers and fiscal
intermediaries”generally health insurance companies”that annually
process about 900 million claims submitted by nearly 1 million
providers and private health plans. Medicare is estimated to have
spent nearly $240 billion in fiscal year 2001 for services provided to
approximately 40 million elderly and disabled beneficiaries.
In order to receive reimbursement from Medicare, CMS requires
physicians to submit claims that identify the services they have
performed by using the agency's national uniform procedure coding
system. Like other Medicare providers, physicians are responsible for
billing Medicare correctly for services performed and informing
beneficiaries of the level of Medicare coverage at the time of
service. To do this they need reliable information on Medicare
coverage, claims coding and documentation requirements, claims
submission instructions, program changes, and carrier policies.
CMS communicates information describing its billing requirements, as
well as other relevant regulations and policies, to physicians
primarily through its carriers. The carriers communicate with
physicians in several ways. They send physicians bulletins
periodically to update them on new rules and program changes, provide
toll-free lines to call centers so physicians can obtain answers to
questions, and maintain Web sites that include postings of, among
other things, new Medicare developments and carrier-sponsored
training. CMS and its carriers also sponsor a variety of provider
education activities, such as workshops and on-line training courses,
to help familiarize physicians with billing rules and other aspects of
the program and to update them on program changes.
Physicians have become increasingly vocal about the timeliness and
quality of the Medicare information CMS and its carriers provide. For
example, last year, in congressional testimony, physicians and their
representatives reported frustration because carrier communications
are often unclear and do not always provide them with advance notice
of program changes. They also charged that, when they seek
clarification, carrier personnel often give them incorrect answers to
their questions.
CMS establishes carrier requirements, including some related to
communications, in its annual budget and performance requirements
(BPR). For example, the BPRs require carriers to communicate with
physicians about local medical review policies (LMRP)[Footnote 4] and
claims submission procedures. CMS is responsible for monitoring the
performance of its carriers to ensure that they accurately and
efficiently fulfill their requirements and properly implement Medicare
policies. Much of CMS's oversight is accomplished through its periodic
evaluations of carrier performance. In addition, the agency also
requires carriers to routinely submit evidence of their own self-
monitoring activities.
Carrier Communications Are Often Difficult to Use, Out of Date,
Inaccurate, and Incomplete:
Medicare information provided by carriers for physicians is often
difficult to interpret and use, out of date, inaccurate, and
incomplete. Our analysis of the three main methods that carriers use
to communicate information to physicians”printed bulletins, provider
assistance call centers, and Web sites”revealed problems with all
three types of communication.
Carrier Bulletins Can Be Difficult to Use and Lack Current Information:
Carrier bulletins contain important information for physicians but
present this information in formats that may be difficult for them to
use. In addition, critical information, including changing program
requirements, may be late in reaching physicians who need to take
steps to implement these changes.
CMS relies heavily on carrier bulletins”which each carrier is required
to issue at least quarterly”to give physicians official notice of
their responsibilities and requirements under Medicare law,
regulations, and guidelines. Carriers have discretion regarding the
bulletins' format and organization, but they are required to reprint
certain CMS-provided information verbatim. For example, carriers
receive and reproduce CMS-issued guidance-”known as program
memorandums (PM)-”which convey details about upcoming program changes
scheduled to become effective in the next few months.
Our review of bulletins issued from March through July 2001 by 10
randomly selected carriers[Footnote 5] showed that there are several
aspects of the bulletins, including their organization and length,
which hinder their usefulness. As a result of carriers' freedom to
develop their own bulletins with little direct CMS guidance, there was
considerable variation in the organization and format of the bulletins
we reviewed. While bulletins issued by 6 of the 10 carriers organized
information by subject matter or specialty, the others provided only
an alphabetical key word index instead of a table of contents to
assist the user. Providing only a key word index makes it difficult to
identify information relevant to different physician practices. Some
carriers that serve physicians in several states issued a single
bulletin for all their states. Some of these bulletins had information
for each state contained in a separate insert or section. Other, less
helpful, multistate bulletins only noted state differences within
individual articles, requiring physicians or their staffs to scan each
article to determine whether it was relevant and applicable to their
practices. In addition, the bulletins were typically over 50 pages in
length and several exceeded 80 pages, making them lengthy documents to
search.
In several instances, bulletins were late, or provided little advance
notice, in communicating HCFA-issued program changes to physicians. To
test the timeliness of carrier bulletins in communicating information,
we selected four PMs that HCFA issued from February through April 2001
concerning program changes that physicians would need to be aware of
in billing for certain services. We then reviewed the bulletins issued
from March through July by the 10 carriers we sampled, to determine
when the four PMs were included in the carriers' bulletins. In 11
instances, PMs were either not communicated through carriers'
bulletins until after their scheduled implementation dates, or they
did not appear at all in the bulletins we reviewed, as shown in table
1. In 11 additional instances, bulletins communicated the memorandums
less than 30 days prior to the implementation date, giving physicians
little advance notice to help ensure their compliance with Medicare
rules.[Footnote 6] Overall, 6 of the 10 carriers did not communicate
at least one of the four PMs before its scheduled implementation.
Table 1: Timeliness of 10 Carriers' Publication of Program Memorandums
(PMs):
PMs (topic and number): Claims for drugs and biologicals, PM: B-01-10;
Number of carriers that included the PMs in their bulletins at least
30 days before implementation: 10;
Number of carriers that included the PMs in their bulletins less than
30 days before implementation: 0;
Number of carriers that included the PMs in their bulletins 1 to 30
days after implementation: 0;
Number of carriers that had not included PM in the bulletins as of 30
days after implementation: 0.
PMs (topic and number): Coverage for verteporfin,[A] PM: AB-01-37;
Number of carriers that included the PMs in their bulletins at least
30 days before implementation: 6;
Number of carriers that included the PMs in their bulletins less than
30 days before implementation: 2;
Number of carriers that included the PMs in their bulletins 1 to 30
days after implementation: 1;
Number of carriers that had not included PM in the bulletins as of 30
days after implementation: 1.
PMs (topic and number): Levels of physician supervision required for
diagnostic tests, PM: B-01-28;
Number of carriers that included the PMs in their bulletins at least
30 days before implementation: 1;
Number of carriers that included the PMs in their bulletins less than
30 days before implementation: 3;
Number of carriers that included the PMs in their bulletins 1 to 30
days after implementation: 5;
Number of carriers that had not included PM in the bulletins as of 30
days after implementation: 1.
PMs (topic and number): Billing codes for splints and casts, PM: AB-01-
60;
Number of carriers that included the PMs in their bulletins at least
30 days before implementation: 1;
Number of carriers that included the PMs in their bulletins less than
30 days before implementation: 6;
Number of carriers that included the PMs in their bulletins 1 to 30
days after implementation: 3;
Number of carriers that had not included PM in the bulletins as of 30
days after implementation: 0.
[A] Verteporfin is a light-sensitive drug used in laser treatments of
the eye.
Source: GAO analysis, based on PMs obtained from CMS and bulletins
obtained from selected carriers.
[End of table]
Carrier Call Centers Often Provide Inaccurate and Incomplete
Information and Lack Standard Policies and Sufficient Resources:
Customer service representatives (CSR) at carrier call centers we
tested rarely provided appropriate answers to questions we posed.
Eighty-five percent of the responses we received from CSRs from 5
carrier call centers were inaccurate or incomplete.
To assess the accuracy of responses provided by CSRs, we made 61 calls
to the provider inquiry lines at call centers and asked three
questions from the FAQ pages on carriers' Web sites concerning the
appropriate way to bill Medicare in circumstances commonly encountered
by physicians.[Footnote 7] When calling, we identified ourselves as
GAO representatives and asked the CSRs to answer our questions as if
we were physicians. CSR responses were recorded verbatim and submitted
to a Medicare coding expert at CMS along with the text of the
questions and answers used. We used the following questions when
making our calls:
1. If a physician provides critical care for 1 hour and 15 minutes,
how should the services be reported? Should code 99292 (for an
additional 30 minutes) be reported? Should the reduced services
modifier be used?
2. What is the proper way to bill for an office visit on the same day
as a surgical procedure?
3. Can code 99211 be reported if a nurse in the physician's office
provides instruction on self-administering insulin?
Appendix II provides the answers that appear on the Web sites.
The results of the test, which were validated by the coding expert,
showed that 32 percent of the answers were inaccurate, 53 percent were
incomplete, and only 15 percent were complete and accurate. These
results are illustrated in table 2. There was little variation among
the carriers in the overall accuracy and completeness of their answers.
Table 2: Summary of the Accuracy of Responses by Question:
Question 1: Critical care coding;
Inaccurate response: 8;
Incomplete response: 6;
Accurate and complete response: 6;
Nonresponse[A]: 1.
Question 2: Office visits and surgical procedure;
Inaccurate response: 6;
Incomplete response: 10;
Accurate and complete response: 3;
Nonresponse[A]: 1.
Question 3: Nurse providing instruction;
Inaccurate response: 5;
Incomplete response: 15;
Accurate and complete response: 0;
Nonresponse[A]: 0.
Number of call center responses;
Inaccurate response: 19;
Incomplete response: 31;
Accurate and complete response: 9;
Nonresponse[A]: 2.
Percentage of call center responses;
Inaccurate response: 32%;
Incomplete response: 53%;
Accurate and complete response: 15%;
Nonresponse[A]: N/A.
[A] Nonresponses omitted from the sample.
Source: GAO analysis of carrier call center responses.
[End of table]
Many physicians we spoke to expressed frustration that CSRs will not
always provide information on how to properly code certain claims.
Carrier call centers had varying policies about providing physicians
with specific coding information. Knowing the appropriate code for a
medical service is essential to properly billing Medicare. Although
CMS does not have a policy preventing them from doing so, managers at
the carrier call centers we visited reported that it is not their
policy to provide information to callers on how to code a specific
claim. Carriers reported that they are reluctant to provide specific
codes because the CSRs lack the medical expertise to appropriately
make coding judgments, and they do not have the physician's clinical
documentation at the time of the calls to understand the procedure or
service in context.
During our test of call center accuracy, we noted that CSRs followed
different procedures regarding coding-related inquiries and frequently
did not adhere to the carriers' stated policy. While in 19 cases the
CSRs provided neither a code nor referral to a source of coding
information, specific codes were given in 24 instances. Specific
referral to a bulletin issue or to a regulation number was given in 16
other cases, but for 7 of these cases the information was too vague to
enable someone to locate the coding rules. Even when the referrals to
information sources were accurate, physicians told us that being
directed to other carrier publications does not respond to their need
for readily accessible interpretation of Medicare regulations.
Our visits to 3 call centers also revealed that there is no uniformity
or standardization across carriers in the types of technological
resources available to CSRs. For example, 1 call center we visited had
an on-line searchable database of LMRPs that facilitated quick
retrieval of the appropriate information by the CSRs. Representatives
at the 2 other call centers used hard copy bulletins or bulletins
posted on their Web sites in a nonsearchable format. CSRs without
easily searchable tools told us that they relied heavily on their more
experienced colleagues, in the absence of more authoritative sources,
for answers.
The lack of technological resources at call centers can affect
centers' abilities to monitor the performance of their CSRs. One call
center we visited was able to record calls from providers and the
computer screens accessed by CSRs to determine whether their responses
were accurate and complete, while the other two call centers could
only record the telephone calls Two call centers we visited were able
to electronically observe each CSR's phone line activity to track the
length and origin of calls; however, another call center had no
electronic information and could only monitor lines and identify the
type of caller by listening to the calls as they took place.
Carrier Web Sites Not Easy to Use and Often Did Not Meet HCFA-Mandated
Requirements:
Most of the 10 carrier Web sites we reviewed did not contain features
that would allow physicians to quickly and directly obtain the
information they needed. The Web sites frequently lacked logical
organization and navigation tools and search functions that increase a
site's usability and value. Only 4 of the 10 Web sites we examined
contained site maps. Only 6 contained search functions and in two
instances, the search functions did not work. Three sites had neither
search functions nor site maps, making them difficult to navigate to
access information. Furthermore, the Web sites often contained out-of-
date information. Nine of the 10 sites included the required schedule
of upcoming workshops or seminars but 5 of these sites were out of
date. Only 1 site contained a potentially useful "What's New" page,
but the page contained a single document of regulations that went into
effect 8 months prior to the date of our Web site review.[Footnote 8]
Although HCFA's 2001 BPRs contain specific requirements for carrier
Web sites, most of the sites we reviewed did not meet all of these
standards. Only 2 of the 10 sites complied with all 11 of the BPRs'
content requirements,[Footnote 9] as shown in table 3. In addition,
other requirements, such as a federally mandated privacy statement
outlining the type of information the site collects on visitors and a
section containing FAQs were not consistently met. Five Web sites
contained the privacy statement, and 5 contained a link to FAQs.
Table 3: Compliance with Fiscal Year 2001 BPR Content Requirements by
10 Carrier Web Sites:
HCFA Web site requirement: Recent bulletins;
Carrier 1: Web site met the HCFA standard;
Carrier 2: Web site met the HCFA standard;
Carrier 3: Web site met the HCFA standard;
Carrier 4: Web site met the HCFA standard;
Carrier 5: Web site met the HCFA standard;
Carrier 6: Web site met the HCFA standard;
Carrier 7: Web site met the HCFA standard;
Carrier 8: Web site met the HCFA standard;
Carrier 9: Web site met the HCFA standard;
Carrier 10: Web site met the HCFA standard;
Total carriers meeting requirement: 10.
HCFA Web site requirement: Compatibility with multiple browsers;
Carrier 1: Web site met the HCFA standard;
Carrier 2: Web site met the HCFA standard;
Carrier 3: Web site met the HCFA standard;
Carrier 4: Web site met the HCFA standard;
Carrier 5: Web site met the HCFA standard;
Carrier 6: Web site met the HCFA standard;
Carrier 7: Web site met the HCFA standard;
Carrier 8: Web site met the HCFA standard;
Carrier 9: Web site met the HCFA standard;
Carrier 10: Web site met the HCFA standard;
Total carriers meeting requirement: 10.
HCFA Web site requirement: Schedule of training sessions;
Carrier 1: Web site met the HCFA standard;
Carrier 2: Web site did not meet the HCFA standard;
Carrier 3: Web site met the HCFA standard;
Carrier 4: Web site met the HCFA standard;
Carrier 5: Web site met the HCFA standard;
Carrier 6: Web site met the HCFA standard;
Carrier 7: Web site met the HCFA standard;
Carrier 8: Web site met the HCFA standard;
Carrier 9: Web site met the HCFA standard;
Carrier 10: Web site met the HCFA standard;
Total carriers meeting requirement: 9.
HCFA Web site requirement: Link to HCFA.gov;
Carrier 1: Web site met the HCFA standard;
Carrier 2: Web site met the HCFA standard;
Carrier 3: Web site met the HCFA standard;
Carrier 4: Web site did not meet the HCFA standard;
Carrier 5: Web site met the HCFA standard;
Carrier 6: Web site met the HCFA standard;
Carrier 7: Web site met the HCFA standard;
Carrier 8: Web site met the HCFA standard;
Carrier 9: Web site met the HCFA standard;
Carrier 10: Web site did not meet the HCFA standard;
Total carriers meeting requirement: 8.
HCFA Web site requirement: Link to HCFA's Medicare Learning Network[A];
Carrier 1: Web site met the HCFA standard;
Carrier 2: Web site did not meet the HCFA standard;
Carrier 3: Web site met the HCFA standard;
Carrier 4: Web site met the HCFA standard;
Carrier 5: Web site did not meet the HCFA standard;
Carrier 6: Web site met the HCFA standard;
Carrier 7: Web site did not meet the HCFA standard;
Carrier 8: Web site met the HCFA standard;
Carrier 9: Web site met the HCFA standard;
Carrier 10: Web site met the HCFA standard;
Total carriers meeting requirement: 7.
HCFA Web site requirement: Search function;
Carrier 1: Web site did not meet the HCFA standard;
Carrier 2: Web site met the HCFA standard;
Carrier 3: Web site met the HCFA standard;
Carrier 4: Web site did not meet the HCFA standard;
Carrier 5: Web site met the HCFA standard;
Carrier 6: Web site met the HCFA standard;
Carrier 7: Web site met the HCFA standard;
Carrier 8: Web site did not meet the HCFA standard;
Carrier 9: Web site met the HCFA standard;
Carrier 10: Web site did not meet the HCFA standard;
Total carriers meeting requirement: 6.
HCFA Web site requirement: Privacy policy published;
Carrier 1: Web site did not meet the HCFA standard;
Carrier 2: Web site did not meet the HCFA standard;
Carrier 3: Web site met the HCFA standard;
Carrier 4: Web site met the HCFA standard;
Carrier 5: Web site did not meet the HCFA standard;
Carrier 6: Web site met the HCFA standard;
Carrier 7: Web site did not meet the HCFA standard;
Carrier 8: Web site did not meet the HCFA standard;
Carrier 9: Web site met the HCFA standard;
Carrier 10: Web site met the HCFA standard;
Total carriers meeting requirement: 5.
HCFA Web site requirement: FAQs;
Carrier 1: Web site did not meet the HCFA standard;
Carrier 2: Web site did not meet the HCFA standard;
Carrier 3: Web site met the HCFA standard;
Carrier 4: Web site met the HCFA standard;
Carrier 5: Web site did not meet the HCFA standard;
Carrier 6: Web site met the HCFA standard;
Carrier 7: Web site did not meet the HCFA standard;
Carrier 8: Web site did not meet the HCFA standard;
Carrier 9: Web site met the HCFA standard;
Carrier 10: Web site met the HCFA standard;
Total carriers meeting requirement: 5.
HCFA Web site requirement: Link to Medicare.gov;
Carrier 1: Web site met the HCFA standard;
Carrier 2: Web site met the HCFA standard;
Carrier 3: Web site met the HCFA standard;
Carrier 4: Web site did not meet the HCFA standard;
Carrier 5: Web site did not meet the HCFA standard;
Carrier 6: Web site met the HCFA standard;
Carrier 7: Web site did not meet the HCFA standard;
Carrier 8: Web site did not meet the HCFA standard;
Carrier 9: Web site met the HCFA standard;
Carrier 10: Web site did not meet the HCFA standard;
Total carriers meeting requirement: 5.
HCFA Web site requirement: E-mail support;
Carrier 1: Web site did not meet the HCFA standard;
Carrier 2: Web site did not meet the HCFA standard;
Carrier 3: Web site did not meet the HCFA standard;
Carrier 4: Web site met the HCFA standard;
Carrier 5: Web site did not meet the HCFA standard;
Carrier 6: Web site met the HCFA standard;
Carrier 7: Web site did not meet the HCFA standard;
Carrier 8: Web site did not meet the HCFA standard;
Carrier 9: Web site met the HCFA standard;
Carrier 10: Web site met the HCFA standard;
Total carriers meeting requirement: 4.
HCFA Web site requirement: Register for events;
Carrier 1: Web site did not meet the HCFA standard;
Carrier 2: Web site did not meet the HCFA standard;
Carrier 3: Web site did not meet the HCFA standard;
Carrier 4: Web site did not meet the HCFA standard;
Carrier 5: Web site did not meet the HCFA standard;
Carrier 6: Web site met the HCFA standard;
Carrier 7: Web site met the HCFA standard;
Carrier 8: Web site did not meet the HCFA standard;
Carrier 9: Web site met the HCFA standard;
Carrier 10: Web site did not meet the HCFA standard;
Total carriers meeting requirement: 3.
HCFA Web site requirement: Percentage of BPR requirements met;
Carrier 1: 55%;
Carrier 2: 46%;
Carrier 3: 82%;
Carrier 4: 64%;
Carrier 5: 46%;
Carrier 6: 100%;
Carrier 7: 55%;
Carrier 8: 55%;
Carrier 9: 100%;
Carrier 10: 55%.
[A] The Medicare Learning Network is a Web site featuring information
on training resources for physicians.
Source: GAO analysis of carrier Web sites.
[End of table]
Although CMS has set standards for carrier Web sites, each carrier
independently develops its own Web site. This has resulted in
duplication of effort and variations in the usability and complexity
of the information provided.
CMS's Management and Oversight of Communications With Physicians Are
Insufficient:
CMS is ultimately responsible for managing and overseeing carrier
performance to ensure that carriers supply physicians with consistent
and accurate information. However, the agency's standards and
technical assistance to guide carriers in physician communications
activities are not sufficient to produce consistent, high-quality
products and effective communication strategies. The lack of standard
approaches to communication by carriers makes consistent oversight
more challenging for CMS. Neither of the two principal oversight tools
used by CMS”-contractor performance evaluations (CPE)[Footnote 10] and
carrier self-monitoring and reporting-”provide enough information to
reveal problems carriers may have in providing quality communications.
CMS's Communications Management Lacks Sufficient Standards and
Resources:
CMS has established few standards to guide carriers' primary
communication activities, including publishing bulletins, providing
telephone assistance to callers, and establishing and maintaining Web
sites. The BPRs only require carriers to issue bulletins at least
quarterly. There is no substantive guidance regarding content or
readability.[Footnote 11] Carrier call centers are instructed to
perform "quality monitoring" no more than 10 times a quarter for each
CSR, but CMS's definition of what constitutes accuracy and
completeness in call center responses is neither clear nor specific.
For example, CMS defines accuracy as not being inaccurate”as opposed
to providing necessary and complete information to allow physicians to
correctly bill the program. In the case of Web-based communication,
the BPRs contain few requirements about the clarity or timeliness of
information. Instead, they generally focus on legal issues”such as
measures to protect copyrighted material”that, while important, do not
enhance physicians' understanding of, or ability to correctly
implement, Medicare policy.
CMS officials acknowledged that physician communications have received
less support and oversight than other aspects of carrier operations
and attributed this, in part, to a lack of resources. CMS's regional
offices, which are most directly responsible for carrier oversight,
provide assistance to carriers through business function experts (BFE)
whose principal method of oversight is participation on CPE teams. A
CMS official told us that there are not enough BFEs to provide direct
technical assistance to all carriers in all areas of communication.
Furthermore, a lack of budgetary resources limits BFEs' travel to
carrier sites. One regional BFE we interviewed handles four functional
areas, including provider education and provider phone inquiries, for
6 separate Medicare carriers. The BFE interviewed noted that little
hands-on technical assistance is provided. Despite the fact that
bulletins are a key means of physician communication, and Web sites
are growing in importance, some regions have not been allocated any
BFEs for these functions. Moreover, no region has a full-time
equivalent staff member dedicated to these critical forms of
communication, leaving carriers to solve problems independently.
CMS's efforts to assist carriers in sharing successful approaches are
also limited. The agency's annual conference for call center managers
provides a forum for sharing information and strategies. However,
similar opportunities do not exist for carrier staff members working
with bulletins and Web sites. CMS collects and posts on-line a carrier
Best Practices Handbook relating to provider communications and
education, but as of January 2002, the information had not been
updated in a year. Further, the handbook contains little detail about
how to implement the strategies for improving communications.
The lack of specific standards, sufficient technical assistance, and
best practice guidance creates an environment in which, as one CMS
business function expert said, each carrier must develop its own
communication strategies, resulting in duplication of carriers'
efforts and variations in the quality of their service to physicians.
At the time of our review, CMS did not have any efforts that would be
implemented in the near future to develop more standardized carrier
communications to physicians.
Monitoring of Carriers Is Not Sufficient to Ensure Quality and
Accuracy in Physician Communication:
HCFA has not traditionally undertaken comprehensive evaluations of the
quality or usefulness of carriers' bulletins or Web sites. For 21
years, the agency has conducted on-site evaluations to directly
monitor carriers' performance in a variety of areas. However, the
agency is just beginning to focus CPEs on provider communications. In
2001, it expanded the focus of its call center CPEs to include call
centers that serve providers, including physicians. Previously, these
reviews had been limited to beneficiary call centers.
We observed one CPE team as it evaluated the operations of a provider
call center. This team focused mainly on performance standards that
address procedures, such as how long a caller is kept on hold or
whether the CSR had given an appropriate greeting, rather than whether
information provided was complete and accurate. In order to evaluate
the carrier's performance in monitoring its CSRs, the CPE auditor
listened to 10 prerecorded calls that had been evaluated by the
carrier at an earlier date. However, the CPE auditor did not access
the claims information to evaluate whether the information being
provided to the callers was correct. While assessing procedural
performance is important, helping ensure that callers receive the
correct information is essential.
In addition to CMS's evaluation of call centers through CPEs, the
agency requires carriers to evaluate the performance of their call
center CSRs. Carriers must monitor up to 10 calls for each CSR each
quarter”amounting to about 90 of the more than 30,000 provider
inquiries received by a given carrier each quarter. Carriers we
visited agreed with one call center industry expert[Footnote 12] that
this level of monitoring is far short of what is necessary to
thoroughly evaluate quality. Accuracy and completeness are a
relatively small component (40 percent of the total score) in the
overall performance evaluation of a CSR. The remaining components
focus on CSR attitude and helpfulness.
CMS's oversight beyond the CPE process and carrier self-monitoring
consists principally of CMS staff reviewing carriers' self-reported
data, with little direct feedback from the regional BFEs. Carriers
submit monthly reports summarizing certain call center data, such as
how long callers were kept on hold and the number of calls abandoned.
They also submit quarterly activity reports on communications. The
reports include items such as the number of provider training sessions
offered and the questions most frequently asked by providers. Feedback
from CMS is geared toward correcting specific problems, such as
lengthy caller waiting times, rather than identifying ways to improve
performance on a broader scale.
CMS is Making Efforts to Improve Physician Communications:
Through the feedback it has received from the physician community, CMS
is aware of a need to improve Medicare communications. It is working
to issue new Medicare rules and regulations on a more consistent and
predictable schedule, expand information resources available to
physicians, and obtain more physician feedback relating to Medicare
policies and communications. However, most of these efforts are in
early stages of planning or implementation; therefore, we could not
assess their ultimate impact.
In June 2001, CMS announced plans to reduce the burden on providers of
frequent and irregularly occurring Medicare program changes by issuing
and communicating regulations on a more consistent schedule. CMS plans
to institute a new, Web-based quarterly compendium of program changes,
including all regulations that it expects to publish in the coming
quarter, as well as references or electronic links to regulations
published in the previous quarter. By doing so, CMS hopes to make
physicians aware of program changes and provide them with sufficient
lead time to implement them. The compendium was originally to be
introduced in October 2001, but according to a CMS official, as of
January 2002 the compendium's format was still being developed.
CMS is attempting to improve the consistency of information that
carriers provide to physicians and has both short-term and long-term
projects under way. Currently, the agency is establishing a new on-
line training program for carrier call center CSRs, and over the past
year it has provided in-person training to carrier staffs.
Installation of satellite dish technology at Medicare carriers was
recently completed so that CMS could broadcast training to carrier
staffs. In addition to these shorter-term initiatives, agency
officials told us that they are developing some longer-term projects
to enhance carriers' communications. For example, they are developing
a standard template for carrier bulletins. In 2001, CMS also awarded a
contract for the design of a standardized computer system that would
be used by CSRs at all carrier call centers to improve CSRs' access to
information as they respond to telephone inquiries. A CMS official
told us this will be tested first at a durable medical equipment
contractor this spring, but had no estimate of when it would be
installed at carrier sites.
CMS is also addressing information that it provides directly to the
physician community. In November 2001, CMS mailed the physician
edition of Medicare and You 2002 to physicians participating in
Medicare, which was the first issuance of a physician-oriented version
of their annual Medicare and You beneficiary handbook. This physician
information includes a summary of recent Medicare program changes, an
overview of physician concerns that CMS is currently addressing, and
guidance on contacting carriers or CMS for claims submission and
billing information. The agency is also focusing on improving its
national Web site. Plans include installation of a new navigational
system to make information on CMS's Web site more accessible and
consolidation of all information relevant to providers in a single Web-
based source”a project that will take several years to complete.
In recent years, CMS has also increased efforts to obtain feedback
from physicians regarding communications and training. In response to
the physician community's concerns, the agency established the
Physicians' Regulatory Issues Team (PRIT) in 1998. PRIT has
collaborated with the physician community to identify Medicare
requirements, procedures, and communications that cause the most
problems for physicians, and is working to address the most
significant of them. In July 2001, the administrator of CMS announced
the formation of "open door" policy committees, including one focused
on physicians, consisting of top CMS staff members and provider group
representatives that would meet regularly to discuss regulations that
are troubling to providers. Finally, in the fall of 2001, CMS sent out
two surveys to obtain the views of physicians and other providers on
their Medicare education needs and their experiences with CMS's
program integrity efforts.
Conclusions:
The scope and complexity of the Medicare program make complete,
accurate, and timely communication of program information vital to
physicians who need up-to-date knowledge of Medicare requirements in
order to serve their patients and bill correctly for the services they
provide. Although CMS has delegated this responsibility to carriers,
our work demonstrates that physicians cannot rely on carrier
bulletins, call centers, or Web sites to meet their information needs.
In addition, CMS's lack of standard requirements for carrier
communications results in carriers developing their own approaches to
convey information, leading to duplication of effort and varying
degrees of timeliness, accuracy, and completeness.
CMS has initiated a number of efforts, although some are just getting
underway, to improve the way its carriers communicate with physicians
and, in doing so, has acknowledged that improvements are needed.
However, these efforts focus on the individual methods of
communication and do not consider more fundamental matters such as
whether the current, and almost complete, reliance on carriers to
communicate with physicians is in the best interest of the program. We
believe it is important for CMS to initiate a more comprehensive and
standardized approach to physician communications through
coordination, leadership, and management of CMS's carrier-based
communications. This approach should focus on communicating timely,
accurate, and complete information in formats that physicians find
easy to use. It should include meaningful performance standards for
carrier communications, enhanced requirements for carrier self-
monitoring, effective monitoring and feedback by CMS's staff, and more
substantive periodic CPE reviews of carrier communications.
Recommendations for Executive Action:
In order to improve its assistance to, and oversight of, its Medicare
carriers' physician communications efforts, we recommend that the
administrator of CMS adopt a standardized approach that would promote
the quality, consistency, and timeliness of Medicare communications
while also strengthening CMS's management and oversight. Specifically
we recommend that CMS take the following actions:
* Assume responsibility for the publication of a national bulletin for
physicians, in addition to issuing a quarterly compendium of
regulations. Carriers would be responsible for preparing supplements
to CMS's national bulletin regarding local medical policy issues.
* Establish new performance standards for carrier call centers that
emphasize providing complete and accurate answers to physician
inquiries. Carriers' monitoring of their carrier call center
operations should also be expanded to assure that these performance
standards and policies are followed.
* Set standards and provide technical assistance to carriers to
promote consistency, accuracy, and user-friendliness of all carrier
Web sites, which should be limited to local Medicare information and
should be designed to link to CMS's Web site for national program
information.
* Strengthen its contractor evaluation and management process by
relying on expert teams to conduct more substantive CPE reviews on all
physician communications activities.
Agency Comments and Our Evaluation:
In written comments on a draft of this report, CMS agreed that
improvement is needed in its communications with physicians
participating in Medicare and recognized that providing them with the
best possible information is integral to successfully serving Medicare
beneficiaries. CMS described its current efforts to develop a
comprehensive customer service plan and elaborated on several efforts
to improve communications that the agency currently has under way. For
example, CMS pointed out that it is enhancing its services to
physicians by establishing a new program to disseminate information at
professional conferences and by instituting its "Open Door Forums"
where physicians can meet with CMS officials and share their views on
Medicare program rules. We have reprinted CMS's letter in appendix IV.
CMS also provided us with technical comments, which we incorporated as
appropriate.
In addressing our first recommendation to assume responsibility of a
national bulletin for physicians, CMS pointed out that it is taking
steps to "nationalize" information contained in these bulletins. It
said it is already including articles of national interest regarding
Medicare issues in carrier bulletins. CMS also said it is planning a
National Provider Bulletin Project to study the practicality of
establishing a national source for the information included in these
bulletins as well as potential changes to the publication and
distribution process.
In response to our second recommendation that new performance
standards be established for carrier call centers, CMS described a
variety of initiatives it has under way to help enhance the quality of
these communications. CMS agreed that providing timely, correct, and
consistent answers to physicians' questions is imperative. The agency
stated that it has instituted a new program of performance standards
that features more effective oversight and evaluation and that
includes new quality call monitoring procedures. Although this new
plan appears to contain key components of an effective communication
strategy, CMS's description of this effort does not contain sufficient
detail for us to fully assess its usefulness. We believe such a plan
ultimately needs to incorporate specific performance measures for
which the carriers could be held accountable. Although CMS indicated
it plans to devise ways of objectively measuring carrier performance,
it said that it does not yet have such measures in place.
In response to our third recommendation to set standards and provide
carriers with additional technical assistance to enhance carrier Web
sites, CMS outlined the requirements that carriers must meet. CMS
indicated it was satisfied with carriers' performance in this area,
pointing out that an examination of Web sites was part of this year's
annual CPE reviews. According to CMS, none of the carriers have been
deficient in their compliance with CMS requirements, and CPE reviewers
found most of the Web sites to be user-friendly. Although these CPE
reviews may not have detected deficiencies at carrier Web sites, as we
have noted most of the Web sites we reviewed did not comply with some
of CMS's requirements. CMS has agreed to reexamine its Web site
monitoring efforts.
Regarding out fourth recommendation, CMS agreed that utilizing expert
teams to conduct CPE reviews would be the best means of ensuring
substantive evaluations. However, CMS said that it believed that
implementing our recommendation would require the agency to establish
a team of dedicated review staff, which would not be feasible given
the agency's available resources. Although CMS said it could not
implement our recommendation at this time, it indicated that it will
nonetheless try to continue building the expertise of its review
staff. According to CMS, many of the staff members that performed
these reviews last year will perform them this year as well. In
addition, CMS said it will continue to provide relevant training to
these staff members.
Officials of the American Medical Association and the Medical Group
Management Association also reviewed a draft of this report. In oral
comments, officials from both organizations said they generally agreed
with our findings and recommendations and offered technical comments,
which we incorporated as appropriate.
We are sending copies of this report to the secretary of Health and
Human Services, the administrator of CMS, and other interested
parties. We will make copies available to others upon request.
If you or your staffs have any questions about this report, please
call me at (312) 220-7600. An additional GAO contact and other staff
members who made major contributions to this report are listed in
appendix V.
Signed by:
Leslie G. Aronovitz:
Director, Health Care-”Program Administration and Integrity Issues:
[End of section]
Appendix I: Scope and Methodology:
To develop an understanding of physicians' concerns about the Medicare
communications they receive, we obtained the cooperation of seven
physician practices. These practices were of varying sizes, were
located in different geographic regions, and were served by three
different Medicare carriers. Each practice agreed to send us the
Medicare-related information that it received during the 3-month
period from February 1 through April 30, 2001. Besides participating
in this communications collection effort, representatives from these
practices shared their views on the quality of the information they
received during this period. We also discussed these matters with
representatives from the following 10 professional associations:
* American Academy of Family Physicians,
* American Academy of Professional Coders,
* American College of Emergency Physicians,
* American College of Physicians-American Society of Internal Medicine,
* American Health Information Management Association,
* American Medical Association,
* Health Care Billing Managers Association,
* Health Care Compliance Association,
* Medical Group Management Association, and,
* Professional Association of Health Care Office Managers.
Because the majority of Medicare communications to physicians are
issued by carriers on behalf of CMS, we focused on the three main
methods these carriers use to communicate with physicians”carrier
bulletins, carrier provider assistance call centers, and carrier Web
sites. We did not review communications from every Medicare carrier.
Our findings are limited to the carriers we reviewed and cannot be
projected to other carriers. The scope of our work did not permit us
to examine provider education efforts such as seminars and training
sessions except in the form of documents submitted by physician
practices and conversations with agency and carrier officials. In
addition to assessing the quality of carrier communications, we also
reviewed the agency's oversight of physician communications and its
plans to improve these communications. Finally, we interviewed
officials from other agencies within BIB to discuss their
communications with physicians participating in the Medicare program.
Quality of Carrier Medicare Communications:
To evaluate the quality of carrier bulletins, we randomly selected 10
carriers and reviewed the bulletins they issued from March through
July 2001. We reviewed the bulletins from the standpoint of whether
their format and organization facilitated a reader's ability to locate
information. To test the bulletins' timeliness and completeness in
communicating required information, we identified approximately 40 PMs”
issued by HCFA from February 1 through April 30, 2001”that addressed
program changes relevant to physicians. We then selected four of these
memorandums and reviewed the bulletins issued by the sampled carriers
to determine when, or whether, the memorandums were published.
To evaluate the accuracy and completeness of responses given on
carrier-operated provider inquiry lines, we made calls to five call
centers operated by 3 carriers for a total of 59 usable responses (two
nonresponses were eliminated from the sample). We selected call
centers operated by the 3 carriers that serve the geographic areas
where the seven physician practices participating in our data
collection were located. The three test questions were selected from
FAQs posted on carrier Web sites, to represent common physician
billing concerns. The questions and answers are listed in appendix II.
Our methodology was to ask each of the three questions, four times, at
each of the five call centers, for a total of 12 test calls to each
center and 20 test calls for each question. Calls were placed at
different times of day and different days of the week from early May
through June 2001.
HCFA officials were aware of our test. Call center managers were also
informed that their CSRs would be receiving test calls from us. When
calling, we identified ourselves as GAO representatives and asked the
CSR to answer our question as if we were physicians. Prompts were only
given if the CSR probed for more specific information or gave
conditional responses that depended upon different circumstances. In
those situations, we asked the CSR to provide the correct answer for
each set of circumstances (such as, whether the office visit was
related or unrelated to the surgical procedure). Following the
response, we asked the CSR if there was any additional information he
or she would like to provide. CSR responses were recorded verbatim and
submitted to a Medicare coding expert at CMS along with the text of
the questions and answers used. The coding expert verified our results
using the following criteria.
* Correct and complete: The answer provided enough information to
correctly bill, including (1) a correct explanation of how to apply
the billing policy and (2) correct billing codes or a referral to
specific documentation that provides coding information.
* Partial or incomplete: The answer referred to material, but (1) did
not provide assistance in interpretation or warn about special
circumstances that would affect billing, or (2) provided
interpretation but no directions to specific documentation, or (3) was
correct but not complete.
* Incorrect: The answer contained fully or partially incorrect
information, such that a physician might incorrectly bill or not file
a claim for a billable service.
* Nonresponse: The CSR refused to answer the question. (Nonresponses
occurred because CSRs would not answer questions for callers who were
not physicians.)
To test the usefulness of carriers' electronic communications with
physicians, we randomly selected 10 carrier Web sites for review. We
investigated Web sites to determine whether they were in compliance
with the content requirements for electronic media as detailed in
HCFA's 2001 budget and performance requirements and in the contractor
Web site standards and guidelines posted on the agency Web site. To
identify best practices for effective, user-friendly Web sites, we
interviewed four individuals familiar with Web site development,
including the Web master for HHS and two private Web designers. We
used information from these sources to evaluate the 10 carrier Web
sites for their accessibility, privacy, format, content, ease of
navigation, organization, contact information, appearance, and use of
graphics.
HCFA Oversight of Physician Communications:
We identified HCFA requirements for carrier bulletins, call center
operations, and carrier Web sites, and discussed the agency's
oversight and monitoring of carriers' communications with both
headquarters and regional office officials. We researched call center
standards used in private industry through conversations with an
industry expert and the manager of a large call center, and visited
three carrier call centers to discuss technology, standards, best
practices, and support from HCFA. We also observed carrier call
centers' monitoring of calls for quality at the three call centers we
visited. In addition, we observed a contractor performance evaluation”
the agency's independent review of "at-risk" contractor activities”
conducted at one of the carrier call centers in our review.
Improving Medicare Communications:
Throughout this review, as we met with HCFA and carrier officials and
representatives of the physician practices participating in our
communications collection, we solicited their views on problems with
the Medicare communications process and potential best practices.
Agency officials also identified their current and planned efforts to
improve its process for communicating with Medicare providers. In
addition, we discussed related issues in our conversations with
representatives from professional associations.
Other HHS Agencies' Communications to Physicians:
HHS is the principal federal department responsible for protecting the
health of Americans and providing other essential health services.
Although the focus of our work was Medicare communications that
originated with CMS, we were also asked to identify the quantity and
type of communications that physicians receive from other HHS
agencies. Based on our review of background information and
discussions with HHS officials, we identified nine HHS offices and
agencies, other than CMS, as potential sources of information or
instructions for practicing physicians. These include the Office of
the Secretary, Office of the Inspector General, Agency for Healthcare
Research and Quality, Centers for Disease Control and Prevention, Food
and Drug Administration, Health Resources and Services Administration,
Indian Health Service, National Institutes of Health, and Substance
Abuse and Mental Health Services Administration.
We contacted officials in these offices and agencies and reviewed
information available through their Web sites to determine whether
they issued instructions or requirements that affected practicing
physicians. Compared to CMS, the other HHS agencies we contacted issue
relatively few requirements for practicing physicians and rarely
communicate instructions or information directly to the physicians, as
does CMS through its Medicare carriers. Generally, officials we
contacted indicated that these agencies rely primarily on posting
information to their Web sites to communicate with the medical
community and the general public. Many of the HHS agencies also offer
subject-specific e-mail notification of new Web postings to physicians
and others who register to receive this service. Some agencies have
newsletters or publications to which physicians and others can
subscribe or they provide specific information upon request.
[End of section]
Appendix II: Call Center Accuracy Test Questions:
The questions and answers we used to test the accuracy of carrier call
center responses to physician inquiries are shown in table 4.
Table 4: Questions and Answers for Test of Carrier Call Centers:
Question:
If a physician provides critical care for 1 hour and 15 minutes, how
should the services be reported? Should code 99292 (for an additional
30 minutes) be reported? Should the reduced services modifier be used?
Answer:
Code 99291, Critical care, first hour. Should be used to report the
services of a physician providing constant attention to a critically
ill patient for a total of 30 minutes to 1 hour on a given day. If the
total duration of critical care provided by the physician on a given
day is less than 30 minutes, the appropriate evaluation and management
code should be used. In the hospital setting, it is expected that the
level 3 subsequent hospital care code (99233) would most often be used.
Code 99292, critical care, each additional 30 minutes. Should be used
to report the services of a physician providing constant attention to
the patient for 15 to 30 minutes beyond the first hour of critical
care on a given day.
Question:
What is the proper way to bill for an office visit on the same day as
a surgical procedure?
Answer:
If the office visit is unrelated to the surgical procedure, separate
payment can be allowed by applying the "25" modifier to the office
visit procedure code. Medicare will not pay separately for a visit on
the same day as a minor surgery or endoscopic procedure unless other
significant, separately identifiable services are performed in
addition to the procedure. If other significant evaluation and
management services are performed on the same day, the physician may
bill for the visit with modifier "25."
Question:
Can code 99211 be reported if a nurse in the physician's office
provides instruction on self-administering insulin?
Answer:
Yes. If a physician's employee performs a limited service, a physician
may use this code to report services that may not require personal
performance.[A] The definition of code 99211 is as follows: office or
other outpatient visits for the evaluation and management of an
established patient that may not require the presence of a physician.
However, this code should not be reported in addition to other
evaluation and management services performed by the physician on the
same day.
[A] CMS advised us that the following sentence should be inserted for
this answer to be accurate: "All of the requirements for an 'incident
to' service must be met."
Source: Frequently asked questions and answers posted on carrier Web
sites.
[End of section]
Appendix III: Results of Communications Collection from Seven
Physician Practices:
To identify the quantity and sources of Medicare information received
by physicians, we enlisted the assistance of seven physician practices
to collect communications that related to their practices and were
received during the 3-month period from February 1 through April 30,
2001. A 3-month period was selected so that practices would receive at
least one carrier bulletin. HCFA representatives and participating
practices reported that the period selected was typical in relation to
the release of Medicare regulations and information. The participating
physicians represented both urban and rural practices and were located
in four states served by three carriers and three HCFA regional
offices. They also varied in size and specialty and included:
* a 600-physician multispecialty group;
* a 450-physician teaching hospital-based group;
* a 43-physician network of small internal medicine/family practice
groups;
* a 10-physician internal medicine, obstetrics/gynecology, and
pediatric group;
* a 4-physician multispecialty group;
* a 4-physician internal medicine group; and;
* a 4-physician ophthalmology group.
The practices collected and submitted full copies or excerpts of
practice-related communications received by mail, fax, or e-mail, or
downloaded from the Internet, regardless of the source, during this
period.[Footnote 13] We asked the practices to omit certain items from
their collection due to lack of relevance or privacy issues. Material
the practices were asked to include and exclude from their submissions
to us is shown in table 5.
Table 5: Summary of Communications Included and Excluded by Physician
Practices:
Communications included:
* Written communications containing information that the physician, or
his or her practice, was required to comply with a) to participate in
or submit claims to Medicare, other federal or state programs, or
private payers; or b) to legally operate his or her practice;
* Written communications that the physician was not required to comply
with, but had to review in order to determine that compliance was not
required;
* Information that was not compliance-related but was relevant to the
practice, such as professional journals, newsletters or public health
alerts.
Communications excluded:
* Internal practice communications or communications with patients;
* Statements and correspondence as part of the routine claims
processing cycle, including claims denials and documentation requests;
* Marketing and advertising information;
* Information on conferences or educational opportunities (other than
compliance training);
* Communications from agencies such as the Internal Revenue Service;
the Occupational Safety and Health Administration; or other federal,
state, or local government entities that have no direct bearing on
medical practice;
* Subpoenas, demand letters, or similar legal communications.
[End of table]
We collected 947 documents from the physician practices. Based on the
table of contents or section titles of these documents, we categorized
them as (1) directly related to Medicare, (2) unrelated to Medicare
but involving some other requirement relevant to the physician
practice, and (3) information relevant to the physician practice that
did not include any requirement the practice needed to act upon. We
also classified communications by their source, including HCFA or its
carriers, other HHS agencies, state and local government agencies,
insurance companies and managed care plans, and all other sources,
such as professional journals, newsletters, or other information sent
to physicians. We could not independently verify that the physician
practices submitted all relevant communications they received, nor
could we reliably distinguish between communications that the practice
requested and those that were unsolicited. Most of the documents
submitted by the practices had some Medicare content, indicative of
the pervasiveness of the Medicare program. Frequently appearing topics
included Medicare fraud and abuse, Medicare coding issues, contractor
audits, and the Medicare appeals process.
The information that was submitted by the seven physician practices
shows that while Medicare-related information accounts for much of
this material, a relatively small portion of the documents came from
HCFA, its carriers, or other governmental sources. About half of the
documents we received from the physician practices contained mostly
Medicare information. We found that a relatively small amount of all
documents”about 10 percent”was sent by HCFA or its carriers. Material
from other HHS agencies accounted for less than 3 percent of all
documents the physician practices collected. The majority of the
information came from other organizations, such as consulting firms
and medical specialty or professional societies.
Table 6 shows the source and subject of all documents collected and
submitted by the participating physician practices.
Table 6: Percentages of Medicare Communication Subjects and Sources
Collected by Seven Physician Practices from February 1, 2001 through
April 30, 2001:
Source of communication: HCFA;
Subject of the Communication: Medicare Information: 9.9%;
Subject of the Communication: Practice information not related to
Medicare: 0.2%;
Subject of the Communication: Information not required for Medicare or
medical practice: 0;
Total[A]: 10.1%.
Source of communication: All HHS other than HCFA;
Subject of the Communication: Medicare Information: 1.5%;
Subject of the Communication: Practice information not related to
Medicare: 0.8%;
Subject of the Communication: Information not required for Medicare or
medical practice: 0;
Total[A]: 2.3%.
Source of communication: All government other than HHS (federal,
state, and local)[B];
Subject of the Communication: Medicare Information: 0.3%;
Subject of the Communication: Practice information not related to
Medicare: 2.3%;
Subject of the Communication: Information not required for Medicare or
medical practice: 0.5[A];
Total[A]: 3.2%.
Source of communication: Private insurance;
Subject of the Communication: Medicare Information: 0.1%;
Subject of the Communication: Practice information not related to
Medicare: 6.2%;
Subject of the Communication: Information not required for Medicare or
medical practice: 0.1%;
Total[A]: 6.4%.
Source of communication: Private sector other than insurance;
Subject of the Communication: Medicare Information: 36.0%;
Subject of the Communication: Practice information not related to
Medicare: 19.1%;
Subject of the Communication: Information not required for Medicare or
medical practice: 22.8%;
Total[A]: 78.0%.
Source of communication: Total[A];
Subject of the Communication: Medicare Information: 47.8%;
Subject of the Communication: Practice information not related to
Medicare: 28.7%;
Subject of the Communication: Information not required for Medicare or
medical practice: 23.4%;
Total[A]: 100%.
[A] Some columns and rows do not equal the total percentage shown
because of rounding.
[B] Category includes local public health department warnings and
proposed legislation at all levels of the government. Category does
not include communications from agencies such as the Internal Revenue
Service, the Occupational Safety and Health Administration, or other
federal, state, or local government entities that have no direct
bearing on medical practice.
Source: GAO analysis of 947 documents collected from seven physician
practices.
[End of table]
The number of Medicare-related documents and number of pages submitted
by each practice was generally related to the size of the practice.
This was true both of documents from HCFA and from the private sector.
Three of the smaller practices sent us fewer than 5 documents that
they received from HCFA. In one case, the 3 documents submitted by a
small practice totaled 217 pages. The largest practice, a
multispecialty clinic, sent 57 HCFA documents totaling 704 pages. A
small rural practice sent 3 private-source documents totaling 12
pages, while the multispecialty clinic sent 148 documents totaling
1,174 pages. The number of documents received by a practice may be
influenced by the practice's breadth of specialties and participation
in professional organizations.
[End of section]
Appendix IV: Comments from the Centers for Medicare and Medicaid
Services:
Department Of Health Sr Human Services:
Centers for Medicare & Medicaid Services:
Administrator:
Washington, DC 20201:
Date: February 25, 2002:
To: Leslie G. Aronovitz:
Director, Health Care”Program:
General Accounting Office:
From: [Signed by] Thomas A. Scully:
Administrator:
Centers for Medicare and Medicaid Services:
Subject: General Accounting Office (GAO) Draft Report, Medicare:
Provider Communications Can Be Improved (GAO-02-249):
Thank you for sending the above-referenced report for comments. We
appreciate GAO's efforts to identify areas for improving the Centers
for Medicare & Medicaid Services' (CMS) communications with Medicare
providers. We agree that improvement is needed in this area for the
agency. Providing the best possible information to physicians and
other providers and suppliers is integral to successfully serving our
Medicare beneficiaries.
The CMS is currently examining its customer service strategy and is
formulating a comprehensive strategic plan in this area. Once the full
potential of this plan is realized, we believe the concerns raised by
GAO will be significantly diminished. We are grateful to GAO for its
timely report as it will serve to strengthen our strategic planning
effort.
Before commenting on the specific recommendations outlined in the GAO
report, we would like to outline some activities we currently have
underway, and some ideas we are exploring for the future.
The CMS is enhancing and expanding its outreach, education, and
overall service to physicians, providers and suppliers by building on
its current education and customer service systems with a renewed
spirit of openness, mutual information sharing, and partnership.
Several national programs have been established to more effectively
communicate directly with physician and provider organizations and to
enhance their relationship with the Medicare program.
The following list of activities delineates some of the most important
education measures CMS has recently undertaken (some during and/or
after GAO conducted its review) in its spirit of responsiveness to the
needs of physicians, providers and suppliers:
* We provide Medicare contractors with in-person instruction and a
standardized training manual for them to use in educating physicians,
providers, and suppliers on new CMS policy initiatives (e.g., new
prospective payment systems). These programs provide consistency and
help ensure that our contractors speak with one voice on national
issues.
* Via our Satellite Learning Channel, which we launched in November
2001, we provide Medicare contractors with the latest information on
contemporary topics of interest. We recently completed the
installation of a network of satellite dishes at all contractor call
centers to improve our training efforts with contractor customer
service representatives.
* We now have a program for monitoring the training sessions conducted
by our contractors so that we can obtain feedback from providers and
work collaboratively to find new ways of communicating with them.
* We are in the process of re-evaluating Medicare contractor bulletins
and other communications with providers, and have taken steps to
standardize and make more consistent the information contained in
contractor bulletins by developing national information articles on
significant Medicare policies.
* Over the past year, CMS has made it a practice to make available a
list of Web-Based, frequently asked questions (FAQs) for major
Medicare program initiatives, which are publicly available to all
providers over the Internet.
* We have established electronic listservs on priority initiatives
that have enabled us to keep thousands of subscribers informed about
the latest Medicare changes. We expect to continue these practices for
future significant initiatives, as well as investigate the feasibility
of developing a new system to capture, compile, and index FAQs.
* We provide a variety of resources, such as Reference Guides, FAQs
and Computer-Based Training courses, online at the Medicare Learning
Network homepage, [hyperlink, http://www.hcfa.gov/MedLearn.htm].
MedLearn provides timely, accurate, and relevant information about
Medicare coverage and payment policies, and serves as an efficient,
convenient provider education tool.
* We recently established a National Physician and Provider
Organization Exhibit Program designed to disseminate information from
CMS to physicians and providers at various professional conferences
held throughout the country.
* Eleven Open Door Forums were established in August 2001 for
virtually every physician and provider type that participates in the
Medicare program. Regularly held listening sessions are being
conducted throughout the country to allow us to hear directly from
physicians and health care providers about what it's like to live and
work every day under the rules we develop.
* Strengthening of the operational support of the Practicing Physician
Advisory Council, which plays a key role as a Federal Advisory
Committee Act-compliant advisor body, is assisting CMS in identifying
issues challenging practicing physicians.
* This year we are establishing plans for a customer satisfaction
survey and focus group program in order to advance our initiative for
obtaining physician/provider/supplier input to their customer service
needs.
In tandem with our efforts to improve physician and provider
education, we are focused on improving the quality of our provider
customer service. Last year, our Medicare contractors received 24
million telephone calls from physicians and providers, and we know it
is imperative that the contractors provide timely, correct, and
consistent answers. One significant step towards service improvement
is our recent move from toll to toll-free telephone answer-centers at
all Medicare contractors.
We agree with GAO about the importance of accurate and consistent
answers to provider inquiries and this past year we implemented a new
program of performance standards, including more effective oversight
and evaluation. We have quality call monitoring procedures, contractor
guidelines, and performance standards in place to ensure that
contractors know what is expected and so that we can be satisfied that
the contractors are meeting/exceeding our expectations. We also want
to know about the issues and misunderstandings that most affect
provider satisfaction with our call centers so that we can provide our
customer service representatives with the information and guidance to
make a difference. We are exploring various feedback mechanisms and
contractor profiling to obtain this information.
Because our physician and provider education, outreach, and customer
service activities are relatively new, we do not yet have outcome
measures to demonstrate that what we are doing is effective. While we
are implementing tools to measure the impact of our interventions
(e.g., a Quality Call Monitoring Scorecard and Customer Service
Representative standards), we will not be able to objectively measure
the effect of those interventions until we are farther down the road.
We believe, however, that we are doing the right things and are
optimistic that these activities will improve our communication with
physicians and other providers and suppliers.
We appreciate GAO's recognizing that our resources are limited. Many
of the observations and suggestions contained throughout the report
represent initiatives CMS would gladly undertake if it had the
resources to do so. We are doing a lot with the resources we have and
will continue to seek additional resources. In the meantime, we
continue to examine ways to use our existing resources in creative
ways, such as making greater the use of the Internet, other e-commerce
tools, and other media, as a way of improving the ways in which we
share information with, and receive information from, physicians and
other providers and suppliers.
Physicians and other providers play a crucial role in caring for
Medicare beneficiaries, and their concerns regarding the program's
regulatory burden must be addressed. Enhancement of our communication
and education efforts is essential to the success of Medicare, and we
believe it will ultimately reduce the level of physicians', providers'
and suppliers' frustration with the Medicare program, as well as
increase beneficiaries' options and satisfaction.
GAO Recommendation:
Assume responsibility for the publication of a national bulletin, for
providers, in addition to issuing a quarterly compendium of
regulations. Carriers would be responsible for preparing supplements
to CMS' national bulletin regarding local medical policy issues.
CMS Response:
The CMS is very interested in making the information that is furnished
to physicians, providers and suppliers as useful, clear, and
understandable as possible. To this end, CMS has taken steps to
"nationalize" information contained in contractor bulletins and
newsletters sent to physicians, providers, and suppliers. The CMS
often has developed national information articles on significant
Medicare policies, programs, or issues. These articles are carefully
written to be lucid and comprehensible and to effectively communicate
with the target audience. These national articles are distributed to
all Medicare contractors who are instructed to publish them in their
next provider bulletins.
Additionally, for fiscal year (FY) 2002, CMS is planning a National
Provider Bulletin Project. The project will be used to determine the
practicality of establishing a national source for the information and
material included in provider bulletins while also allowing for the
communication of local contractor concerns. The effort will also
evaluate the publication and distribution process for the bulletin.
GAO Recommendation:
Establish new performance standards for carrier call centers that
emphasize providing complete and accurate answers to physician
inquiries. Carriers' monitoring of their carrier call center
operations should also be expanded to assure that these performance
standards and policies are followed.
CMS Response:
As previously stated, we agree with the need to focus on improving the
quality of our provider customer service. Last year, our Medicare
contractors received 24 million telephone calls from physicians and
providers, and it is imperative that the contractors provide timely,
correct, and consistent answers.[Footnote 14] We have several
initiatives underway to address this need:
* Contractor Performance Evaluation (CPE) Reviews. We have performance
standards, quality call monitoring procedures, and contractor
guidelines in place to ensure that contractors know what is expected
and so that we can be satisfied that the contractors are reaching our
expectations. For the FY 2001 period and for the first time, Medicare
contractors' physician and provider telephone customer service
operations were reviewed against these standards and procedures
separate from our review of their beneficiary customer service. During
these weeklong CPE reviews, we identify areas that need improvement
and "best practices" that can be shared among our other Medicare
physician and provider call centers. As a result of the reviews,
performance improvement plans will be instituted when needed, and CMS
staff in our Regional Offices will continue to monitor the specific
contractor throughout the year. Separate from the CPE reviews, the
Medicare Contractor Consortium Management Officers, responsible for
each contractor, perform regular reviews throughout the year,
including a check on the contractors' provider customer service.
* Desktop Initiative. We have begun a modernization program that gives
the Medicare contractor customer service representatives, who handle
physician/provider inquiries, state-of-the-art desktop tools to enable
improved responsiveness in handling telephone inquiries and combine
this technology upgrade with the development of standardized resource
materials and training for those customer service staff.
* Ouality Call Monitoring (OCM) Procedures. We have recently formed
Central Office/Regional Office/contractor workgroups to review the
contractor performance standards, QCM scorecard, QCM criteria chart,
and the monthly telephone data reporting processes, and make changes
to tailor them to the needs of physicians, providers and suppliers.
The QCM workgroup made significant changes in the wording of
monitoring criteria and in the weighting of segments of the scorecard
to increase its relevance for monitoring provider calls. The scorecard
was tested throughout October and early November 2001, and was
implemented on a national level beginning December 2001. There are two
separate overall scores for the QCM. The first addresses "soft skills"
(common to all customer service operations), and the second addresses
"accuracy/completeness." This allows for more directed coaching
sessions and service improvement.
* Creating Call Center Profiles. In FY 2001, we visited eight of our
largest Medicare contractors to collect information on their
operations, their use of technology, their performance data, their
most frequently asked provider questions, and their training needs. We
subsequently collected similar information from all of the remaining
Medicare call centers via an online profile. The profiles have been
analyzed to identify additional training needs and other improvements
we can make at our contractors. These improvements will be implemented
through a Customer Service Training Plan (see below).
* Creating a Customer Service Training Plan. Based upon the call
center profiles we have gathered, we have drafted a Customer Service
Training Plan to address the training needs of our Medicare customer
service representatives. This training plan will bring uniformity to
the contractor training, and improve the accuracy and consistency of
the information that representatives give to physicians and providers
across the country. Our first training effort will focus on the
Correct Coding Initiative. Customer service representatives will be
trained on the language and concepts of coding issues so that they can
properly direct physicians and providers to the best sources of
information or make sure that the appropriate technical expert
responds to the caller in a timely fashion. We plan to offer this and
other training via a satellite network.
* Holding Telephone Customer Service Conferences. In March 2001, we
held our first National Telephone Customer Service Conference for
Medicare contractor call center managers and our Central and Regional
Office staff. The conference emphasized our goal of improved customer
service and served as a forum for exchanging ideas on best practices.
Our next conference is scheduled for July 2002.
* Conducting Monthly Call Center Meetings. We currently hold monthly
conference calls with contractor call center managers and CMS Central
and Regional Office staff to identify problems, give contractors
additional information, and resolve issues.
* Analyzing Baseline Performance Data. Medicare call center managers
were required to report data from October 1999 through May 2001 (and
monthly thereafter), on a variety of performance measures. We are
analyzing these data to determine contractors' relative performance
and the impact of the installation of toll-free lines on contractor
workload and performance.
GAO Recommendation:
Set standards and provide technical assistance to carriers to promote
consistency, accuracy, and user-friendliness of all carrier Web sites,
which should be limited to local Medicare information and should be
designed to link to CMS's Web site for national program information.
CMS Response:
As GAO indicates, CMS has established requirements for the features
and content of Medicare contractor Web sites used to furnish
physicians, providers and suppliers timely and understandable Medicare
program information. These requirements are contained in the annual
Budget and Performance Requirements for fiscal intermediaries and
carriers, and in the Statement of Work for Durable Medical Equipment
Regional Carriers. For FY 2002, all Medicare contractor
provider/supplier Web sites must contain the following:
* all bulletins/newsletters;
* a schedule of upcoming events (seminars, workshops, fairs, etc.);
* ability to register for contractor-sponsored events via the Web site;
* features which permit providers to order and receive copies of
bulletins;
* a quarterly listing of provider frequently asked questions;
* search engine functionality;
* e-mail based support/help/customer service;
* a "What's New" or similarly titled section;
* an ability to link to other provider interest sites and;
* an area designated as the Medicare Learning Network which will
contain promotional material supplied by CMS as well as link to CMS's
MedLearn and Best Practices Web sites.
Additionally, all Medicare contractor Web sites must comply with CMS's
"Contractor Website Standards and Guidelines."
These Medicare contractor Web sites were examined as part of this
year's annual CPE. In all of the CPE reports received to date, none
has cited any contractor provider Web site for being deficient from
CMS requirements. In fact, most reports indicate that the provider Web
sites were generally clearly presented, user friendly and contained an
abundant amount of easily retrievable Medicare provider information.
However, we appreciate the findings from GAO and we will reexamine our
monitoring efforts to make certain our guidelines are being followed.
For FY 2002 CMS has instructed its Medicare contractors to establish
and maintain electronic mailing lists listservs for physicians,
providers and suppliers. These listservs will be used to notify
registrants via e-mail of important and time sensitive Medicare
program information, upcoming provider education and training events,
and other announcements or messages necessitating immediate attention.
Contractors will also use their listservs to notify registrants of the
availability of contractor bulletins on their Web sites.
GAO Recommendation:
Strengthen its contractor evaluation and management process by relying
on expert teams to conduct more substantive CPE reviews on all
provider communications activities.
CMS Response:
Performing CPE is part of our strategy to achieve consistency in the
communications we have with physicians and providers while also
serving as a tool to hold contractors accountable for the service they
provide. The FY 2001 was the first year we performed CPE reviews for
provider education and customer service activities, including provider
inquiry telephone lines. Teams consisted of Central Office and
Regional Office staff working in the provider education arena, many of
whom participated in the development of the standards used to evaluate
contractors' performance in their provider communication activities.
We acknowledge that expert teams of reviewers would be the best tools
for ensuring substantive evaluations. However, we also believe that
establishment of expert teams for review of provider communications
would require CMS staff dedicated to the conduct of reviews. Given the
work faced by the Agency and the resources available, CMS is not able
to have a dedicated review staff at this time. We will, however,
continue to provide training and increased review experience to staff
that are available to conduct reviews.
Results from the first year's reports provided us with baseline
information on the activities performed by the contractors in relation
to the priorities of the Agency. Modifications have been made to the
protocols being used this year to better focus on the vast array of
activities used to communicate with physicians and providers. The
expertise of the teams continues to build as many of these same staff
are performing CPE reviews again this year.
[End of section]
Appendix V: GAO Contact and Staff Acknowledgments:
GAO Contact:
Geraldine Redican-Bigott, (312) 220-7678:
Staff Acknowledgments:
Donald Kittler, Victoria Smith, Christi Turner, and Margaret Weber made
key contributions to this report.
[End of section]
Footnotes:
[1] On June 14, 2001, the secretary of Health and Human Services
announced that the name of the Health Care Financing Administration
(HCFA) had been changed to the Centers for Medicare and Medicaid
Services. In this report, we will refer to HCFA where our findings
apply to operations that took place under that organizational
structure and name.
[2] Medicare consists of two parts-”A and B. Contractors that process
Part A claims”those covering inpatient hospital, skilled nursing
facility, hospice, and certain home health services”are known as
fiscal intermediaries. Contractors processing Part B claims”covering
physician services, diagnostic tests, and related services and
supplies”are referred to as carriers.
[3] In addition to CMS, other HHS agencies generate information and
guidance that are relevant to certain physicians or specialties that
may affect their care of Medicare beneficiaries. For example, the Food
and Drug Administration publicizes information on recalls of drugs or
medical devices. The Centers for Disease Control and Prevention issues
disease prevention guidance and manages a national surveillance system
for approximately 60 infectious diseases. The Office of Inspector
General issues Medicare-related fraud alerts and compliance guidance
for specific provider types, including physicians.
[4] LMRPs specify under what circumstances a carrier will or will not
provide Medicare payment for a type of service. LMRPs are developed by
carriers to reflect their interpretation of Medicare coverage and to
enhance or clarify national Medicare guidance. Because carriers may
differ in how they assess the reasonableness and necessity of services
provided, one carrier might pay for services that would not be paid
for by another carrier.
[5] Carriers vary in how frequently they issue bulletins. The carriers
we sampled issued from two to five bulletins each during the 5-month
period.
[6] CMS has no standard for the amount of advance notice providers
should receive before program changes are implemented. However, it
does require that providers receive a 30-day notice before fee
schedule or other payment changes are to take effect.
[7] Although carrier officials told us that the majority of
physicians' calls concern the status of claims, we were not able to
ask for information about specific claims due to concerns about
beneficiary confidentiality.
[8] We did not review HCFA's own Web site during our review. In 2001,
a consultant to the agency completed a needs assessment and design
plan for the Web site, and the agency is working to improve the site's
usability.
[9] Additional BPRs, not related to Web site content, focus on
copyright guidelines for billing codes developed by the American
Medical Association.
[10] Teams of CMS staff annually conduct CPEs, reviewing the
performance of some contractors in selected functions.
[11] As of fiscal year 2001, the only BPR requirement relating to
content was that bulletins must include a statement that they should
be shared with all health care practitioners and managers of the
provider staff.
[12] This expert was a featured speaker at HCFA's 2001 Telephone
Customer Service Conference.
[13] In the case of the three largest practices, we collected
documents from only some of their departments. Due to the size of some
of these documents, we often received excerpts containing the front
page, table of contents, and a description of the document.
[14] Coding questions, such as those presented to Contractor Customer
Service Representatives by the GAO auditors, are not the typical and
frequent questions received by the call centers. Of the 24 million
calls we received in FY 2001, the vast majority of those, based on CPE
reviews of call monitoring processes, are handled accurately,
completely, and courteously.
[End of section]
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