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Medicare Compliance & Reimbursement

Policy:

Got A Question? Don't Ask Your Carrier

Published on Thu Aug 26, 2004

They only get the answers right 5 percent of the time, GAO says.

If you have questions on Medicare coverage or billing policies, don't expect help from the toll-free telephone hot line.
 
That appears to be the advice that the General Accountability Office is offering when it comes to the call centers through which Medicare contractors answer provider questions on behalf of the Centers for Medicare and Medicaid Services, at least when it comes to questions about policy-related matters.
 
Thirty-four call centers around the country fielded around 21 million provider inquiries in fiscal year 2003, according to GAO, Congress' nonpartisan investigative arm, previously known as the General Accounting Office. In most of the calls, providers sought factual information from databases such as the status of a particular claim or confirmation of an individual's Medicare eligibility.
 
However, other questions involved more complex, policy-related issues, related to program changes, medical policies, billing requirements and the like, and it's on these questions that service suffers, says GAO. About 500,000 calls fell into this category in FY 2003, according to CMS' estimate.
 
GAO placed a total of 300 calls to the 34 centers, asking four different policy questions 75 times each. Only 4 percent - or 12 - of the answers GAO auditors received were deemed "correct and complete" by the research agency.
 
"The level of correct and complete responses for each individual billing question ranged from 1 to 5 percent," with the "majority of remaining responses ... incorrect, or partially correct or incomplete."
 
The four questions involved billing policies for beneficiaries transferred from one hospital to another, for services delivered by therapy students, for multiple same-day surgeries on one patient, and for a same-day office visit and procedure on one patient. Causes of the poor performance include fragmented information sources, confusing and confusingly worded policies, and retention difficulties among customer service representatives, according to GAO. Because of the nature of the study, it is not possible to extrapolate from its data how many of the 500,000 total policy calls received incorrect answers.
 
CMS' oversight of the centers has been lacking, with the agency performing only one performance evaluation related to the call centers in FY 2002 and none at all in 2003.
 
In the future, CMS will require contractors who operate call centers to increase the level of self-monitoring they conduct using a Quality Call Monitoring tool, the agency says in its response to the analysis. CMS also is exploring the possibility of including call center-related performance requirements into contractors' performance evaluations.
 
However, GAO says the planned steps aren't specifically related to policy-oriented questions. It recommends that call centers triage calls and route billing and other policy questions to staff with special expertise.

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