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entitled 'Medicare: Call Centers Need to Improve Responses to Policy-
Oriented Questions from Providers' which was released on August 16, 
2004.

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Report to the Ranking Minority Member, Subcommittee on Health, 
Committee on Ways and Means, House of Representatives: 

United States Government Accountability Office: 

GAO: 

July 2004: 

Medicare: 

Call Centers Need to Improve Responses to Policy-Oriented Questions 
from Providers: 

GAO-04-669: 

GAO Highlights: 

Highlights of GAO-04-669, a report to the Ranking Minority Member, 
Subcommittee on Health, Committee on Ways and Means, House of 
Representatives

Why GAO Did This Study: 

In 2002, GAO reported that the Centers for Medicare & Medicaid 
Services (CMS) needed to improve its communications with providers who 
deliver medical care to beneficiaries. GAO reported that 85 percent of 
the responses it received to 61 calls made to call centers operated by 
Medicare carrierscontractors that help manage the Medicare 
programwere incorrect or incomplete. GAO also found that CMSs 
primary oversight tools were insufficient to ensure accuracy in 
communication. 

GAO was asked whether call centers now provide correct and complete 
information to providers. GAO (1) reviewed carriers effectiveness in 
providing correct and complete responses to policy-oriented telephone 
inquiries and CMSs efforts to improve communications with providers 
and (2) evaluated CMSs efforts to provide oversight of carrier call 
centers.

What GAO Found: 

Only 4 percent of the responses GAO received in 300 test calls to 34 
call centers were correct and complete. GAO posed four 
policy-oriented questions 75 times each to carrier call centers. The 
level of correct and complete responses for each individual billing 
question ranged from 1 to 5 percent. The majority of remaining 
responses were incorrect, or partially correct or incomplete. Several 
factors, including fragmented sources of information, confusing policy 
information, and difficulties in retaining the CSRs responding to 
calls appear to account for the lack of correct and complete answers. 
There are many call centers serving other industries that triage 
incoming calls by first identifying the nature of the call and then 
distributing it to the CSR who is best qualified to respond. Although 
CMS has not adopted this approach, it is currently implementing two 
other initiatives that may improve CSRs access to information. 
However, neither initiative is specifically designed to support CSRs 
responding to policy-oriented questions. 

In addition, CMSs efforts to provide oversight of carrier call 
centers are inadequate. Although CMS requires carriers to monitor the 
performance of their call centers, the standards used and the 
technological resources available to evaluate performance do not allow 
carriers to thoroughly assess whether CSRs responses are correct and 
complete. In addition, CMSs own monitoring efforts are too 
infrequent. CMS only performed one contractor performance evaluation 
related to carrier telephone services in fiscal year 2002 and none 
were performed in fiscal year 2003. Moreover, when performed, these 
evaluations did not provide sufficiently detailed information to 
assess CSRs performance.

Provider Call Centers Responses to Four Policy-Oriented Questions for 
Billing Medicare: 

[See PDF for image]

[End of figure]

What GAO Recommends: 

To improve the responses to policy-oriented inquiries from providers, 
GAO recommends that CMS develop (1) a process to route policy 
inquiries to staff with the appropriate expertise, (2) clear and 
easily accessible policy-oriented material to assist customer service 
representatives (CSR), and (3) an effective monitoring program for 
call centers. CMS generally agreed with the recommendations.

Contents: 

Letter: 

Results in Brief: 

Background: 

CSRs' Responses to Policy-Oriented Questions Were Largely Incorrect: 

Call Center Oversight Does Not Adequately Assess CSRs' Responses to 
Policy-Oriented Questions: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments: 

Appendix I: Scope and Methodology: 

Appendix II: Carrier Call Center Accuracy Test Questions: 

Appendix III: Comments from the Centers for Medicare & Medicaid Services: 

Appendix IV: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Acknowledgments: 

Tables: 

Table 1: Summary of Accuracy of CSR Responses by Question: 

Table 2: Questions and Answers for Test of Carrier Call Centers: 

Abbreviations: 

CMS: Centers for Medicare & Medicaid Services: 
CPE: contractor performance evaluation: 
CPT: current procedural terminology:
CSR: customer service representative: 
FAQ: frequently asked question:
IVR: interactive voice response: 
MMA: Medicare Prescription Drug, Improvement, and Modernization Act of 
2003:
NGD: Next Generation Desktop: 
OT: occupational therapist:
PT: physical therapist:
PPS: prospective payment system:
SLP: speech language pathologist: 

United States Government Accountability Office: 

Washington, DC 20548: 

July 16, 2004: 

The Honorable Pete Stark: 
Ranking Minority Member: 
Subcommittee on Health: 
Committee on Ways and Means: 
House of Representatives: 

Dear Mr. Stark: 

In fiscal year 2003, Medicare paid more than $271 billion to health 
care providers for medical services to about 41 million elderly and 
disabled beneficiaries. Since the creation of Medicare in 1965, an 
extensive body of statutes, regulations, policies, and procedures has 
been promulgated that specifies what the program will pay for, and 
under what circumstances. Because of the complexity of the program and 
the high volume of claims submitted annually--about 930 million in 
fiscal year 2003--it is critical that physicians and other providers 
who bill Medicare have access to clear and comprehensive information 
about the program.

One of the responsibilities of the Centers for Medicare & Medicaid 
Services (CMS)--the federal agency that manages the Medicare program--
is to communicate program information to medical providers so that they 
can bill the program properly. To facilitate communication, in fiscal 
year 2001, CMS expanded the responsibilities of the 
contractors[Footnote 1] that assist it in managing the Medicare program 
to include the operation of toll-free assistance call centers for 
providers. These call centers were established to respond to the 
information needs of providers serving Medicare beneficiaries.

Carriers' call centers responded to over 21 million provider inquiries 
in fiscal year 2003. The majority of these calls were status-oriented 
calls, in which providers[Footnote 2] checked the status of a claim in 
the payment process or sought confirmation of an individual's 
eligibility for Medicare. However, providers also called with more 
complex, policy-oriented questions regarding a variety of topics such 
as Medicare coverage, medical policies, program changes, and billing 
requirements that affect their ability to receive Medicare payment.

In 2002, we reported[Footnote 3] that the responses we received to 85 
percent of 61 calls we made across five carrier call centers posing 
policy-oriented questions were incorrect or incomplete. We found that 
some customer service representatives (CSR) who respond to provider 
inquiries lacked ready access to easily searchable databases, limiting 
their ability to respond to providers' inquiries. We also found that 
CMS's primary tools to oversee these call centers--carrier self-
monitoring and contractor performance evaluations (CPE)--were 
insufficient to ensure accuracy in communication. In addition, we noted 
that there was a lack of standardization in the type of technological 
resources available among call centers, which affected both CSRs' 
access to information and carriers' ability to conduct self-monitoring. 
CMS agreed improvements were needed and said it had a variety of 
initiatives under way to help enhance carrier call center 
communications. At the time we performed our work, these initiatives 
were too new for us to evaluate. You expressed concern about whether 
the call centers now provide correct and complete information to 
providers.

You asked us to reexamine how well call centers communicate with 
providers. Specifically, we evaluated (1) carriers' effectiveness in 
providing correct and complete responses to policy-oriented telephone 
inquiries and CMS's efforts to improve communications with providers 
and (2) CMS's efforts to provide oversight of carrier call centers.

To determine carriers' effectiveness in providing correct and complete 
responses, we placed a total of 300 calls to 34 carrier call centers 
and posed questions, similar to those from Medicare providers, 
concerning the proper way to bill Medicare in order to obtain payment 
from the program. Our questions included a variety of circumstances 
commonly encountered by physicians and other Part B providers. We 
compiled a group of 18 frequently asked questions (FAQ) from providers 
from a variety of carriers' Web sites and asked CMS to review our 
questions. We solicited this input to give CMS officials an opportunity 
to identify questions that they considered to be an inappropriate 
question for our test. Based on their comments, we decided to eliminate 
3 questions that they considered problematic. For example, we 
eliminated 1 question that involved a matter that they said was the 
subject of an ongoing lawsuit. We then chose 4 of the 15 remaining 
questions to use during our 300 test calls. These questions addressed 
(1) billing for beneficiaries transferred from one hospital to another, 
(2) billing for services delivered by therapy students, (3) billing for 
multiple surgeries for the same patient on the same day, and (4) 
billing for an office visit and procedure for the same patient on the 
same day. We classified responses in three categories: correct and 
complete, partially correct or incomplete, and incorrect.[Footnote 4] 
CMS officials validated our assessments of whether responses were 
correct and complete. To evaluate CMS's efforts to enhance 
communications with providers, we conducted site visits to two carrier 
call centers where we observed CSRs responding to callers' questions. 
We also reviewed materials related to CMS's two ongoing initiatives to 
improve the accessibility of information, including the development of 
a computer application to increase accessibility of claims related 
information at carrier call centers. One of the call centers we visited 
was responsible for pilot testing this new application, and we observed 
a CSR demonstrating how it would be used. We also reviewed the agency's 
other key effort to improve access to policy-oriented information--the 
publication of clarifications regarding new policies that affect 
providers. Finally, we interviewed CMS and carrier officials familiar 
with these initiatives.

To evaluate CMS's efforts to provide oversight of carrier call centers, 
we reviewed CMS's protocols for CPEs of carrier call centers as well as 
reports for CPEs performed in fiscal years 2001 and 2002. In addition, 
during our site visits to carrier call centers we observed supervisory 
monitoring of CSRs' conversations with providers for quality purposes. 
We also observed CMS regional staff demonstrate the use of the agency's 
new remote monitoring capabilities, which enable CMS staff in their own 
regional offices to listen to CSRs' conversations with callers. 
Appendix I contains more information about the scope and methodology of 
our work. The specific questions we posed to call centers and the 
correct answers are contained in appendix II. We performed our work 
from September 2003 through June 2004 in accordance with generally 
accepted government auditing standards.

Results in Brief: 

During our test calls, CSRs typically provided incorrect and incomplete 
answers to the 300 policy-oriented questions we posed. Only 4 percent-
-or 12--of their responses were correct and complete. Our test 
suggested several factors that may account for poor performance, 
including the fragmented array of information available to CSRs, 
confusing policy information, as well as difficulties in retaining 
CSRs. Although CMS is currently implementing two initiatives that may 
improve CSRs' access to information, neither of these new tools is 
designed to support the CSRs' responding to providers' policy-oriented 
questions.

CMS requires carriers to monitor the performance of their call centers, 
but these monitoring activities do not effectively evaluate the 
accuracy and completeness of CSRs' responses to policy-oriented 
questions. Neither the standards used by the carriers to evaluate the 
CSRs' performance nor the technological resources used in the 
evaluations are adequate to assess whether the responses are correct. 
Similarly, monitoring performed by CMS does not provide a method to 
evaluate CSRs' performance. CMS's periodic CPEs focus more on the 
procedural, rather than the substantive, components of a call--for 
example, how long callers are kept on hold rather than whether 
questions were answered correctly. Moreover, in the last 2 years only 
one carrier call center has been the subject of such an evaluation. And 
while CMS has developed a new capacity to remotely listen to calls 
placed to carrier call centers, agency staff are unable to fully assess 
whether CSRs are providing callers with correct and complete answers 
because they cannot view the material accessed by the CSRs during these 
calls.

We are making recommendations to the CMS administrator to (1) create a 
process to routinely screen calls and route complex policy inquiries to 
staff with expertise; (2) develop policy-oriented information that is 
easily available to CSRs in a clear and understandable format; and (3) 
establish an effective monitoring program for carrier call centers to 
assess CSRs' performance. CMS generally agreed with our 
recommendations.

Background: 

CMS develops regulations and policies to implement the statutory 
provisions governing the Medicare program, and it communicates the 
information to providers primarily through its Medicare contractors. 
The contractors share information with providers through their Web 
sites, written bulletins, and carrier call centers. To respond to 
inquiries from providers, carriers operate 34 call centers.[Footnote 5] 
Most of the carrier call centers--31 of 34--are "blended," that is they 
respond to inquiries from beneficiaries as well as from providers. In 
most cases, CSRs at "blended" call centers answer calls from both 
providers and beneficiaries.[Footnote 6]

More than 21 million inquiries were made to carrier call centers in 
fiscal year 2003. The vast majority of these were "status-oriented" 
calls. Typically status-oriented calls are relatively simple to answer 
and involve inquiries concerning the status of a claim or confirmation 
of an individual's eligibility for Medicare. Such calls generally do 
not require CSRs to provide callers with complex information. On the 
other end of the spectrum are "policy-oriented" questions, which 
involve more complicated issues, such as billing rules, covered 
services, and medical policies. The remaining calls include elements of 
both status-oriented and policy-oriented inquiries. For example, a 
provider may call to learn why a claim was denied. In some instances, 
the explanation may be simple, such as the claim form omitted necessary 
information. In others, the reason for the denial may be more complex 
and involve an assessment of whether the particular circumstance 
required to obtain Medicare payment was met. Although CMS requires that 
carriers report data that categorize calls by type, these categories 
are not standardized, and carriers differ in the criteria they use to 
define call type. CMS officials estimate the volume of calls received 
by CSRs involving policy-oriented questions to have been approximately 
500,000 in fiscal year 2003.

In fiscal year 2001, CMS required that all carrier call centers install 
automated voice response systems. The interactive voice response (IVR) 
unit allows providers to use their telephone keypads to respond to 
automated prompts and obtain status-oriented information without 
speaking to CSRs. Use of the IVR has been growing, and in fiscal year 
2003, the automated system handled more than 52 percent of provider 
inquiries answered at carrier call centers. CSRs are available to 
respond to inquiries that providers believe are beyond the capability 
of the IVR, including policy-oriented calls. Generally, calls to CSRs 
are electronically routed by the carriers' automated systems based on 
CSR availability. The routing process does not consider the nature and 
complexity of the question or the expertise of the CSRs. Despite the 
diversion of many calls to the IVR, CSRs recently experienced an 
increase in the number of calls that they answer. According to CMS, the 
number of calls CSRs answered increased from 9 million in fiscal year 
2002 to 10 million in fiscal year 2003.

CSRs responding to status-oriented calls can typically access the 
relevant claims or enrollment information to respond to the inquiry. In 
addition, to assist CSRs, carriers have developed scripted responses to 
answer standard questions from beneficiaries, such as how to enroll in 
Medicare. To respond to inquiries from providers, CSRs may use FAQs 
posted on their carriers' Web sites. In addition, they may search a 
variety of other sources, including CMS's Web sites. If CSRs cannot 
locate information to respond to a provider's question, they may 
arrange to contact the provider--after conferring with a specialist.

In addition, CMS requires each carrier to analyze provider inquiry data 
and develop a list of questions most frequently asked and areas of 
concern or confusion for providers. They must also tally problem areas 
identified when providers submit erroneous claims for payment. Each 
quarter, carriers report the 10 most frequent inquiries and claim 
submission errors to CMS and update the list of FAQs on their own Web 
sites. Because the nature of calls may vary by carrier, the types of 
questions posted on these Web sites may also vary. In addition, some 
carrier Web sites only list FAQs that are policy related, while others 
list routine questions about the mechanics of claims submissions and 
correcting billing errors.

Carriers are required to monitor their own call centers and report to 
CMS on their performance, such as the average time that calls wait 
before being connected to a CSR and the percentage of provider calls 
that are abandoned before they reach a CSR. Carriers are also required 
to listen to, and rate, a selection of CSR calls on customer and 
knowledge skills, such as the manner in which they greet callers, 
conduct the call, offer additional assistance at the conclusion of the 
call, and whether their responses are correct and complete. Through 
CPEs, CMS also evaluates call center compliance with performance 
measures it establishes. Recently, CMS piloted remote call monitoring, 
which allows CMS staff to listen in on provider calls.

CMS's administration of the Medicare program will undergo significant 
changes over the next several years as the Medicare Prescription Drug, 
Improvement, and Modernization Act of 2003 (MMA) is implemented. MMA 
provides CMS with increased flexibility in contracting with new 
entities to assist it in operating the Medicare program.[Footnote 7] 
Instead of primarily relying on the claims administration contractors 
to perform most of the key business functions[Footnote 8] of the 
program, the law authorizes CMS to enlist a variety of contractors to 
perform these tasks. For example, the MMA will allow CMS to use new 
contractors to communicate program information to its providers and 
deliver provider education and training. CMS is just beginning to 
develop plans to implement MMA's contracting reform provisions. Phase-
in of certain provisions may begin as early as October 2005, and all 
carrier and fiscal intermediary contracts are scheduled to end by 
October 1, 2011. After this date, new contracts must be based on CMS's 
new authority. The agency expects to issue its implementation plan for 
contracting by October 1, 2004.

CSRs' Responses to Policy-Oriented Questions Were Largely Incorrect: 

CSRs at the carrier call centers we tested rarely provided correct and 
complete answers to our policy-oriented questions. Only 4 percent of 
the responses we received from CSRs were correct and complete. Our test 
suggested several factors that may account for poor performance, 
including fragmented information scattered among a variety of sources, 
confusing information that may be difficult for CSRs to understand and 
interpret, and difficulties in retaining CSRs. CMS is developing two 
initiatives that may improve CSRs' access to information; however, 
neither of these new tools is designed to provide a comprehensive 
source of information to support the CSRs who respond to providers' 
policy-oriented questions.

CSRs Almost Never Provided Correct and Complete Responses to Our Policy 
Questions: 

We found that CSRs provided incorrect, partially correct, or incomplete 
responses to 96 percent of the 300 policy-oriented test calls we made 
to carrier call centers. The four questions we posed concerned a 
variety of circumstances on the proper way to bill Medicare in order to 
be paid for services rendered. Our questions specifically addressed the 
following topics: billing for beneficiaries transferred from one 
hospital to another, billing for services delivered by therapy 
students, billing for multiple surgeries on the same day, and billing 
for an office visit and services on the same day. The results of our 
test, which CMS Medicare coding and policy experts validated, are shown 
in table 1.

Table 1: Summary of Accuracy of CSR Responses by Question: 

Question: Question 1: Billing for beneficiaries transferred from one 
hospital to another; 
Correct and complete response: 2; 
Partially correct or incomplete response: 22; 
Incorrect response: 51; 
Total responses: 75.

Question: Question 2: Billing for services delivered by therapy 
students; 
Correct and complete response: 5; 
Partially correct or incomplete response: 32; 
Incorrect response: 38; 
Total responses: 75.

Question: Question 3: Billing of multiple surgeries for the same 
patient on the same day; 
Correct and complete response: 1; 
Partially correct or incomplete response: 36; 
Incorrect response: 38; 
Total responses: 75.

Question: Question 4: Billing of an office visit and procedure for the 
same patient on the same day; 
Correct and complete response: 4; 
Partially correct or incomplete response: 35; 
Incorrect response: 36; 
Total responses: 75.

Question: Number of carrier call center responses; 
Correct and complete response: 12; 
Partially correct or incomplete response: 125; 
Incorrect response: 163; 
Total responses: 300.

Question: Percentage of carrier call center responses; 
Correct and complete response: 4; 
Partially correct or incomplete response: 42; 
Incorrect response: 54; 
Total responses: 100. 

Source: GAO analysis of CSR call center responses.

Notes: CMS officials validated responses for correctness and 
completeness. Differences between GAO and CMS assessments were 
reconciled.

[End of table]

Variety of Factors Contributed to CSRs' Incorrect and Incomplete 
Responses: 

Our analysis of CSR responses to test questions and discussions with 
CMS officials identified several factors that contributed to CSRs' 
errors. They include the following: 

Fragmentation of information: When responding to Medicare inquires from 
providers, CSRs rely on fragments of information from multiple 
electronic sources. In addition, many CSRs use printed Medicare program 
information, including policy changes, which CMS estimates at about 200 
per year. For example, at one carrier call center, we observed that 
CSRs relied on electronic information from CMS and carrier Web sites, 
along with paper documents, including the Medicare carrier manual, 
program memorandums, and carrier bulletins. Further, CMS officials told 
us that the agency does not prepare scripted responses to follow when 
answering questions from providers as it does for CSRs responding to 
beneficiaries' inquiries.

During the site visit, we also asked one CSR to demonstrate the process 
that would typically be followed to answer our four policy-oriented 
questions. In responding to one of our questions, we observed that this 
CSR did not have a source of comprehensive information that she could 
easily access to find the answer to our question. Instead, she accessed 
multiple information sources, including both electronic materials and 
paper documents, in an attempt to respond to our question. We further 
noted, as we toured the call center, that other CSRs also had access 
to, and appeared to be using, both paper and automated resources as 
they responded to calls. According to CMS and carrier officials, CSRs 
have to learn to operate multiple information systems, including CMS's 
claims information processing system and carrier developed information 
system. They also must access other sources, such as carrier or CMS Web 
sites, to respond to policy-oriented questions. Although CMS required 
that all CSRs have access to the Internet in fiscal year 2003, some 
CSRs continue to rely heavily on paper documents because of their 
familiarity with these materials.

During our 300 test calls, CSRs referred us to a total of 13 different 
information sources when answering our second question regarding 
billing for services delivered by therapy students. Twelve of the 
references were either incorrect or did not include all of the 
information needed to give a correct and complete answer. Our review of 
the 13th document, which was structured in a question and answer 
format, included our specific test question but without the complete 
answer. Fragments of the answer, however, were located earlier in the 
document. We also found other parts of this answer on a different page, 
attached to a different but related question. It was evident to us that 
without reading the entire document, it would be plausible for the CSR 
to have read the test question and mistakenly given the caller the 
wrong answer, while assuming that the response given was correct and 
complete.

Confusing information: Some of the information that CSRs must access to 
respond to policy-oriented questions is difficult to interpret. CMS 
officials acknowledged that some policies contain complex language. In 
addition, they told us that the agency's goal of quickly publishing a 
policy that is technically correct may sometimes overshadow its effort 
to develop a clear and understandable document. For example, we 
identified confusion among CSRs who responded to our second question 
concerning billing for services delivered by therapy students. Based on 
their exact responses, we were able to determine that 12 percent of the 
incorrect responses to this question were caused by the CSRs' confusion 
over a different Medicare policy, regarding the billing for services 
delegated by one professional provider to another, and not a student.

CMS acknowledges that specialized training is required to understand 
the billing codes and modifiers[Footnote 9] that providers must include 
on their claims forms to receive payment from the program. Although CMS 
requires carriers to train CSRs, the agency has determined that 
answering providers' coding questions about specific claims is beyond 
the scope of CSRs' responsibilities. CMS also indicated that CSRs do 
not have the expertise to instruct a provider on the nuances of coding 
a service. CSRs, however, are permitted to respond to general questions 
about codes and modifiers, including coding definitions and 
explanations regarding the appropriate use of modifiers. We identified 
confusion among CSRs when they responded to such questions. In response 
to two of the four questions we posed, CSRs should have included 
specific modifiers with their answers because our questions were 
general and did not involve specific claims information. However, CSRs 
provided specific modifiers in only 16 of the 150 responses to these 
two questions. And, in most of these instances--9 of 16--the modifiers 
they cited were incorrect. For example, in one of our test questions, 
we asked for the extenuating circumstances for which carriers may pay 
the full amount for a second surgical procedure. In eight of the calls, 
CSRs responded that the provider should use either modifier "51" for 
multiple surgeries on the same day, modifier "59" denoting a distinct 
surgical procedure, modifier "58" for a staged procedure, modifier "76" 
indicating that a procedure was repeated by the same physician, or 
modifier "78" for a return to the operating room for a related 
procedure. The correct answer is modifier "22," indicating that the 
service performed was an unusual procedure. Without the correct 
modifier, the claim could be inappropriately denied or improperly paid.

In addition, according to one CMS Medicare official--and confirmed by 
CSRs' responses to our test questions--CSRs may gravitate toward 
generic explanations and apply them to questions, even when they are 
not specific. For example, when answering our third question regarding 
billing for multiple surgeries to the same patient on the same day, 56 
percent of the CSRs failed to address the extenuating circumstances in 
which a provider would be paid for multiple surgeries. Instead, their 
responses were based on their knowledge of general multiple surgery 
payment rules, which indicate that Medicare will pay 100 percent of 
costs for a beneficiary's first surgery and a reduced percentage for 
the second surgery. In addition, we categorized about 15 percent of 
CSRs' answers to our 300 test questions as vague and nonresponsive 
because, in these instances, CSRs simply responded that Medicare 
services must be medically necessary or that they cannot be 
preapproved. Although the vague answers may be correct, the responses 
did not address the specific elements contained in our questions.

Difficulties in retaining CSRs: Difficulties in retaining staff limits 
carriers' ability to maintain a core of CSRs who are proficient on a 
range of complex, policy-oriented issues. CMS officials told us that 
retaining CSRs has been a major staffing problem. According to CMS 
officials, many of the most qualified CSRs are promoted to different 
positions within the call centers or resign to pursue better 
opportunities elsewhere. An internal CMS study found the turnover rate 
for carrier call center CSRs to be as high as 23 percent from calendar 
years 1999 through 2001 for all carrier call centers. This is 
significantly higher than the attrition rate for CMS's call centers for 
beneficiaries, 1-800-MEDICARE help lines, which one CMS official 
estimates is close to industry standards--about 10 percent. Although 
there are no more recent data, CMS officials view this as troubling. 
They explained that the CSR position is particularly challenging 
because, in addition to learning how to access and utilize multiple 
information systems, these employees must stay abreast of Medicare 
policy changes to answer the broad range of inquiries received by the 
carrier call centers.

CMS's Efforts Not Targeted to Supplying Policy-Oriented Information to 
CSRs: 

Although CMS is currently implementing two initiatives that may improve 
CSRs' access to information, neither of these new tools is designed to 
support the CSRs who respond to providers' policy-oriented questions. 
One is intended to enhance CSRs' accessibility to claims information; 
the other is aimed at clarifying information on new Medicare policies.

First, CMS has begun deployment of a new computer application, Next 
Generation Desktop (NGD), to provide a single source of consolidated 
claims and related information to assist CSRs when they respond to 
status-oriented questions. Although NGD also contains some policy-
oriented information, such as scripted responses for CSRs who respond 
to questions from beneficiaries, it does not improve CSRs' ability to 
respond to policy-oriented questions from providers. Recognizing the 
broader range of issues and the relative complexity of provider 
inquiries, CMS officials have not attempted to develop scripted 
responses to such questions. Although CMS is continuing to study the 
role of NGD in providing policy-oriented information, agency officials 
told us they are uncertain whether NGD is the appropriate mechanism to 
enhance the availability of such information to CSRs. Until CMS makes a 
final determination, CSRs can continue to access policy-oriented 
information on the agency's Web site.

Second, CMS has developed a new strategy to clarify Medicare policy for 
providers, which CMS officials told us will also benefit the CSRs who 
respond to provider questions. CMS has retained a consulting firm to 
write explanatory articles about new Medicare policies. Although these 
articles may educate providers, they will be no more accessible to CSRs 
than the existing array of materials. For example, these articles are 
available to CSRs through CMS's Web site and carriers' Web-based 
bulletins. Although these articles contain citations to regulations and 
laws, for example, they are not electronically linked to the policies 
they describe. In addition, the policies they support are not annotated 
to reflect that an article exists, making it unlikely that CSRs can 
easily locate the clarifying information. Moreover, there are no plans 
to publish articles for the majority of existing policies.

Like CMS-sponsored call centers, there are thousands of other call 
centers serving a large range of businesses and government agencies in 
the United States. Many of these centers rely on IVRs to route calls to 
the next available CSR. Other call centers have implemented systems 
that are more advanced than those used by carriers. Many of these 
centers triage incoming calls through a feature known as "skill-based 
routing." Skill-based routing systems are designed to enhance customer 
service by allowing the call center to first identify the nature of an 
incoming call and to then distribute the call to the CSR who is best 
qualified to respond to the caller's question. CSRs working in a skill-
based routing environment develop expertise in key specialty areas so 
they can quickly and knowledgably respond to callers' questions. 
Although CMS has indicated it is committed to improving communications 
with providers, it has not taken steps that would enable it to identify 
the subject of providers' policy-oriented questions and route their 
calls to the most appropriate CSRs.

Call Center Oversight Does Not Adequately Assess CSRs' Responses to 
Policy-Oriented Questions: 

CMS requires carriers to monitor the performance of their call centers. 
However, the performance standards that carriers are required to use, 
and the technology available to most of them, do not facilitate 
thorough assessments of whether CSRs provide correct and complete 
responses to policy-oriented questions. In addition, CMS's own 
monitoring efforts--CPEs and remote monitoring of select calls--do not 
provide sufficiently detailed or meaningful information regarding CSR 
accuracy.

Carrier Self-Monitoring Does Not Effectively Evaluate CSRs' Responses 
to Policy-Oriented Questions: 

CMS does not require carriers to monitor a sufficient number of calls 
to fully evaluate the CSRs' performance. CMS requires carriers to 
monitor their own call center performance by periodically listening to, 
and rating, a sample of each CSR's calls. On average, each CSR answers 
more than 1,700 calls a month. In fiscal year 2004, CMS required 
carriers to evaluate three calls per CSR per month. Furthermore, for 
the 31 "blended" call centers, which respond to inquiries from both 
providers and beneficiaries, carriers are only required to monitor one 
provider call per CSR per month. This falls short of one call center 
industry expert's recommendation to monitor a minimum of eight provider 
calls per CSR per month to obtain accurate statistics on CSR 
performance.[Footnote 10] It is also lower than the most frequent 
monitoring of calls per month from a survey of 735 North American call 
centers that represent help lines in various industries, including 
telecommunications, financial services, and health care.[Footnote 11] 
According to this study, there is a wide variance in the number of 
calls monitored per month per CSR. However, the most commonly reported 
monthly monitoring frequencies by survey respondents were 4 to 5 and 10 
or more--exceeding CMS's requirement.

In addition, CMS-developed quality standards used by carriers to 
conduct self-monitoring do not measure CSR performance in a meaningful 
way. CMS requires that CSRs be evaluated on customer skills--such as 
vocal tone, volume and politeness--and knowledge skills--including the 
accuracy and completeness of responses. However, we reported in 2002 
that CMS's definition of what constitutes accuracy is neither clear nor 
specific. For example, according to CMS's standards, carriers should 
consider a response "accurate" if the CSR "gives an accurate response 
or referral" as opposed to providing necessary and complete information 
for the provider to bill the program correctly. Without such guidance 
or other criteria linked to measurable outcomes, the carrier has little 
basis to evaluate the correctness and completeness of CSRs' responses 
to policy-oriented questions. Although we recommended that CMS 
establish new performance standards for CSRs that emphasize providing 
correct and complete answers to provider inquiries, CMS has not revised 
the definition.

Moreover, CMS has not instituted standard requirements for the 
technology used by carriers when conducting self-monitoring activities. 
As a result, there is a broad range of self-monitoring capabilities 
among the carriers, which, according to CMS officials, can affect a 
supervisor's ability to determine whether a CSR's response was correct 
and complete. For example, only 14 of the 34 carrier call centers have 
the capability of recording both the audio portion of monitored calls 
and the associated computer screens viewed by CSRs. This technology 
enables the supervisors monitoring calls to follow the actions taken by 
CSRs, step by step, as they respond to callers. Not only can these 
supervisors hear callers' questions and CSRs responses, but they can 
also view every computer screen accessed by CSRs during calls, 
enhancing their ability to determine whether CSRs supplied answers that 
were correct and complete. However, the remaining 20 call centers do 
not have this capability. While supervisors at 17 of them can record 
the audio portion of calls, they cannot view the computer screens 
accessed by the CSRs. Supervisors at 3 centers have no recording 
capability and are limited to listening to and evaluating "live" calls 
as they are received.

CMS Does Not Adequately Evaluate CSRs' Responses to Policy-Oriented 
Questions: 

Although CMS's principal oversight tools--CPEs--are designed to 
evaluate call centers' compliance with performance standards, they do 
not provide a comprehensive assessment of whether information provided 
by CSRs is correct and complete. As we noted in our previous report, 
these on-site evaluations, which are conducted by CMS staff and follow 
a structured protocol, focus on performance standards that address 
procedures. For example, in preparing that report, we observed a CPE 
review team concentrated on procedural items such as how long a caller 
was kept on hold, rather than on whether the information provided was 
correct and complete. Although CPE evaluators also review call center 
data and interview call center managers, these activities do not 
provide a method to measure the correctness and completeness of CSR 
responses.

We found that the CPE evaluation criteria are not designed to verify 
that CSRs' responses to providers are accurate. Instead, they focus on 
evaluating whether carriers are appropriately adhering to CMS's self-
monitoring requirements. For example, the CPE evaluators listen to a 
sample of calls self-monitored by the carrier to verify that the 
carrier is properly evaluating and documenting the CSRs' performance. 
In listening to these sampled calls, the CPE evaluators are not 
required to evaluate the correctness or completeness of responses 
provided by a CSR, rather they are expected to ensure that the carrier 
has a system in place to monitor calls. Although our earlier report 
included a recommendation that CMS employ expert teams to conduct more 
substantive reviews of calls to strengthen CPEs, CMS told us at that 
time that this was not feasible. CMS officials recently told us, 
however, that in many instances, CPE evaluators do not have the 
expertise to evaluate the accuracy of CSRs' responses.

In addition, CPEs are not performed often enough to provide current 
feedback on either call center or CSR performance. In fiscal year 2002, 
only one carrier call center had a CPE covering provider telephone 
inquiries. Not one CPE was performed in fiscal year 2003. We also found 
that CPEs are based on an assessment of too few calls to provide 
meaningful data and are conducted too infrequently to provide current 
information on call center performance. The required CPE sample is too 
small to provide reliable results. CPE evaluators listen to a sample of 
10 calls monitored by the carrier. If the call center is "blended"--as 
31 of the 34 are--the CPE evaluators will listen to 5 provider calls. 
As a point of comparison, if a call center with the smallest number of 
CSRs monitors 216 provider calls from its CSRs annually, we found that 
CPE evaluators would have to draw a simple random sample of 138 
provider calls annually to estimate the percentage of correct and 
complete calls within a margin of error of plus or minus 5 percent, 
with a 95 percent confidence level. CPE evaluators monitoring a call 
center with a larger number of CSRs would have to conduct more 
monitoring. For example, a call center that monitors 1,800 provider 
calls from its CSRs annually, would require the CPE evaluators to draw 
a simple random sample of 317 provider calls annually to reach this 
same confidence level.[Footnote 12]

In July 2003, CMS introduced a pilot project that provides a second 
means of monitoring carrier call centers. CMS can now remotely monitor 
calls by dialing into carrier call centers and listening to calls as 
they occur. Remote monitoring provides CMS with an opportunity to hear 
providers' questions, as well as CSRs' responses, firsthand. Initially, 
CMS staff listened to 10 calls per month for each center, to develop a 
general understanding of provider inquiries and to contribute to 
developing the strategy for future monitoring. However, the staff 
responsible for remote monitoring reported being overwhelmed by the 
burden inherent in the task, and in January 2004, CMS reduced the 
number to five calls per center per month. Staff engaged in remote 
monitoring can only access the audio portion of calls, limiting their 
ability to thoroughly evaluate the correctness and completeness of 
CSRs' responses. In addition, CMS officials recognize that like CPE 
evaluators, staff engaged in remote monitoring lack the necessary 
understanding of substantive policy issues involved in the call to 
determine whether CSR responses were correct. Agency officials stated 
that they are studying how to best make use of this new capability. 
They told us that they are uncertain whether the pilot project will be 
expanded because they are not convinced that remote monitoring is the 
most appropriate vehicle for evaluating the correctness and 
completeness of CSR responses to provider questions.

Conclusions: 

Ensuring that physicians and other providers receive correct and 
complete answers to their policy-oriented questions is critical to 
their ability to correctly bill Medicare for services rendered to the 
program's beneficiaries. Although policy-oriented questions may 
represent a small proportion of inquiries made to call centers, it is 
nonetheless important to ensure that providers can rely on the 
information they receive. Many call centers serving a variety of 
businesses have taken advantage of skill-based routing to identify a 
caller's specific question and direct the call to the CSR most 
qualified to respond. However, CMS has not done so, nor has it 
developed other strategies to improve the ability of CSRs to respond to 
inquiries from providers. Our test calls continue to show that carrier 
call centers do not adequately respond to policy-oriented questions. 
When responding to our questions, it was evident that CSRs lacked 
access to comprehensive materials that would facilitate correct and 
complete answers. Instead, CSRs relied on fragmented information 
sources and were also confused about Medicare policy issues. 
Furthermore, while CMS is attempting to enhance its monitoring efforts, 
it has not established a program that can sufficiently evaluate whether 
providers receive correct and complete answers to their policy-oriented 
questions. Now that CMS has been given new authority to contract with a 
variety of entities to assist it with managing the Medicare program, it 
should take the opportunity to improve its communications with 
providers. The new law gives CMS the opportunity to identify 
organizations that can best assist it with developing policy expertise 
among staff who respond to providers' questions, improving access to 
policy-oriented materials, and enhancing call center monitoring.

Recommendations for Executive Action: 

In order to improve the accuracy and completeness of responses to 
policy-oriented inquiries from providers, we recommend that the 
Administrator of CMS take steps to ensure that all CSRs have the 
necessary tools to respond to such calls. Specifically, we recommend 
that the Administrator take the following three actions: 

* Create a process to routinely screen and triage calls by routing 
complex policy-oriented questions to staff with the expertise to 
adequately address them.

* Develop clear and easily accessible policy-oriented materials to 
assist CSRs. The materials should be electronically searchable so that 
CSRs can expeditiously provide correct and complete responses to 
policy-oriented questions.

* Establish an effective monitoring program for call centers to assess 
CSRs' performance. The program should include the development of 
specific performance standards that will allow CMS to thoroughly and 
routinely measure the correctness and completeness of information given 
by CSRs in response to policy-oriented questions.

Agency Comments: 

In written comments on a draft of this report, CMS expressed its 
commitment to improving communications with providers and generally 
agreed with our recommendations. CMS agreed with our first 
recommendation to create a process to routinely screen and triage 
calls. CMS said it plans to establish a tiered system using specialty 
staff to respond to provider inquiries by fiscal year 2005. CMS also 
agreed with our second recommendation that clear and easily accessible 
policy-oriented materials should be available and electronically 
searchable for CSRs. However, they went further to state that clear and 
accessible information will also be available to specialty staff tasked 
with responding to complex policy-oriented questions. CMS also 
described its efforts to make information available to providers 
through customized Web pages and other educational materials. While CMS 
agreed with the concept of establishing an effective monitoring 
program--our third recommendation--it stated that it is in the process 
of determining how to do so once its new approach of triaging calls is 
implemented. CMS also said it is exploring other initiatives to enhance 
monitoring such as modifying its CPE requirements, developing 
performance-based standards for provider telephone inquiries, and 
surveying providers on their satisfaction with call centers' 
performance.

We have reprinted CMS's letter in appendix III. CMS also provided us 
with technical comments, which we have incorporated as appropriate.

As agreed with your office, unless you announce its contents earlier, 
we plan no further distribution of this report until 30 days after its 
issuance. At that time, we will send copies to the Administrator of CMS 
and other interested parties. We will then make copies available to 
others upon request. In addition, the report will be available at no 
charge on GAO's Web site at http://www.gao.gov.

If you or your staff have any questions about this report, please call 
me at (312) 220-7600. An additional GAO contact and other staff who 
made contributions to this report are listed in appendix IV.

Sincerely yours,

Signed by: 

Leslie G. Aronovitz: 
Director, Health Care--Program Administration and Integrity Issues: 

[End of section]

Appendix I: Scope and Methodology: 

To determine carriers' effectiveness in providing correct and complete 
responses, we placed 300 calls to 34 carrier call centers. We searched 
a variety of carriers' Web sites and compiled a group of 18 questions 
that physicians and other Part B providers frequently asked when 
contacting call centers. The questions represented common, policy-
oriented questions concerning the proper way to bill Medicare in order 
to obtain payment from the program, as opposed to status-oriented 
claims inquiries. We asked Center for Medicare & Medicaid Services 
(CMS) officials to review our questions to determine whether they 
considered any of the 18 questions inappropriate for our test calls. 
For example, we did not want to pose a question that would unfairly 
test a customer service representative (CSR) knowledge and thus we did 
not want to include a question on a new or recently changed policy. We 
also did not want to pose questions that were the subject of an ongoing 
controversy. Based on input from CMS officials, we eliminated three 
questions. The first question we eliminated referred to pricing rules 
for multiple surgeries. CMS officials stated that the response to this 
question, as posted on a carrier's Web site, was unclear. The second 
question we excluded referred to reimbursements for nurse practitioner 
services. CMS officials also expressed hesitancy about the phrasing of 
this question and answer as shown on a carrier's Web site. Although CMS 
ultimately suggested language to rephrase this question and answer, we 
opted to remove the question from consideration. The third question we 
eliminated referred to an issue that CMS officials told us was the 
subject of an ongoing lawsuit.

After obtaining CMS's input, we selected 4 questions (see app. II) from 
the remaining 15 questions. These questions addressed: (1) billing for 
beneficiaries transferred from one hospital to another, (2) billing for 
services delivered by therapy students, (3) billing for multiple 
surgeries for the same patient on the same day, and (4) billing for an 
office visit and procedure for the same patient on the same day. We did 
not inform CMS before making the calls of the final questions we 
selected. Each of the four questions was randomly assigned across the 
34 carrier call centers and each question was posed 75 times. Calls 
were placed at different times of day and different days of the week 
from October 20 through November 3, 2003. Twenty-eight of the carrier 
call centers were called nine times and the remaining six call centers 
were each called eight times.

To facilitate our calls, CMS officials informed call center managers of 
our test. They also agreed not to disclose any of the potential 
questions to carrier call center staff. During our calls, we identified 
ourselves as GAO representatives and asked each CSR to answer our 
question as if we were providers. To prevent us from biasing CSRs' 
responses and to ensure fairness, we read each question to CSRs without 
offering additional information or explanations. However, we repeated 
questions upon request. 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. Following the 
response, we asked the CSR if there was any additional information he 
or she would like to provide. We also told CSRs we were manually 
recording their responses verbatim. We analyzed the CSR responses and 
simultaneously submitted them to Medicare coding experts at CMS. Our 
assessment of CSR responses and the coding experts' verification of 
results relied on the following criteria: 

* Correct and complete: The answer provided enough information to 
correctly bill the Medicare program, including (1) a correct 
explanation of how to apply the billing policy and (2) correct billing 
codes or a referral to specific documentation that provided coding 
information.

* Partially correct or incomplete: The answer provided some 
explanation, but (1) did not provide assistance in interpretation or 
warn about special circumstances that would affect billing; (2) 
provided interpretation but no directions to specific documentation; or 
(3) was correct, but not sufficiently complete to ensure that the claim 
would consistently pass claims processing edits.

* 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.

Following CMS's verification, we discussed and resolved all 
discrepancies between our assessment of responses and CMS's 
verification. For example, when initially assessing CSRs' responses, we 
attempted to locate Web site documents that CSRs referred to during our 
call. If we found that the reference contained all the accurate 
information necessary to bill the program properly, we considered the 
CSRs' responses to be correct and complete even if they did not tell us 
the information themselves. Although CMS coding experts did not 
initially review these documents, and therefore may have considered the 
CSR's response to be incorrect and incomplete, they subsequently agreed 
that this was a fair and appropriate criterion to add to our 
assessment.

The results from our 300 test calls are limited only to those calls and 
are not generalizable to the population of calls routinely made to call 
centers by providers. Although the four policy-oriented questions we 
posed were frequently asked questions obtained from carrier Web sites, 
they do not encompass all of the questions that providers might ask.

We also interviewed carrier and CMS officials to determine what efforts 
the agency had in place to enhance CSRs' access to information. We 
reviewed information regarding the Next Generation Desktop (NGD) 
application, including videotape and internal documents outlining the 
phase-in schedule for the application. In addition, we observed a 
demonstration of the NGD application and monitored its capability to 
facilitate CSR's responses to providers' questions.

To determine the efforts CMS has made to provide oversight, we 
identified CMS requirements for carrier call center operations and 
discussed with CMS staff the agency's oversight and monitoring of 
carrier call center activities. We reviewed the agency's protocol for 
its contractor performance evaluations (CPE) to determine the scope of 
work evaluators would perform and evaluated carrier call center 
performance standards to identify the types of problems found during 
their site visits. We also reviewed CPE reports from fiscal years 2001 
and 2002. CMS did not perform any CPEs in fiscal year 2003. We visited 
two carrier call centers and consulted an industry expert on issues 
related to call center technology and standards. In addition, we 
observed carrier call centers' monitoring of calls for quality at one 
of the carrier call centers we visited. We also observed CMS regional 
staff performing remote monitoring of provider calls. We performed our 
work from September 2003 through June 2004 in accordance with generally 
accepted government auditing standards.

[End of section]

Appendix II: Carrier Call Center Accuracy Test Questions: 

The questions and answers we used to test the accuracy of carrier call 
center responses to policy-oriented questions are shown in table 2.

Table 2: Questions and Answers for Test of Carrier Call Centers: 

GAO question: Question 1: Billing for beneficiaries transferred from 
one hospital to another; 
Question from carriers' Web sites: If Dr. Smith transfers a patient 
from hospital A to hospital B for treatment, will Medicare pay Dr. 
Smith for both the hospital discharge day management services at 
hospital A and hospital admission at hospital B? 
Answer from carriers' Web sites: Physicians may bill both the hospital 
discharge management code and an initial hospital care code when the 
discharge and admission do not occur on the same day if the transfer 
is between (1) different hospitals, (2) different facilities under 
common ownership which do not have merged records, or (3) between the 
acute care hospital and a PPS[A] exempt unit within the same hospital 
when there are no merged records. In all other transfer circumstances, 
the physician should bill only the appropriate level of subsequent 
hospital care for the date of transfer.

GAO question: Question 2: Billing for services delivered by therapy 
students; 
Question from carriers' Web sites: The Current Procedural Terminology, 
or CPT, codes for therapeutic procedure state, the "physician or 
therapist are required to have direct, that is, one-on- one, patient 
contact." What if the therapist, for example a PT, OT, or SLP,[B] has 
some contact with the patient, say, 10 minutes direct patient contact 
time, and then the student assumes responsibility for treatment under 
supervision? Does Medicare cover that? 
Answer from carriers' Web sites: Medicare will pay for the one unit of 
direct services the therapist provides to the patient under Medicare 
Part B. If the therapy student assumes responsibility for treatment, 
the services are not payable under Medicare Part B; Note: However, if 
the qualified therapist maintains responsibility for the service and 
one- on-one contact with the patient, the student may participate at 
the direction of the therapist and Medicare will pay for the service 
because it is provided by the therapist.

GAO question: Question 3: Billing for multiple surgeries on the same 
day; 
Question from carriers' Web sites: Are there any circumstances for 
which carriers may pay the full amount for a second surgical procedure 
performed by the same physician on the same day but during a different 
operative session? 
Answer from carriers' Web sites: If a physician believes that 
extenuating circumstances exist for performing multiple surgeries on 
the same day and that these surgeries should be paid at the full 
amount, he or she may bill for the surgeries with modifier "22." After 
reviewing the operative report, the carrier may determine that the 
standard adjustment rules do not apply and pay "by report."

GAO question: Question 4: Billing for an office visit and a procedure 
on the same day; 
Question from carriers' Web sites: Will Medicare pay for a visit and a 
procedure on the same day if reported by the same physician for the 
same patient? 
Answer from carriers' Web sites: 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. The payment amount for the procedure covers 
such pre-and postservice work as record keeping, counseling, and 
prescribing recovery therapy; However, if other significant evaluation 
and management services are performed on the same day, the physician 
may bill for the visit with modifier "25." In determining the level of 
visit to bill with the modifier, physicians should consider only the 
content and time associated with the separate evaluation and management 
service, not the content or time of the procedure; Visits that are 
related to a major surgery are not paid for separately if reported by 
the same physician on the same day as the surgery. However, the initial 
evaluation or consultation by the surgeon will be paid for separately 
even if reported on the same day. 

Source: Carrier Web sites: 

[A] PPS stands for prospective payment system.

[B] PT, OT, and SLP stand for physical therapist, occupational 
therapist, and speech language pathologist, respectively.

[End of table]

[End of section]

Appendix III: Comments from the Centers for Medicare & Medicaid 
Services: 

DEPARTMENT OF HEALTH & HUMAN SERVICES:	
Centers for Medicare & Medicaid services:
Administrator Washington, DC 20201:

DATE: JUN 29 2004:

TO: Leslie G. Aronovitz:
Director, Health Care-Program Administration and Integrity Issues:

FROM: Mark B. McClellan, MD, Ph.D. 
Administrator:

SUBJECT: General Accounting Office's (GAO) Draft Report: MEDICARE: Call 
Centers Need to Improve Responses to Policy-Oriented Questions from 
Providers (GAO-04-669):

Thank you for the opportunity to review and comment on the General 
Accounting Office's draft report: MEDICARE: Call Centers Need to 
Improve Responses to Policy-Oriented Questions from Providers." The 
following are our general comments to the report.

In 2001, the Centers for Medicare & Medicaid Services (CMS) began an 
initiative to improve provider communications when it required its 
contractors fiscal intermediaries (Fls) and carriers to institute toll-
free phone service to answer inquiries from providers who bill for 
services under fee-for-service Medicare. That initiative has continued 
to expand including:

* Fourteen individual Open Door Forums held on a regular basis (monthly 
for physicians). 

* Town Hall meetings on new initiatives.

* Provider specific Web pages and listservs on www.cms.hhs.g ov/
providers. 

* Increased number of centrally developed educational 
products.

* A fee-for-service provider educational Web page on www.cms.hhs.gov/
medleam.

* An extensive provider partnership network with provider associations 
and organizations whereby providers give input on products and CMS 
information tools and assist in dissemination of CMS information.

Each year the call volume handled by the 61 FI and carrier provider 
call centers has increased. In fiscal year (FY) 2004, the number of 
calls is projected to be over 41 million. Of the 41 million calls, 28.6 
million are expected to be handled by the Medicare carriers.

The FIs and carriers process close to 1 billion claims annually. Most 
of the provider inquiries are related to specific claims that the 
provider has submitted to the contractor. Customer service 
representatives (CSRs) typically answer telephone inquiries in the 
context of a specific claim. At the time of a call, CSRs have access to 
claim information and Remittance Advice (RA) codes to guide their 
answers. Providers receive written and/or electronic RA for every claim 
submitted. The RA consists of Health Insurance Portability & 
Accountability Act (HIPAA) code sets that explain and document the 
actions taken on a particular claim.

Based on a recent sample of calls monitored by CMS and information 
reported by the call centers, about 95 percent of all inquiries are 
related to claims status checks, claims denial inquiries, or inquiries 
about a beneficiary's eligibility under the Medicare program. This 
report looked at the remaining small, but important percentage of calls 
(less than 5 percent) where the caller asks about specific Medicare 
policy, where there is no associated claim.

The CMS appreciates the GAO recommendations in this area and is 
preparing to implement a solution to improve contractor responses to 
complex policy questions from providers. The Medicare program is 
complex and broad in scope. We believe that the most efficient way to 
correct this problem is to establish a triage system with contractor 
staff, apart from the CSR pool, who have the time, training, and tools 
to research and carefully consider provider policy questions.

Attached are specific CMS' comments to GAO recommendations and 
findings.

Attachments:

CMS Comments to the GAO Draft Report: "MEDICARE: Call Centers Need to 
Improve Responses to Policy-Oriented Questions from Providers" (GAO-04-
669):

GAO Recommendations:

CMS should create a process to routinely screen and triage calls by 
routing complex policy-oriented questions to staff with the expertise 
to adequately address them.

CMS Response:

The CMS agrees. The CMS will soon issue a requirement that all call 
centers create a tiered approach to answering provider inquiries. Such 
a restructuring will establish an expertise continuum, with the most 
complex tier being handled by staff who have the time to research, 
investigate and respond to policy-oriented questions. We plan to 
establish this approach as of FY 2005.

A tiered approach may also help with retention as promotion 
opportunities are created within a call center.

GAO Recommendations:

The CMS should develop clear and easily accessible policy-oriented 
materials to assist CSRs. The materials should he electronically 
searchable so that CSRs can expeditiously provide correct and complete 
responses to policy-oriented questions.

CMS Response:

The CMS agrees that clear and easily accessible policy-oriented 
materials should be available and electronically searchable. Unlike the 
GAO recommendation, however, as described above, CMS envisions a staff 
other than the CSRs as the primary user. The CMS has made significant 
progress in this area in the last 2 years. For example, CMS now has an 
on-line manual of Medicare policy and billing instructions on 
www.cms.hhs.gov/manuals . We have also established customized provider 
Web pages where physicians, hospitals, ambulances, durable medical 
equipment suppliers, and other providers can quickly access relevant 
Medicare information. These Web pages, found on www.cms.hhs.gov/
providers, have associated listservs which ensure that providers will 
get new information as it becomes available.

The CMS also now issues nationally consistent provider education 
materials to accompany contractor instructions that implement new or 
revised policy. "Medlearn Matters ... Information for Medicare 
Providers" educational articles are written in consultation with 
clinicians, billing experts, and other medical professionals and are 
tailored in content and language to the specific provider types who are 
affected by the program change. They explain in layman terms what the
program instructions are saying and, more importantly, explain the 
specific impact that the change has on the affected providers. 
Additionally, the articles are housed in one central, easily accessible 
location www.cms.hhs.gov/medlearn/matters.

GAO Recommendations:

The CMS should establish an effective monitoring program for call 
centers to assess CSR's performance. The program should include the 
development of specific performance standards that will allow CMS to 
thoroughly and routinely measure the correctness and completeness of 
information given by CSRs in response to policy-oriented questions.

CMS Response:

The rare occurrence of these kinds of calls would require very large 
sample sizes at the CSR level.	We are, as stated above, proposing that 
complex policy-oriented calls be triaged to specialty staff when 
necessary, allowing the critical mass of claim-related calls to be 
answered by CSRs. We agree that regardless of where the responsibility 
falls, monitoring is important. However, we are in the process of 
determining how to monitor this new approach to responding to provider 
inquiries. The monitoring process will include both contractor self-
monitoring and CMS monitoring.

For CSRs, CMS will be requiring carriers to increase their self-
monitoring efforts using the Quality Call Monitoring (QCM) tool. 
Presently, we require carriers to monitor 3 calls per CSR per month. 
Because so many of the carrier call centers are "blended," those 
centers may only monitor 1 provider call per CSR per month. The other 2 
calls may be beneficiary calls. With this requirement, it is not 
surprising that the knowledge skills scores are close to 100 percent 
given that 95 percent of the call volume is claims status, claims 
denial or beneficiary eligibility inquiries. In FY 2005 there will be 
no blended calls centers and we are increasing the QCM requirement from 
3 calls to 5 calls per CSR per month. For those call centers that today 
only monitor 1 provider call per CSR per month, the new requirement 
reflects a 500 percent increase in monitoring. The increase in 
monitoring, added to a tiered structure to respond to inquiries, will 
more accurately measure the ability of CSRs to correctly and completely 
answer provider inquiries of varying complexity.

A second measure CMS is exploring is to modify the contractor 
performance evaluation (CPE) requirements to include some direct 
measure of call accuracy. Expanding CPE continues to be a resource 
problem because it requires CMS staff from around the country to spend 
significant time away from ongoing work. There are not enough CMS staff 
dedicated to perform contractor evaluations.

As part of Medicare contractor reform resulting from the Medicare 
Prescription Drug, Improvement and Modernization Act of 2003 (MMA), 
contracts will be performance-based.

The CMS must develop performance standards for each of the business 
functions handled by the Medicare Administrative Contractors (MACS). In 
preparation for MAC contracts, CMS is testing performance standards for 
provider telephone inquiries that get at the accuracy of the responses 
provided.

The CMS is, in early FY 2005, pilot testing a provider customer 
satisfaction survey that will include contractor call performance. 
Under section 911 of the MMA, such a survey is required. Once the pilot 
is complete and refinements made, the survey will be distributed 
nationally. This survey gathers information about providers' 
perceptions of many of the contractor business functions, but provider 
telephone service is a key area being surveyed.

Technical Comments:

1. We recommend that the title be changed to "MEDICARE: Carrier Call 
Centers Need to Improve Responses to Policy-Oriented Questions from 
Providers." By adding the word "carrier" to the title, it more 
accurately represents the findings.

2. In the first full sentence on page 2 of the report, the word 
"providers" should be modified to read "providers and billing staff" 
The reality is that providers rarely call the contractor themselves. 
The caller is usually a member of a providers' billing staff. The cover 
memo and the report should reflect that fact.

3. The first paragraph of the background section on page 5 discusses how 
31 of the 34 carrier call centers are "blended." While that is 
currently an accurate statement, by October l, 2005, that will no 
longer be true: We will be requiring these "blended" call centers to 
have CSRs that are dedicated to provider inquiries. This same paragraph 
also uses the words "contractor" and "carrier " interchangeably. To 
avoid confusion, a reiteration of the distinction between FIs and 
carriers would be helpful.

4. In the discussion about the call backs on page 6, CMS does not have a 
5 day requirement in its manual, but it is the way CMS requires call 
centers to report the data in Customer Service Assessment and 
Management System (CSAMS). The language in the first full paragraph 
leads the reader to infer incorrectly that CMS has a 5-business day 
requirement.

5. In the first full paragraph on page 7 of the draft report, the GAO 
recommends that "CMS could use new contractors to communicate program 
information to its providers and deliver provider education and 
training." Section 911 of the MMA specifically lists provider services 
as a function of the MACS. Those provider services include provider 
education and outreach, provider telephone inquiries, and provider 
written inquiries. However, CMS does use contractors to assist in the 
development of national educational and training materials. The current 
FIs and carriers, and in the future, MACS, will disseminate the 
national materials.

6. At the top of page 10, the report reads "...CMS officials told us 
that the agency does not ... give CSRs "suggested" language to follow 
when answering questions from providers...." In fact, on occasion, CMS 
has provided job aids for CSRs to follow when answering specific 
questions. CMS plans to develop more of these job aids in the future. 
We will be posting job aids on a Web page and establishing a contractor 
job aid listserv in order to notify call centers when anew job aid is 
available. These job aids will also be added to the Next Generation 
Desktop (NGD) to make them easily accessible to call centers that have 
deployed the NGD.

7. In the second paragraph of the discussion on page 11, the report 
states that "the agency has determined that answering providers' coding 
questions about specific claims is beyond the scope of CSRs' 
responsibilities." It is important that the report note that CMS is 
prohibited from providing guidance about Current Procedural Terminology 
(CPT) codes because these codes are proprietary to the American Medical 
Association. In addition, CSRs do not, as a matter of course, have the 
expertise to instruct a provider on the nuances of coding a service. 
Ultimately, the provider is the best judge of what to code because the 
provider knows the details of the service given.

8. The last full paragraph on page 13 discusses the CMS strategy for 
national educational articles. It states that the Medleam Matters 
articles are not linked to the policies they describe. In fact these 
articles contain policy citations (e.g., contractor instructions, 
regulations, law). 

[End of section]

Appendix IV: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Geraldine Redican-Bigott, (312) 220-7678: 

Acknowledgments: 

Shaunessye Curry, Margaret Weber, Helen Chung, Mary Reich, and Marie 
Stetser made key contributions to this report.

FOOTNOTES

[1] The contractors that process Part A claims, which cover inpatient 
hospital, skilled nursing facility, hospice, and certain home health 
services, are referred to as fiscal intermediaries. The contractors 
that process Part B claims, which include physician services, 
diagnostic tests, durable medical equipment, and related services and 
supplies, are referred to as carriers.

[2] In this report, we use the term provider to include a doctor, 
hospital, health care professional, and health care facility, and their 
billing staffs. 

[3] U.S. General Accounting Office, Medicare: Communications with 
Physicians Can Be Improved, GAO-02-249. Washington, D.C.: Feb. 27, 
2002.

[4] We defined a correct and complete response as an answer that 
provided enough information to correctly bill Medicare, including (1) a 
correct explanation of how to apply the billing policy and (2) correct 
billing codes or a referral to specific documentation that provided 
coding information. A partially correct or incomplete response 
contained an answer that provided some explanation, but (1) did not 
provide assistance in interpretation or warn about special 
circumstances that would affect billing; (2) provided interpretation 
but no directions to specific documentation; or (3) was correct, but 
not sufficiently complete to ensure that the claim would consistently 
pass claims processing edits. We defined an incorrect response as an 
answer containing fully or partially incorrect information, such that a 
physician might incorrectly bill or not file a claim for a billable 
service. For more detailed information on our scope and methodology, 
see app. I.

[5] CMS has also established beneficiary toll-free telephone lines at 
six other call centers to handle beneficiaries' inquiries about the 
program. These centers are referred to as 1-800-MEDICARE call centers. 
These six centers are operated by a special contractor that is neither 
a carrier nor a fiscal intermediary. CMS reports that in 2003 CSRs in 
these centers responded to almost 6 million calls regarding topics such 
as Medicare enrollment and coverage; replacement of Medicare 
identification cards; and available health plan options, such as 
traditional fee for service, preferred provider organizations, and 
health maintenance organizations. 

[6] Beginning October 1, 2005, CMS will require all "blended" call 
centers to have CSRs that are dedicated to responding to provider 
inquiries.

[7] Pub. L. No. 108-173,  911(a)(1), 117 Stat. 2066, 2378-2386 (to be 
codified at 42 U.S.C. 1395kk-1 note).

[8] There are nine key business functions: claims processing, 
beneficiary and provider customer service, appeals, provider education, 
financial management, provider enrollment, reimbursement, payment 
safeguards, and information systems security.

[9] Modifiers provide a means by which a reporting physician can 
indicate that a service or procedure that has been performed has been 
altered by some specific circumstance but not changed in its definition 
or code.

[10] The expert is the director of a university-based center for 
benchmarking the performance of call centers and was a featured speaker 
at CMS's 2001 Telephone Customer Service Conference.

[11] Incoming Calls Management Institute, Call Center Monitoring Study 
II Final Report. (Annapolis, Md.: 2002).

[12] We based this analysis on the number of CSR full-time equivalents 
for carrier call centers in fiscal year 2003, which ranged from 6 to 
55. Carriers are expected to monitor three calls per CSR per month. As 
a result, depending on the number of full-time equivalents for each 
call center, carriers would be expected to have monitored from 216 to 
1,980 calls during fiscal year 2003. 

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