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 
www.gao.gov/cgi-bin/getrpt?GAO-04-669.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Leslie G. 

Aronovitz at (312) 220-7600. 

Highlights of GAO-04-669, a report to the 

Ranking Minority Member, Subcommittee 

on Health, Committee on Ways and 

Means, House of Representatives 

July 2004

MEDICARE

Call Centers Need to Improve Responses 

to Policy-Oriented Questions from 

Providers 

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 policyoriented questions. 

In addition, CMS’s 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, CMS’s 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 

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 carriers—

contractors that help manage the 

Medicare program—were incorrect 

or incomplete. GAO also found that 

CMS’s 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 policyoriented telephone inquiries and 

CMS’s efforts to improve 

communications with providers 

and (2) evaluated CMS’s efforts to 

provide oversight of carrier call 

centers. 

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. 
Page i GAO-04-669 Medicare Call Centers 

Letter 1

Results in Brief 4

Background 5

CSRs’ Responses to Policy-Oriented Questions Were Largely 

Incorrect 7

Call Center Oversight Does Not Adequately Assess CSRs’ 

Responses to Policy-Oriented Questions 13

Conclusions 16

Recommendations for Executive Action 17

Agency Comments 18

Appendix I Scope and Methodology 20 

Appendix II Carrier Call Center Accuracy Test Questions 23 

Appendix III Comments from the Centers for Medicare & Medicaid 

Services 25 

Appendix IV GAO Contact and Staff Acknowledgments 30 

GAO Contact 30

Acknowledgments 30

Tables 

Table 1: Summary of Accuracy of CSR Responses by Question 8

Table 2: Questions and Answers for Test of Carrier Call Centers 23

Contents 
Page ii GAO-04-669 Medicare 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 

This is a work of the U.S. government and is not subject to copyright protection in the 

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reproduce this material separately. 
Page 1 GAO-04-669 Medicare Call Centers 

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 contractors1

 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 

 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. 

United States Government Accountability Office

Washington, DC 20548 
Page 2 GAO-04-669 Medicare Call Centers 

which providers2 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 reported3

 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 

 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. 
Page 3 GAO-04-669 Medicare Call Centers 

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.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 

 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. 
Page 4 GAO-04-669 Medicare Call Centers 

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. 

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 

Results in Brief 
Page 5 GAO-04-669 Medicare Call Centers 

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. 

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.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.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 policyoriented 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 

 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. 

Background 
Page 6 GAO-04-669 Medicare Call Centers 

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 
Page 7 GAO-04-669 Medicare Call Centers 

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.7

 Instead of primarily 

relying on the claims administration contractors to perform most of the 

key business functions8

 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 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 

 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. 

CSRs’ Responses to 

Policy-Oriented 

Questions Were 

Largely Incorrect 
Page 8 GAO-04-669 Medicare Call Centers 

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’ policyoriented 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 

Correct and 

complete response

Partially correct or 

incomplete response Incorrect response Total responses

Question 1: 

Billing for beneficiaries transferred 

from one hospital to another 2 22 51 75

Question 2: 

Billing for services delivered by 

therapy students 5 32 38 75

Question 3: 

Billing of multiple surgeries for the 

same patient on the same day 1 36 38 75

Question 4: 

Billing of an office visit and procedure 

for the same patient on the same day 4 35 36 75

Number of carrier call center 

responses 12 125 163 300

Percentage of carrier call center 

responses 4 42 54 100

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. 

CSRs Almost Never 

Provided Correct and 

Complete Responses to 

Our Policy Questions 
Page 9 GAO-04-669 Medicare Call Centers 

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 

Variety of Factors 

Contributed to CSRs’ 

Incorrect and Incomplete 

Responses 
Page 10 GAO-04-669 Medicare Call Centers 

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 modifiers9

 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 

 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. 
Page 11 GAO-04-669 Medicare Call Centers 

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. 
Page 12 GAO-04-669 Medicare Call Centers 

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 statusoriented 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.” Skillbased routing systems are designed to enhance customer service by 

CMS’s Efforts Not Targeted 

to Supplying PolicyOriented Information to 

CSRs 
Page 13 GAO-04-669 Medicare Call Centers 

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’ policyoriented questions and route their calls to the most appropriate CSRs. 

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. 

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.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.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 

 10The 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. 

11Incoming Calls Management Institute, Call Center Monitoring Study II Final Report. 

(Annapolis, Md.: 2002). 

Call Center Oversight 

Does Not Adequately 

Assess CSRs’ 

Responses to PolicyOriented Questions 

Carrier Self-Monitoring 

Does Not Effectively 

Evaluate CSRs’ Responses 

to Policy-Oriented 

Questions 
Page 14 GAO-04-669 Medicare Call Centers 

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 policyoriented 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. 
Page 15 GAO-04-669 Medicare Call Centers 

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 selfmonitoring 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. 

CMS Does Not Adequately 

Evaluate CSRs’ Responses 

to Policy-Oriented 

Questions 
Page 16 GAO-04-669 Medicare Call Centers 

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.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. 

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 

 12We 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. 

Conclusions 
Page 17 GAO-04-669 Medicare Call Centers 

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. 

In order to improve the accuracy and completeness of responses to policyoriented 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. 

Recommendations for 

Executive Action 
Page 18 GAO-04-669 Medicare Call Centers 

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. 

Agency Comments 
Page 19 GAO-04-669 Medicare Call Centers 

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, 

Leslie G. Aronovitz 

Director, Health Care—Program 

 Administration and Integrity Issues 
Appendix I: Scope and Methodology 

Page 20 GAO-04-669 Medicare Call Centers 

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 

Appendix I: Scope and Methodology 
Appendix I: Scope and Methodology 

Page 21 GAO-04-669 Medicare Call Centers 

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 
Appendix I: Scope and Methodology 

Page 22 GAO-04-669 Medicare Call Centers 

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. 
Appendix II: Carrier Call Center Accuracy 

Test Questions 

Page 23 GAO-04-669 Medicare Call Centers 

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 from carriers’ Web sites Answer from carriers’ Web sites 

Question 1: Billing for 

beneficiaries transferred from 

one hospital to another 

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? 

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 PPSa

 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. 

Question 2: Billing for services 

delivered by therapy students 

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? 

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. 

Question 3: Billing for multiple 

surgeries on the same day 

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? 

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.” 

Appendix II: Carrier Call Center Accuracy 

Test Questions 
Appendix II: Carrier Call Center Accuracy 

Test Questions 

Page 24 GAO-04-669 Medicare Call Centers 

GAO question Question from carriers’ Web sites Answer from carriers’ Web sites 

Question 4: Billing for an office 

visit and a procedure on the same 

day 

Will Medicare pay for a visit and a procedure on 

the same day if reported by the same physician 

for the same patient? 

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

Page 25 GAO-04-669 Medicare Call Centers 

Appendix III: Comments from the Centers for 

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

Page 26 GAO-04-669 Medicare Call Centers 
Appendix III: Comments from the Centers for Medicare & Medicaid Services 

Page 27 GAO-04-669 Medicare Call Centers 
Appendix III: Comments from the Centers for Medicare & Medicaid Services 

Page 28 GAO-04-669 Medicare Call Centers 
Appendix III: Comments from the Centers for Medicare & Medicaid Services 

Page 29 GAO-04-669 Medicare Call Centers 
Appendix IV: GAO Contact and Staff 

Acknowledgments 

Page 30 GAO-04-669 Medicare Call Centers 

Geraldine Redican-Bigott, (312) 220-7678 

Shaunessye Curry, Margaret Weber, Helen Chung, Mary Reich, and Marie 

Stetser made key contributions to this report. 

Appendix IV: GAO Contact and Staff 

Acknowledgments 

GAO Contact 

Acknowledgments 

(290307) 
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