Medicare: Communications with Physicians Can Be Improved
Published: 2002-02-27T00:00:00

Fast Facts:

Highlights:
section_title: What GAO Found
paragraphs: Unlike other federal programs that make expenditures under the direct control of the government, Medicare constitutes a promise to pay for covered medical services provided to its beneficiaries by about one million providers. Given this open-ended entitlement, it is essential that appropriate and effective rules and policies be specified so that only necessary services are provided and reimbursed. Congress and the Centers for Medicare and Medicaid Services (CMS) have promulgated an extensive body of statutes, regulations, policies, and procedures on what shall be paid for and under what circumstances. Information that carriers give to physicians is often difficult to use, out of date, inaccurate, and incomplete. Medicare bulletins that carriers use to communicate with physicians are often poorly organized and contain dense legal language. Similarly, other means of communicating with physicians, such as toll-free provider assistance lines and websites, have problems with accuracy and completeness. Although all carriers issue bulletins, operate call centers, and maintain websites, each carrier develops its own communications policies and strategies. This approach results in a duplication of effort as well as variations in the quality of carrier communications. CMS provides little technical assistance to help carriers develop effective communication strategies. Neither CMS carrier oversight nor self-monitoring by the carriers is comprehensive enough to provide sufficiently detailed information that could either pinpoint specific communication problems or identify poorly performing carriers. CMS is working to improve its physician communications by consolidating new instructions and regulations and issuing them on a more predictable schedule to lessen the burden of frequent policy changes that physicians cannot anticipate. CMS is also enhancing its education programs for both physicians and carrier staffs and expanding its efforts to obtain physician feedback. Finally, CMS is improving its national website and intends to develop a single web-based source of information for physicians.

section_title: Letter
paragraphs: Medicare, serving nearly 40 million beneficiaries, is the nation’s largest health insurer and second largest federal program. Unlike other federal programs that make expenditures under the direct control of the government, Medicare constitutes a promise to pay for covered medical services provided to its beneficiaries by about 1 million providers. Given this open-ended entitlement, it is essential that appropriate and effective rules and policies be specified so that only necessary services are provided and reimbursed. To accomplish this, the Congress and the Centers for Medicare and Medicaid Services (CMS)—the federal agency within the Department of Health and Human Services (HHS) that administers Medicare—have promulgated an extensive body of statutes, regulations, policies, and procedures regarding what shall be paid for and under what circumstances. CMS, which relies on the assistance of about 50 claims administration contractors to operate the Medicare program, is charged with communicating this information to medical providers, including  physicians, so that they can bill the program properly.
Recently, physicians and their representatives testified at congressional  hearings that their participation in Medicare is becoming increasingly  burdensome. Among other things, they reported being inundated with  large volumes of complicated, unclear, and inconsistent information from  the Health Care Financing Administration (HCFA) and its carriers about  Medicare program requirements. They also expressed concern that,  because rules change frequently, their understanding of billing rules may  be obsolete and incorrect, which could lead to inadvertent billing errors.
This report responds to your request, which recognized both the need for  HHS, and particularly CMS, to routinely communicate regulations,  instructions, and guidance to physicians, and the concerns of physicians  regarding the quality of the materials they receive. Specifically, you asked  us to examine several aspects of Medicare communications, including (1)  the quality of Medicare information provided to physicians by HHS, and  CMS and its carriers, (2) the quality of CMS’s management and oversight  of carrier communications, and (3) current CMS efforts to enhance the  communication process.
To understand physicians’ concerns regarding Medicare communications,  we first solicited the views of individual physicians from several  specialties and representatives from relevant professional organizations.  As part of this effort, we obtained the cooperation of seven physician  practices of varying sizes that provided us with information on the volume  and type of Medicare communications they received during a 3-month  period. These practices were located in different areas of the country and  received information from different carriers. They also provided us with  excerpts from documents they received and shared their views on the  usefulness of the information they received during that time frame. In  addition, we interviewed officials at several carriers and HCFA. We also  met with officials at other HHS agencies to discuss their communications  with physicians participating in the Medicare program.
On the basis of this information, and because the vast majority of  Medicare communications are issued by carriers on behalf of CMS, we  focused on the information carriers provide to physicians. We then  conducted an evaluation of the quality of the three main methods carriers  use to provide information to physicians—bulletins they publish and mail  to physicians, telephone call centers that respond to physician questions,  and Internet Web sites to serve participating physicians. Specifically, to  assess bulletins we reviewed recently issued bulletins from 10 carriers to  determine whether they organized material in ways that would help  readers locate information. We evaluated the timeliness and completeness  of these bulletins by examining them to determine when certain CMS- issued memorandums, which were relevant to physicians, were included.  To assess the quality of information provided to physicians calling carriers  with questions, we telephoned 5 of the 37 provider assistance call centers  with frequently asked questions (FAQ) taken from carrier Web sites. With  CMS’s assistance, we scored the completeness and accuracy of these  responses. We also visited 3 carrier call centers to observe their operations  and to study the carriers’ approaches to monitoring the performance of the  customer service representatives who are responsible for responding to  physician inquiries. To assess carrier Web sites we examined 10 such sites  to determine if they complied with requirements established by CMS, as  well as to assess whether the information presented on those Web sites  was accurate, complete, and timely. We did not evaluate communications  issued by all Medicare carriers; our findings are limited to those carriers  we reviewed and cannot be projected to other carriers.
To evaluate the quality of CMS’s management and oversight of carriers’  communications activities, we identified relevant requirements that CMS  imposes on carriers regarding their communications with physicians. We  also examined CMS’s allocation of key resources devoted to  communication activities. In addition, we observed CMS officials conduct  an on-site performance evaluation of one carrier’s call center. To identify  CMS’s efforts to improve Medicare communication to physicians, we  spoke with officials from CMS, carriers, medical associations, physicians  and their practice administrators, and reviewed related documentation.  We identified recent initiatives CMS has undertaken to improve physician  communications and also explored its plans for future enhancements.
Appendix I contains more information regarding the scope and  methodology of our work. A more detailed description of our review of  carrier call centers is contained in appendix II. Appendix III summarizes  the amount and types of information the seven physician practices  received from both governmental and nongovernmental sources from  February 1, 2001, through April 30, 2001. CMS provided comments on a  draft of this report. These comments are reproduced in appendix IV.
Our work was conducted from December 2000 through January 2002 in  accordance with generally accepted government auditing standards.
subsections: section_title: Background
paragraphs: The complexity of the environment in which CMS operates the Medicare  program cannot be overstated. CMS manages Medicare, the nation’s  largest health insurer, in a challenging and complex environment in which  medical providers and beneficiaries form a vast network of stakeholders  with differing priorities. The agency is charged with developing  regulations and policies that implement the statutory provisions of the  Medicare program. The program is operated by CMS with the assistance of  approximately 50 carriers and fiscal intermediaries—generally health  insurance companies—that annually process about 900 million claims  submitted by nearly 1 million providers and private health plans. Medicare  is estimated to have spent nearly $240 billion in fiscal year 2001 for  services provided to approximately 40 million elderly and disabled  beneficiaries.
In order to receive reimbursement from Medicare, CMS requires  physicians to submit claims that identify the services they have performed  by using the agency’s national uniform procedure coding system. Like  other Medicare providers, physicians are responsible for billing Medicare  correctly for services performed and informing beneficiaries of the level of  Medicare coverage at the time of service. To do this they need reliable  information on Medicare coverage, claims coding and documentation  requirements, claims submission instructions, program changes, and  carrier policies.
CMS communicates information describing its billing requirements, as  well as other relevant regulations and policies, to physicians primarily  through its carriers. The carriers communicate with physicians in several  ways. They send physicians bulletins periodically to update them on new  rules and program changes, provide toll-free lines to call centers so  physicians can obtain answers to questions, and maintain Web sites that  include postings of, among other things, new Medicare developments and  carrier-sponsored training. CMS and its carriers also sponsor a variety of  provider education activities, such as workshops and on-line training  courses, to help familiarize physicians with billing rules and other aspects  of the program and to update them on program changes.
Physicians have become increasingly vocal about the timeliness and  quality of the Medicare information CMS and its carriers provide. For  example, last year, in congressional testimony, physicians and their  representatives reported frustration because carrier communications are  often unclear and do not always provide them with advance notice of  program changes. They also charged that, when they seek clarification,  carrier personnel often give them incorrect answers to their questions.
CMS establishes carrier requirements, including some related to  communications, in its annual budget and performance requirements  (BPR). For example, the BPRs require carriers to communicate with  physicians about local medical review policies (LMRP) and claims  submission procedures. CMS is responsible for monitoring the  performance of its carriers to ensure that they accurately and efficiently  fulfill their requirements and properly implement Medicare policies. Much  of CMS’s oversight is accomplished through its periodic evaluations of  carrier performance. In addition, the agency also requires carriers to  routinely submit evidence of their own self-monitoring activities.
section_title: Carrier Communications Are Often Difficult to Use, Out of Date, Inaccurate, and Incomplete
paragraphs: Medicare information provided by carriers for physicians is often difficult  to interpret and use, out of date, inaccurate, and incomplete. Our analysis  of the three main methods that carriers use to communicate information  to physicians—printed bulletins, provider assistance call centers, and Web  sites—revealed problems with all three types of communication.
subsections: section_title: Carrier Bulletins Can Be Difficult to Use and Lack Current Information
paragraphs: Carrier bulletins contain important information for physicians but present  this information in formats that may be difficult for them to use. In  addition, critical information, including changing program requirements,  may be late in reaching physicians who need to take steps to implement  these changes.
CMS relies heavily on carrier bulletins—which each carrier is required to  issue at least quarterly—to give physicians official notice of their  responsibilities and requirements under Medicare law, regulations, and  guidelines. Carriers have discretion regarding the bulletins’ format and  organization, but they are required to reprint certain CMS-provided  information verbatim. For example, carriers receive and reproduce CMS- issued guidance—known as program memorandums (PM)—which convey  details about upcoming program changes scheduled to become effective in  the next few months.
Our review of bulletins issued from March through July 2001 by 10  randomly selected carriers showed that there are several aspects of the  bulletins, including their organization and length, which hinder their  usefulness. As a result of carriers’ freedom to develop their own bulletins  with little direct CMS guidance, there was considerable variation in the  organization and format of the bulletins we reviewed. While bulletins  issued by 6 of the 10 carriers organized information by subject matter or  specialty, the others provided only an alphabetical key word index instead  of a table of contents to assist the user. Providing only a key word index  makes it difficult to identify information relevant to different physician  practices. Some carriers that serve physicians in several states issued a  single bulletin for all their states. Some of these bulletins had information  for each state contained in a separate insert or section. Other, less helpful,  multistate bulletins only noted state differences within individual articles,  requiring physicians or their staffs to scan each article to determine  whether it was relevant and applicable to their practices. In addition, the  bulletins were typically over 50 pages in length and several exceeded 80  pages, making them lengthy documents to search.
In several instances, bulletins were late, or provided little advance notice,  in communicating HCFA-issued program changes to physicians. To test  the timeliness of carrier bulletins in communicating information, we  selected four PMs that HCFA issued from February through April 2001  concerning program changes that physicians would need to be aware of in  billing for certain services. We then reviewed the bulletins issued from  March through July by the 10 carriers we sampled, to determine when the  four PMs were included in the carriers’ bulletins. In 11 instances, PMs  were either not communicated through carriers’ bulletins until after their  scheduled implementation dates, or they did not appear at all in the  bulletins we reviewed, as shown in table 1. In 11 additional instances,  bulletins communicated the memorandums less than 30 days prior to the  implementation date, giving physicians little advance notice to help ensure  their compliance with Medicare rules. Overall, 6 of the 10 carriers did not  communicate at least one of the four PMs before its scheduled  implementation.
section_title: Carrier Call Centers Often Provide Inaccurate and Incomplete Information and Lack Standard Policies and Sufficient Resources
paragraphs: Customer service representatives (CSR) at carrier call centers we tested  rarely provided appropriate answers to questions we posed. Eighty-five  percent of the responses we received from CSRs from 5 carrier call  centers were inaccurate or incomplete.
To assess the accuracy of responses provided by CSRs, we made 61 calls  to the provider inquiry lines at call centers and asked three questions from  the FAQ pages on carriers’ Web sites concerning the appropriate way to  bill Medicare in circumstances commonly encountered by physicians.When calling, we identified ourselves as GAO representatives and asked  the CSRs to answer our questions as if we were physicians. CSR responses  were recorded verbatim and submitted to a Medicare coding expert at  CMS along with the text of the questions and answers used. We used the  following questions when making our calls:  1.	 If a physician provides critical care for 1 hour and 15 minutes, how  should the services be reported? Should code 99292 (for an additional  30 minutes) be reported? Should the reduced services modifier be  used?  2.	 What is the proper way to bill for an office visit on the same day as a  surgical procedure?  3.	 Can code 99211 be reported if a nurse in the physician’s office provides  instruction on self-administering insulin?
Appendix II provides the answers that appear on the Web sites.
The results of the test, which were validated by the coding expert, showed  that 32 percent of the answers were inaccurate, 53 percent were  incomplete, and only 15 percent were complete and accurate. These  results are illustrated in table 2. There was little variation among the  carriers in the overall accuracy and completeness of their answers.
Many physicians we spoke to expressed frustration that CSRs will not  always provide information on how to properly code certain claims.  Carrier call centers had varying policies about providing physicians with  specific coding information. Knowing the appropriate code for a medical  service is essential to properly billing Medicare. Although CMS does not  have a policy preventing them from doing so, managers at the carrier call  centers we visited reported that it is not their policy to provide  information to callers on how to code a specific claim. Carriers reported  that they are reluctant to provide specific codes because the CSRs lack the  medical expertise to appropriately make coding judgments, and they do  not have the physician’s clinical documentation at the time of the calls to  understand the procedure or service in context.
During our test of call center accuracy, we noted that CSRs followed  different procedures regarding coding-related inquiries and frequently did  not adhere to the carriers’ stated policy. While in 19 cases the CSRs  provided neither a code nor referral to a source of coding information,  specific codes were given in 24 instances. Specific referral to a bulletin  issue or to a regulation number was given in 16 other cases, but for 7 of  these cases the information was too vague to enable someone to locate the  coding rules. Even when the referrals to information sources were  accurate, physicians told us that being directed to other carrier  publications does not respond to their need for readily accessible  interpretation of Medicare regulations.
Our visits to 3 call centers also revealed that there is no uniformity or  standardization across carriers in the types of technological resources  available to CSRs. For example, 1 call center we visited had an on-line  searchable database of LMRPs that facilitated quick retrieval of the  appropriate information by the CSRs. Representatives at the 2 other call  centers used hard copy bulletins or bulletins posted on their Web sites in a  nonsearchable format. CSRs without easily searchable tools told us that  they relied heavily on their more experienced colleagues, in the absence of  more authoritative sources, for answers.
The lack of technological resources at call centers can affect centers’  abilities to monitor the performance of their CSRs. One call center we  visited was able to record calls from providers and the computer screens  accessed by CSRs to determine whether their responses were accurate  and complete, while the other two call centers could only record the  telephone calls. Two call centers we visited were able to electronically  observe each CSR’s phone line activity to track the length and origin of  calls; however, another call center had no electronic information and  could only monitor lines and identify the type of caller by listening to the  calls as they took place.
section_title: Carrier Web Sites Not Easy to Use and Often Did Not Meet HCFA-Mandated Requirements
paragraphs: Most of the 10 carrier Web sites we reviewed did not contain features that  would allow physicians to quickly and directly obtain the information they  needed. The Web sites frequently lacked logical organization and  navigation tools and search functions that increase a site’s usability and  value. Only 4 of the 10 Web sites we examined contained site maps. Only 6  contained search functions and in two instances, the search functions did  not work. Three sites had neither search functions nor site maps, making  them difficult to navigate to access information. Furthermore, the Web  sites often contained out-of-date information. Nine of the 10 sites included  the required schedule of upcoming workshops or seminars but 5 of these  sites were out of date. Only 1 site contained a potentially useful “What’s  New” page, but the page contained a single document of regulations that  went into effect 8 months prior to the date of our Web site review.
Although HCFA’s 2001 BPRs contain specific requirements for carrier Web  sites, most of the sites we reviewed did not meet all of these standards.  Only 2 of the 10 sites complied with all 11 of the BPRs’ content  requirements, as shown in table 3. In addition, other requirements, such as  a federally mandated privacy statement outlining the type of information  the site collects on visitors and a section containing FAQs were not  consistently met. Five Web sites contained the privacy statement, and 5  contained a link to FAQs.
Although CMS has set standards for carrier Web sites, each carrier  independently develops its own Web site. This has resulted in duplication  of effort and variations in the usability and complexity of the information  provided.
section_title: CMS’s Management and Oversight of Communications With Physicians Are Insufficient
paragraphs: CMS is ultimately responsible for managing and overseeing carrier  performance to ensure that carriers supply physicians with consistent and  accurate information. However, the agency’s standards and technical  assistance to guide carriers in physician communications activities are not  sufficient to produce consistent, high-quality products and effective  communication strategies. The lack of standard approaches to  communication by carriers makes consistent oversight more challenging  for CMS. Neither of the two principal oversight tools used by CMS—  contractor performance evaluations (CPE) and carrier self-monitoring  and reporting—provide enough information to reveal problems carriers  may have in providing quality communications.
subsections: section_title: CMS’s Communications Management Lacks Sufficient Standards and Resources
paragraphs: CMS has established few standards to guide carriers’ primary  communication activities, including publishing bulletins, providing  telephone assistance to callers, and establishing and maintaining Web  sites. The BPRs only require carriers to issue bulletins at least quarterly.  There is no substantive guidance regarding content or readability. Carrier  call centers are instructed to perform “quality monitoring” no more than 10  times a quarter for each CSR, but CMS’s definition of what constitutes  accuracy and completeness in call center responses is neither clear nor  specific. For example, CMS defines accuracy as not being inaccurate—as  opposed to providing necessary and complete information to allow  physicians to correctly bill the program. In the case of Web-based  communication, the BPRs contain few requirements about the clarity or  timeliness of information. Instead, they generally focus on legal issues—  such as measures to protect copyrighted material—that, while important,  do not enhance physicians’ understanding of, or ability to correctly  implement, Medicare policy.
CMS officials acknowledged that physician communications have received  less support and oversight than other aspects of carrier operations and  attributed this, in part, to a lack of resources. CMS’s regional offices,  which are most directly responsible for carrier oversight, provide  assistance to carriers through business function experts (BFE) whose  principal method of oversight is participation on CPE teams. A CMS  official told us that there are not enough BFEs to provide direct technical  assistance to all carriers in all areas of communication. Furthermore, a  lack of budgetary resources limits BFEs’ travel to carrier sites. One  regional BFE we interviewed handles four functional areas, including  provider education and provider phone inquiries, for 6 separate Medicare  carriers. The BFE interviewed noted that little hands-on technical  assistance is provided. Despite the fact that bulletins are a key means of  physician communication, and Web sites are growing in importance, some  regions have not been allocated any BFEs for these functions. Moreover,  no region has a full-time equivalent staff member dedicated to these  critical forms of communication, leaving carriers to solve problems  independently.
CMS’s efforts to assist carriers in sharing successful approaches are also  limited. The agency’s annual conference for call center managers provides  a forum for sharing information and strategies. However, similar  opportunities do not exist for carrier staff members working with bulletins  and Web sites. CMS collects and posts on-line a carrier BestPractices  Handbookrelating to provider communications and education, but as of  January 2002, the information had not been updated in a year. Further, the  handbook contains little detail about how to implement the strategies for  improving communications.
The lack of specific standards, sufficient technical assistance, and best  practice guidance creates an environment in which, as one CMS business  function expert said, each carrier must develop its own communication  strategies, resulting in duplication of carriers’ efforts and variations in the  quality of their service to physicians. At the time of our review, CMS did  not have any efforts that would be implemented in the near future to  develop more standardized carrier communications to physicians.
section_title: Monitoring of Carriers Is Not Sufficient to Ensure Quality and Accuracy in Physician Communication
paragraphs: HCFA has not traditionally undertaken comprehensive evaluations of the  quality or usefulness of carriers’ bulletins or Web sites. For 21 years, the  agency has conducted on-site evaluations to directly monitor carriers’  performance in a variety of areas. However, the agency is just beginning to  focus CPEs on provider communications. In 2001, it expanded the focus of  its call center CPEs to include call centers that serve providers, including  physicians. Previously, these reviews had been limited to beneficiary call  centers.
We observed one CPE team as it evaluated the operations of a provider  call center. This team focused mainly on performance standards that  address procedures, such as how long a caller is kept on hold or whether  the CSR had given an appropriate greeting, rather than whether  information provided was complete and accurate. In order to evaluate the  carrier’s performance in monitoring its CSRs, the CPE auditor listened to  10 prerecorded calls that had been evaluated by the carrier at an earlier  date. However, the CPE auditor did not access the claims information to  evaluate whether the information being provided to the callers was  correct. While assessing procedural performance is important, helping  ensure that callers receive the correct information is essential.
In addition to CMS’s evaluation of call centers through CPEs, the agency  requires carriers to evaluate the performance of their call center CSRs.  Carriers must monitor up to 10 calls for each CSR each quarter—  amounting to about 90 of the more than 30,000 provider inquiries received  by a given carrier each quarter. Carriers we visited agreed with one call  center industry expert that this level of monitoring is far short of what is  necessary to thoroughly evaluate quality. Accuracy and completeness are a  relatively small component (40 percent of the total score) in the overall  performance evaluation of a CSR. The remaining components focus on  CSR attitude and helpfulness.
CMS’s oversight beyond the CPE process and carrier self-monitoring  consists principally of CMS staff reviewing carriers’ self-reported data,  with little direct feedback from the regional BFEs. Carriers submit  monthly reports summarizing certain call center data, such as how long  callers were kept on hold and the number of calls abandoned. They also  submit quarterly activity reports on communications. The reports include  items such as the number of provider training sessions offered and the  questions most frequently asked by providers. Feedback from CMS is  geared toward correcting specific problems, such as lengthy caller waiting  times, rather than identifying ways to improve performance on a broader  scale.
section_title: CMS is Making Efforts to Improve Physician Communications
paragraphs: Through the feedback it has received from the physician community, CMS  is aware of a need to improve Medicare communications. It is working to  issue new Medicare rules and regulations on a more consistent and  predictable schedule, expand information resources available to  physicians, and obtain more physician feedback relating to Medicare  policies and communications. However, most of these efforts are in early  stages of planning or implementation; therefore, we could not assess their  ultimate impact.
In June 2001, CMS announced plans to reduce the burden on providers of  frequent and irregularly occurring Medicare program changes by issuing  and communicating regulations on a more consistent schedule. CMS plans  to institute a new, Web-based quarterly compendium of program changes,  including all regulations that it expects to publish in the coming quarter, as  well as references or electronic links to regulations published in the  previous quarter. By doing so, CMS hopes to make physicians aware of  program changes and provide them with sufficient lead time to implement  them. The compendium was originally to be introduced in October 2001,  but according to a CMS official, as of January 2002 the compendium’s  format was still being developed.
CMS is attempting to improve the consistency of information that carriers  provide to physicians and has both short-term and long-term projects  under way. Currently, the agency is establishing a new on-line training  program for carrier call center CSRs, and over the past year it has  provided in-person training to carrier staffs. Installation of satellite dish  technology at Medicare carriers was recently completed so that CMS could  broadcast training to carrier staffs. In addition to these shorter-term  initiatives, agency officials told us that they are developing some longer- term projects to enhance carriers’ communications. For example, they are  developing a standard template for carrier bulletins. In 2001, CMS also  awarded a contract for the design of a standardized computer system that  would be used by CSRs at all carrier call centers to improve CSRs’ access  to information as they respond to telephone inquiries. A CMS official told  us this will be tested first at a durable medical equipment contractor this  spring, but had no estimate of when it would be installed at carrier sites.
CMS is also addressing information that it provides directly to the  physician community. In November 2001, CMS mailed the physician  edition of Medicare and You 2002to physicians participating in Medicare,  which was the first issuance of a physician-oriented version of their annual  Medicare andYoubeneficiary handbook. This physician information  includes a summary of recent Medicare program changes, an overview of  physician concerns that CMS is currently addressing, and guidance on  contacting carriers or CMS for claims submission and billing information.  The agency is also focusing on improving its national Web site. Plans  include installation of a new navigational system to make information on  CMS’s Web site more accessible and consolidation of all information  relevant to providers in a single Web-based source—a project that will  take several years to complete.
In recent years, CMS has also increased efforts to obtain feedback from  physicians regarding communications and training. In response to the  physician community’s concerns, the agency established the Physicians’  Regulatory Issues Team (PRIT) in 1998. PRIT has collaborated with the  physician community to identify Medicare requirements, procedures, and  communications that cause the most problems for physicians, and is  working to address the most significant of them. In July 2001, the  administrator of CMS announced the formation of “open door” policy  committees, including one focused on physicians, consisting of top CMS  staff members and provider group representatives that would meet  regularly to discuss regulations that are troubling to providers. Finally, in  the fall of 2001, CMS sent out two surveys to obtain the views of  physicians and other providers on their Medicare education needs and  their experiences with CMS’s program integrity efforts.
section_title: Conclusions
paragraphs: The scope and complexity of the Medicare program make complete,  accurate, and timely communication of program information vital to  physicians who need up-to-date knowledge of Medicare requirements in  order to serve their patients and bill correctly for the services they  provide. Although CMS has delegated this responsibility to carriers, our  work demonstrates that physicians cannot rely on carrier bulletins, call  centers, or Web sites to meet their information needs. In addition, CMS’s  lack of standard requirements for carrier communications results in  carriers developing their own approaches to convey information, leading  to duplication of effort and varying degrees of timeliness, accuracy, and  completeness.
CMS has initiated a number of efforts, although some are just getting  underway, to improve the way its carriers communicate with physicians  and, in doing so, has acknowledged that improvements are needed.  However, these efforts focus on the individual methods of communication  and do not consider more fundamental matters such as whether the  current, and almost complete, reliance on carriers to communicate with  physicians is in the best interest of the program. We believe it is important  for CMS to initiate a more comprehensive and standardized approach to  physician communications through coordination, leadership, and  management of CMS’s carrier-based communications. This approach  should focus on communicating timely, accurate, and complete  information in formats that physicians find easy to use. It should include  meaningful performance standards for carrier communications, enhanced  requirements for carrier self-monitoring, effective monitoring and  feedback by CMS’s staff, and more substantive periodic CPE reviews of  carrier communications.
section_title: Recommendations for Executive Action
paragraphs: In order to improve its assistance to, and oversight of, its Medicare  carriers’ physician communications efforts, we recommend that the  administrator of CMS adopt a standardized approach that would promote  the quality, consistency, and timeliness of Medicare communications while  also strengthening CMS’s management and oversight. Specifically we  recommend that CMS take the following actions:
Assume responsibility for the publication of a national bulletin for  physicians, in addition to issuing a quarterly compendium of regulations.  Carriers would be responsible for preparing supplements to CMS’s  national bulletin regarding local medical policy issues.
Establish new performance standards for carrier call centers that  emphasize providing complete and accurate answers to physician  inquiries. Carriers’ monitoring of their carrier call center operations  should also be expanded to assure that these performance standards and  policies are followed.
Set standards and provide technical assistance to carriers to promote  consistency, accuracy, and user-friendliness of all carrier Web sites, which  should be limited to local Medicare information and should be designed to  link to CMS’s Web site for national program information.
Strengthen its contractor evaluation and management process by relying  on expert teams to conduct more substantive CPE reviews on all physician  communications activities.
section_title: Agency Comments and Our Evaluation
paragraphs: In written comments on a draft of this report, CMS agreed that  improvement is needed in its communications with physicians  participating in Medicare and recognized that providing them with the best  possible information is integral to successfully serving Medicare  beneficiaries. CMS described its current efforts to develop a  comprehensive customer service plan and elaborated on several efforts to  improve communications that the agency currently has under way. For  example, CMS pointed out that it is enhancing its services to physicians by  establishing a new program to disseminate information at professional  conferences and by instituting its “Open Door Forums” where physicians  can meet with CMS officials and share their views on Medicare program  rules. We have reprinted CMS’s letter in appendix IV. CMS also provided  us with technical comments, which we incorporated as appropriate.
In addressing our first recommendation to assume responsibility of a  national bulletin for physicians, CMS pointed out that it is taking steps to  “nationalize” information contained in these bulletins. It said it is already  including articles of national interest regarding Medicare issues in carrier  bulletins. CMS also said it is planning a National Provider Bulletin Project  to study the practicality of establishing a national source for the  information included in these bulletins as well as potential changes to the  publication and distribution process.
In response to our second recommendation that new performance  standards be established for carrier call centers, CMS described a variety  of initiatives it has under way to help enhance the quality of these  communications. CMS agreed that providing timely, correct, and  consistent answers to physicians’ questions is imperative. The agency  stated that it has instituted a new program of performance standards that  features more effective oversight and evaluation and that includes new  quality call monitoring procedures. Although this new plan appears to  contain key components of an effective communication strategy, CMS’s  description of this effort does not contain sufficient detail for us to fully  assess its usefulness. We believe such a plan ultimately needs to  incorporate specific performance measures for which the carriers could  be held accountable. Although CMS indicated it plans to devise ways of  objectively measuring carrier performance, it said that it does not yet have  such measures in place.
In response to our third recommendation to set standards and provide  carriers with additional technical assistance to enhance carrier Web sites,  CMS outlined the requirements that carriers must meet. CMS indicated it  was satisfied with carriers’ performance in this area, pointing out that an  examination of Web sites was part of this year’s annual CPE reviews.  According to CMS, none of the carriers have been deficient in their  compliance with CMS requirements, and CPE reviewers found most of the  Web sites to be user-friendly. Although these CPE reviews may not have  detected deficiencies at carrier Web sites, as we have noted most of the  Web sites we reviewed did not comply with some of CMS’s requirements.  CMS has agreed to reexamine its Web site monitoring efforts.
Regarding out fourth recommendation, CMS agreed that utilizing expert  teams to conduct CPE reviews would be the best means of ensuring  substantive evaluations. However, CMS said that it believed that  implementing our recommendation would require the agency to establish  a team of dedicated review staff, which would not be feasible given the  agency’s available resources. Although CMS said it could not implement  our recommendation at this time, it indicated that it will nonetheless try to  continue building the expertise of its review staff. According to CMS,  many of the staff members that performed these reviews last year will  perform them this year as well. In addition, CMS said it will continue to  provide relevant training to these staff members.
Officials of the American Medical Association and the Medical Group  Management Association also reviewed a draft of this report. In oral  comments, officials from both organizations said they generally agreed  with our findings and recommendations and offered technical comments,  which we incorporated as appropriate.
We are sending copies of this report to the secretary of Health and Human  Services, the administrator of CMS, and other interested parties. We will  make copies available to others upon request.
If you or your staffs have any questions about this report, please call me at  (312) 220-7600. An additional GAO contact and other staff members who  made major contributions to this report are listed in appendix V.
section_title: Appendix I: Scope and Methodology
paragraphs: To develop an understanding of physicians’ concerns about the Medicare  communications they receive, we obtained the cooperation of seven  physician practices. These practices were of varying sizes, were located in  different geographic regions, and were served by three different Medicare  carriers. Each practice agreed to send us the Medicare-related information  that it received during the 3-month period from February 1 through April  30, 2001. Besides participating in this communications collection effort,  representatives from these practices shared their views on the quality of  the information they received during this period. We also discussed these  matters with representatives from the following 10 professional  associations:
American Academy of Family Physicians,
American Academy of Professional Coders,
American College of Emergency Physicians,
American College of Physicians-American Society of Internal Medicine,
American Health Information Management Association,
American Medical Association,
Health Care Billing Managers Association,
Health Care Compliance Association,
Medical Group Management Association, and
Professional Association of Health Care Office Managers.
Because the majority of Medicare communications to physicians are  issued by carriers on behalf of CMS, we focused on the three main  methods these carriers use to communicate with physicians—carrier  bulletins, carrier provider assistance call centers, and carrier Web sites.  We did not review communications from every Medicare carrier. Our  findings are limited to the carriers we reviewed and cannot be projected to  other carriers. The scope of our work did not permit us to examine  provider education efforts such as seminars and training sessions except  in the form of documents submitted by physician practices and  conversations with agency and carrier officials. In addition to assessing  the quality of carrier communications, we also reviewed the agency’s  oversight of physician communications and its plans to improve these  communications. Finally, we interviewed officials from other agencies  within HHS to discuss their communications with physicians participating  in the Medicare program.
subsections: section_title: Quality of Carrier Medicare Communications
paragraphs: To evaluate the quality of carrier bulletins, we randomly selected 10  carriers and reviewed the bulletins they issued from March through July  2001. We reviewed the bulletins from the standpoint of whether their  format and organization facilitated a reader’s ability to locate information.  To test the bulletins’ timeliness and completeness in communicating  required information, we identified approximately 40 PMs—issued by  HCFA from February 1 through April 30, 2001—that addressed program  changes relevant to physicians. We then selected four of these  memorandums and reviewed the bulletins issued by the sampled carriers  to determine when, or whether, the memorandums were published.
To evaluate the accuracy and completeness of responses given on carrier- operated provider inquiry lines, we made calls to five call centers operated  by 3 carriers for a total of 59 usable responses (two nonresponses were  eliminated from the sample). We selected call centers operated by the 3  carriers that serve the geographic areas where the seven physician  practices participating in our data collection were located. The three test  questions were selected from FAQs posted on carrier Web sites, to  represent common physician billing concerns. The questions and answers  are listed in appendix II. Our methodology was to ask each of the three  questions, four times, at each of the five call centers, for a total of 12 test  calls to each center and 20 test calls for each question. Calls were placed  at different times of day and different days of the week from early May  through June 2001.
HCFA officials were aware of our test. Call center managers were also  informed that their CSRs would be receiving test calls from us. When  calling, we identified ourselves as GAO representatives and asked the CSR  to answer our question as if we were physicians. Prompts were only given  if the CSR probed for more specific information or gave conditional  responses that depended upon different circumstances. In those  situations, we asked the CSR to provide the correct answer for each set of  circumstances (such as, whether the office visit was related or unrelated  to the surgical procedure). Following the response, we asked the CSR if  there was any additional information he or she would like to provide. CSR  responses were recorded verbatim and submitted to a Medicare coding  expert at CMS along with the text of the questions and answers used. The  coding expert verified our results using the following criteria.
Correct and complete: The answer provided enough information to  correctly bill, including (1) a correct explanation of how to apply the  billing policy and (2) correct billing codes or a referral to specific  documentation that provides coding information.
Partial or incomplete: The answer referred to material, but (1) did not  provide assistance in interpretation or warn about special circumstances  that would affect billing, or (2) provided interpretation but no directions to  specific documentation, or (3) was correct but not complete.  Incorrect: The answer contained fully or partially incorrect information,  such that a physician might incorrectly bill or not file a claim for a billable  service.
Nonresponse: The CSR refused to answer the question. (Nonresponses  occurred because CSRs would not answer questions for callers who were  not physicians.)
To test the usefulness of carriers’ electronic communications with  physicians, we randomly selected 10 carrier Web sites for review. We  investigated Web sites to determine whether they were in compliance with  the content requirements for electronic media as detailed in HCFA’s 2001  budget and performance requirements and in the contractor Web site  standards and guidelines posted on the agency Web site. To identify best  practices for effective, user-friendly Web sites, we interviewed four  individuals familiar with Web site development, including the Web master  for HHS and two private Web designers. We used information from these  sources to evaluate the 10 carrier Web sites for their accessibility, privacy,  format, content, ease of navigation, organization, contact information,  appearance, and use of graphics.
section_title: HCFA Oversight of Physician Communications
paragraphs: We identified HCFA requirements for carrier bulletins, call center  operations, and carrier Web sites, and discussed the agency’s oversight  and monitoring of carriers’ communications with both headquarters and  regional office officials. We researched call center standards used in  private industry through conversations with an industry expert and the  manager of a large call center, and visited three carrier call centers to  discuss technology, standards, best practices, and support from HCFA. We  also observed carrier call centers’ monitoring of calls for quality at the  three call centers we visited. In addition, we observed a contractor  performance evaluation—the agency’s independent review of “at-risk”  contractor activities—conducted at one of the carrier call centers in our  review.
section_title: Improving Medicare Communications
paragraphs: Throughout this review, as we met with HCFA and carrier officials and  representatives of the physician practices participating in our  communications collection, we solicited their views on problems with the  Medicare communications process and potential best practices. Agency  officials also identified their current and planned efforts to improve its  process for communicating with Medicare providers. In addition, we  discussed related issues in our conversations with representatives from  professional associations.
section_title: Other HHS Agencies’ Communications to Physicians
paragraphs: HHS is the principal federal department responsible for protecting the  health of Americans and providing other essential health services.  Although the focus of our work was Medicare communications that  originated with CMS, we were also asked to identify the quantity and type  of communications that physicians receive from other HHS agencies.  Based on our review of background information and discussions with HHS  officials, we identified nine HHS offices and agencies, other than CMS, as  potential sources of information or instructions for practicing physicians.  These include the Office of the Secretary, Office of the Inspector General,  Agency for Healthcare Research and Quality, Centers for Disease Control  and Prevention, Food and Drug Administration, Health Resources and  Services Administration, Indian Health Service, National Institutes of  Health, and Substance Abuse and Mental Health Services Administration.
We contacted officials in these offices and agencies and reviewed  information available through their Web sites to determine whether they  issued instructions or requirements that affected practicing physicians.  Compared to CMS, the other HHS agencies we contacted issue relatively  few requirements for practicing physicians and rarely communicate  instructions or information directly to the physicians, as does CMS  through its Medicare carriers. Generally, officials we contacted indicated  that these agencies rely primarily on posting information to their Web sites  to communicate with the medical community and the general public. Many  of the HHS agencies also offer subject-specific e-mail notification of new  Web postings to physicians and others who register to receive this service.  Some agencies have newsletters or publications to which physicians and  others can subscribe or they provide specific information upon request.
section_title: Appendix II: Call Center Accuracy Test Questions
paragraphs: The questions and answers we used to test the accuracy of carrier call  center responses to physician inquiries are shown in table 4.
section_title: Appendix III: Results of Communications Collection from Seven Physician Practices
paragraphs: To identify the quantity and sources of Medicare information received by  physicians, we enlisted the assistance of seven physician practices to  collect communications that related to their practices and were received  during the 3-month period from February 1 through April 30, 2001. A 3- month period was selected so that practices would receive at least one  carrier bulletin. HCFA representatives and participating practices reported  that the period selected was typical in relation to the release of Medicare  regulations and information. The participating physicians represented  both urban and rural practices and were located in four states served by  three carriers and three HCFA regional offices. They also varied in size  and specialty and included a 600-physician multispecialty group; a 450-physician teaching hospital-based group; a 43-physician network of small internal medicine/family practice groups; a 10-physician internal medicine, obstetrics/gynecology, and pediatric a 4-physician multispecialty group; a 4-physician internal medicine group; and a 4-physician ophthalmology group.
The practices collected and submitted full copies or excerpts of practice- related communications received by mail, fax, or e-mail, or downloaded  from the Internet, regardless of the source, during this period. We asked  the practices to omit certain items from their collection due to lack of  relevance or privacy issues. Material the practices were asked to include  and exclude from their submissions to us is shown in table 5.
We collected 947 documents from the physician practices. Based on the  table of contents or section titles of these documents, we categorized them  as (1) directly related to Medicare, (2) unrelated to Medicare but involving  some other requirement relevant to the physician practice, and (3)  information relevant to the physician practice that did not include any  requirement the practice needed to act upon. We also classified  communications by their source, including HCFA or its carriers, other  HHS agencies, state and local government agencies, insurance companies  and managed care plans, and all other sources, such as professional  journals, newsletters, or other information sent to physicians. We could  not independently verify that the physician practices submitted all relevant  communications they received, nor could we reliably distinguish between  communications that the practice requested and those that were  unsolicited. Most of the documents submitted by the practices had some  Medicare content, indicative of the pervasiveness of the Medicare  program. Frequently appearing topics included Medicare fraud and abuse,  Medicare coding issues, contractor audits, and the Medicare appeals  process.
The information that was submitted by the seven physician practices  shows that while Medicare-related information accounts for much of this  material, a relatively small portion of the documents came from HCFA, its  carriers, or other governmental sources. About half of the documents we  received from the physician practices contained mostly Medicare  information. We found that a relatively small amount of all documents—  about 10 percent—was sent by HCFA or its carriers. Material from other  HHS agencies accounted for less than 3 percent of all documents the  physician practices collected. The majority of the information came from  other organizations, such as consulting firms and medical specialty or  professional societies.
Table 6 shows the source and subject of all documents collected and  submitted by the participating physician practices.
The number of Medicare-related documents and number of pages  submitted by each practice was generally related to the size of the  practice. This was true both of documents from HCFA and from the  private sector. Three of the smaller practices sent us fewer than 5  documents that they received from HCFA. In one case, the 3 documents  submitted by a small practice totaled 217 pages. The largest practice, a  multispecialty clinic, sent 57 HCFA documents totaling 704 pages. A small  rural practice sent 3 private-source documents totaling 12 pages, while the  multispecialty clinic sent 148 documents totaling 1,174 pages. The number  of documents received by a practice may be influenced by the practice’s  breadth of specialties and participation in professional organizations.
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: Donald Kittler, Victoria Smith, Christi Turner, and Margaret Weber made  key contributions to this report.