Medicare: Callers Can Access 1-800-MEDICARE Services, but Responsibility within CMS for Limited English Proficiency Plan Unclear
Published: 2008-12-29T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Centers for Medicare & Medicaid Services (CMS) is responsible for providing beneficiaries timely and accurate information about Medicare. Receiving nearly 30 million calls in 2007, 1-800-MEDICARE, operated by a contractor, is the most common way members of the public get program information. The help line provides services both to English-speaking and limited English proficiency (LEP) callers. In this report, GAO describes (1) the extent to which access performance standards and targets have been met by the current contractor, (2) the efforts by CMS to provide LEP callers access to help line services and wait times experienced by these callers, and (3) CMS's oversight of callers' access to 1-800-MEDICARE and the information's accuracy. To conduct this work, GAO reviewed documents and analyzed help line data through July 2008. In addition, GAO interviewed agency staff, industry experts, and officials at four federal agencies with high call volume contact centers.
section_title: What GAO Found
paragraphs: The 1-800-MEDICARE contractor met most standards and some targets for the required telephone performance metrics and indicators CMS designed to ensure callers' access--from July 2007 through July 2008. The 1-800-MEDICARE contractor's performance met the standard for each of the three access-related metrics--the average amount of time callers wait to reach customer service representatives (CSR), the percent of unhandled calls, such as abandoned calls, and the percent of calls transferred among CSRs--in 10 of 13 months analyzed. Because of waivers granted by CMS, the contractor was considered by the agency to have met the standards in 12 of 13 months. During that time, the contractor met the target for only one of three access-related indicators--the percent of CSRs answering calls. Other indicators were the average amount of time needed to respond to callers' inquiries and the accuracy of CSR call volume forecasting. CMS's efforts to provide LEP callers with access have led to shorter average wait times for Spanish-speaking callers, but are not consistent with all elements of the HHS LEP Plan. CMS requires its help line contractor to provide services to Spanish-speaking callers by employing bilingual CSRs and to provide interpretation services for other LEP callers, which the contractor does by using telephone interpreters. In 20 of the 32 months reviewed, Spanish-speaking callers waited less time, on average, to reach a CSR than English-speaking callers. CMS officials with primary responsibility for 1-800-MEDICARE said they were not aware of the LEP Plan when awarding the current contract, and CMS has not identified an office responsible for acting as a point of contact for management of the LEP Plan. Without a responsible office or official, an internal control for federal agencies, CMS staff lack a source of guidance to assist them in taking steps consistent with the LEP Plan when considering the needs of people with LEP. However, CMS has taken steps consistent with some elements of the agency's adopted LEP Plan, such as the element related to oral language assistance, but not others, such as the element identifying the need for complaint mechanisms for language issues. To oversee 1-800-MEDICARE callers' access to services and accurate information, CMS uses all six commonly used contact center management practices. Based on GAO's review of the literature and interviews with federal agencies and industry experts, these management practices are: (1) clearly defining performance metrics, (2) performing accurate capacity planning, (3) conducting customer satisfaction surveys, (4) ensuring information for CSRs to reference is accurate, (5) evaluating CSRs' interaction with callers, and (6) validating contact center performance reports. These practices are addressed in the current 1-800-MEDICARE contract and reflected in CMS's ongoing contract oversight.

section_title: Letter
paragraphs: The nearly 45 million elderly and disabled Medicare beneficiaries face a  complex set of coverage choices. For example, they must choose whether  to participate in the original Medicare fee-for-service program or obtain  coverage from private health plans that contract with Medicare, and  whether to obtain Medicare coverage for outpatient prescription drugs.  These choices require them to obtain information about the comparative  benefits, costs, and quality of available options. Additionally, once enrolled  and receiving services, Medicare beneficiaries may seek additional  information about their coverage, such as the status of payments for  services or whether their health plan benefits have changed.
The Department of Health and Human Services’ (HHS) Centers for  Medicare & Medicaid Services (CMS), the federal agency that administers  Medicare, is responsible for providing clear, accurate, and timely  information about this complex program. In March 1999, CMS  implemented a nationwide toll-free telephone help line—1-800- MEDICARE—that beneficiaries, their families, and other members of the  public can call to ask questions about Medicare. 1-800-MEDICARE, which  is operated by a contractor, is now the most common way beneficiaries  and other interested members of the public get information from CMS  about Medicare, with the help line receiving more than 30 million calls in  2007. The help line operates 24 hours a day, 7 days a week, with calls first  answered by an automated system and then routed to a customer service  representative (CSR), if requested, for more specific inquiries about  Medicare benefits.
The 1-800-MEDICARE help line provides assistance both to English- and  non-English-speaking callers—in 2007, approximately 1 million callers of  the more than 30 million total callers were assisted in a language other  than English. Among non-English-speaking callers, Spanish was the most  requested language, representing about 98 percent of all non-English- speaking callers to 1-800-MEDICARE in 2007. HHS, like other federal  agencies, is required by Executive Order 13166 to examine the services it  provides and develop and implement a system by which people with  limited English proficiency (LEP) can meaningfully access federally  conducted programs and activities, such as the 1-800-MEDICARE help  line. The executive order also requires federal agencies, including HHS, to  prepare a plan identifying the steps they will take to ensure meaningful  access by people with LEP to such activities.
Since the launch of the help line in 1999, changes to the Medicare program  have required CMS to provide more information through 1-800- MEDICARE. For example, the Medicare Prescription Drug, Improvement,  and Modernization Act of 2003 (MMA) created a voluntary outpatient  prescription drug program for Medicare beneficiaries and required  information on this new program to be made available through 1-800- MEDICARE. This and other changes to the Medicare program have  resulted in increases in the number of calls received by 1-800-MEDICARE.  Additionally, while in the past two contractors operated 1-800-MEDICARE,  in October 2006 CMS opted to begin using a single contractor in an effort  to be more efficient, according to CMS officials. This single contractor  assumed responsibility for 1-800-MEDICARE operations as of October 30,  2006. CMS monitors the contractor’s performance using metrics and  indicators with corresponding performance standards and targets.
Given the complexity of Medicare benefits, it is important that callers  contacting 1-800-MEDICARE be able to access timely and accurate  information as they make health care decisions. You asked us to provide  information on the extent to which 1-800-MEDICARE provides timely  services to callers, including LEP callers, and how CMS oversees the  current 1-800-MEDICARE contractor. In this report, we describe (1) the  extent to which performance standards and targets designed by CMS to  ensure caller access have been met by the current 1-800-MEDICARE  contractor and the extent to which the time a caller waits to reach a CSR  has varied, (2) the efforts by CMS to provide LEP callers access to 1-800- MEDICARE services and the wait times experienced by these callers, and  (3) CMS’s oversight of callers’ access to 1-800-MEDICARE and the  accuracy of the information provided.
To describe the extent to which performance standards and targets  designed by CMS to ensure caller access have been met by the current   1-800-MEDICARE contractor and the extent of efforts by CMS to provide  LEP callers access to 1-800-MEDICARE, we reviewed documents related  to 1-800-MEDICARE access requirements, including both the prior and  current 1-800-MEDICARE contract and other related contracts. We also  interviewed staff from the CMS office with primary responsibility for   1-800-MEDICARE. We used these documents and interviews to identify the  metrics and indicators and their corresponding standards and targets— criteria used to measure the 1-800-MEDICARE contractor’s performance— that we considered to be most closely associated with caller access. In  conducting our work, we focused on telephone services provided by 1-800- MEDICARE and did not review requirements for information provided  through other communication channels, such as e-mail. Using data from  CMS’s National Data Warehouse (NDW) on calls received by 1-800- MEDICARE, we compared the selected performance metrics and  indicators to the contractor’s actual performance. We also used these data  to examine changes in the amount of time callers waited to reach a CSR.  To assess the reliability of the NDW data used, we reviewed CMS  documents describing how the data are collected and CMS’s efforts to  ensure data reliability. We also interviewed CMS officials responsible for  collecting and analyzing the data and conducted a series of tests on the  data files CMS provided. We determined the data were sufficiently reliable  for the purposes of this report and reviewed data for three primary  periods:    December 2005 through July 2008. We identified changes during this time  period in the amount of time callers, including LEP callers, waited to reach  a CSR. This time period encompassed both the prior and current 1-800- MEDICARE contracts.
July 2007 through July 2008. We analyzed data to compare the metrics  and indicators implemented in July 2007 of the current 1-800-MEDICARE  contract with the actual performance of the 1-800-MEDICARE contractor.
September 2007 through July 2008. We identified differences in the  amount of time callers waited to speak to CSRs under the current 1-800- MEDICARE contract, depending on the skill level of staff responding to  the calls, the language in which assistance was provided, and the type of  calls—general inquiries about the Medicare program or calls about  payments for services or benefits, referred to as claims.
To provide additional information on efforts by CMS to provide LEP  callers access to 1-800-MEDICARE services, we reviewed Executive Order  13166 and the LEP Plan developed by HHS. We also interviewed staff from  the HHS Office for Civil Rights and the CMS Office of Equal Opportunity  and Civil Rights. Additionally, we reviewed GAO work related to internal  control standards when considering implementation of the LEP Plan.  While we reviewed certain 1-800-MEDICARE activities to identify steps  consistent with the LEP Plan, we did not review all CMS and 1-800- MEDICARE activities for consistency with the LEP Plan.
To describe how CMS oversees callers’ access to, and the accuracy of  information provided by, 1-800-MEDICARE, we identified six common  oversight practices used by contact centers to ensure both caller access  and information accuracy. To identify these practices, we reviewed prior  GAO work and federal publications related to contact centers and  conducted interviews with four federal agencies that receive inquiries  about their services by telephone and with contact center industry  experts. We selected federal agency contact centers to interview based  on our review of prior related GAO work, selecting those that had annual  call volumes greater than 5 million calls and other characteristics similar  to those of 1-800-MEDICARE, such as a comparable population, extended  hours, periods of particularly high call volume, and service provision in  multiple languages. Using our review of publications and the interviews  with our selected federal contact centers, we identified the six common  oversight practices, which we then confirmed in interviews with industry  experts and an industry publication. To determine whether CMS used  these common oversight practices, we reviewed documents related to  CMS’s oversight of the 1-800-MEDICARE contractor, including meeting  minutes, policies and procedures, and contractor evaluations, and  interviewed CMS officials. We also conducted a site visit to one of the five  1-800-MEDICARE contact center sites to gain a better understanding of  how the centers function. In addition, we reviewed a contract awarded by  CMS in December 2007 to a separate contractor—referred to as the  Training, Quality, and Content (TQC) contractor—responsible for  developing CSR training materials and for conducting quality assurance  efforts for 1-800-MEDICARE. We interviewed officials both from CMS and  the current 1-800-MEDICARE contractor to determine steps the TQC  contractor is taking to assume responsibility for these activities. As the  TQC contract was not fully implemented at the time of our review, we  could not evaluate its effectiveness.
Our work did not assess particular issues encountered by callers with  visual, hearing, or speech impairments or those with low literacy. In  addition, we did not evaluate the accuracy of information callers receive  from 1-800-MEDICARE CSRs, the accuracy of information CSRs use to  answer beneficiary questions, or the appropriateness of CSR training. We  also did not evaluate the effectiveness of the individual management  practices CMS uses to oversee callers’ access to, and accuracy of  information provided by, 1-800-MEDICARE and did not analyze the award  process for, or management of, the contract.
We conducted this performance audit from December 2007 through  November 2008 in accordance with generally accepted government  auditing standards. Those standards require that we plan and perform the  audit to obtain sufficient, appropriate evidence to provide a reasonable  basis for our findings and conclusions based on our audit objectives. We  believe that the evidence obtained provides a reasonable basis for our  findings and conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: CMS administers 1-800-MEDICARE through a single contractor that  operates the telephone help line 24 hours a day, 7 days a week. CMS  initially designed 1-800-MEDICARE to assist beneficiaries in obtaining  information about Medicare programs, including Medicare’s managed care  program, and has since expanded the telephone line to handle increased  call volume and additional inquiries, including inquiries about Medicare’s  prescription drug benefit. Calls are answered by an automated system and,  if requested, callers may be routed to a CSR for additional assistance. The  contractor trains CSRs to respond to two types of inquiries—(1) general  inquiries about the Medicare program (such as general inquiries about  prescription drug coverage or beneficiary address changes) and   (2) specific inquiries about some Medicare Part A and Part B claims—for  both English- and Spanish-speaking callers. CMS uses performance  metrics and indicators to oversee and measure the 1-800-MEDICARE  contractor’s performance. To meet the needs of people with LEP, HHS  developed an LEP Plan that identifies steps for its agencies, including  CMS, to take to improve access for people with LEP to agency programs  and activities, including 1-800-MEDICARE.
subsections: section_title: Contact Center Operations
paragraphs: CMS administers 1-800-MEDICARE to answer callers’ inquiries 24 hours a  day, 7 days a week about Medicare eligibility, enrollment, and benefits.  CMS initially developed 1-800-MEDICARE to assist beneficiaries and other  members of the public in obtaining information about Medicare programs,  including Medicare’s managed care program, as required by the Balanced  Budget Act of 1997 (BBA). In 2003, the MMA required CMS to make  information about the Medicare prescription drug benefit available  through 1-800-MEDICARE and gave CMS increased flexibility in the  administration of Medicare. CMS officials reported that they used this  flexibility to transfer responsibility for information about Medicare-related  Part A and Part B (including DME) claims calls, which previously had been  handled by separate Part A and Part B contractors with their own help line  numbers, to 1-800-MEDICARE. CMS completed the transition of Part A  and Part B claims calls to 1-800-MEDICARE in September 2007.
Each of these initiatives contributed to an increase in the overall volume  of calls received by 1-800-MEDICARE. During the period encompassed in  our review, overall call volume for 1-800-MEDICARE increased  approximately 22 percent, from about 1.6 million calls in July 2005 to more  than 2.0 million calls in July 2008. (See fig. 1.) A large increase in volume  occurred close to the beginning of the Medicare prescription drug benefit  in late 2005 and early 2006. Since that time, monthly call volume has  ranged from about 2 million inquiries to slightly more than 3 million.
Callers to 1-800-MEDICARE receive information from an automated  interactive voice response (IVR) system, a CSR, or a combination of both.  Calls to the line are initially answered by the IVR, which responds to voice  and electronic prompts by the caller. Callers also may use the IVR to  obtain assistance in either English or Spanish. Those who do not indicate a  language preference in the IVR and wish to speak to a CSR are  automatically routed to a CSR for assistance in English. If the IVR cannot  address the needs of the caller or if the caller requests to speak to a  person, the call is routed to a CSR for assistance. (See fig. 2.)
section_title: CSR Assistance
paragraphs: 1-800-MEDICARE classifies incoming calls to CSRs into two types of  requests:  Inquiries about general Medicare issues, such as general inquiries about  prescription drug coverage or beneficiary address changes.
Specific inquiries about claims for Medicare Parts A and B. To provide  assistance with these claims inquiries, 1-800-MEDICARE CSRs are able to  access certain Part A and Part B claims data.
Newly hired CSRs initially receive training to provide services related to  general Medicare inquiries and, as they become more proficient, receive  additional training to respond to claims inquiries. The 1-800-MEDICARE  contractor hires additional, temporary CSRs to handle anticipated  increases during 1-800-MEDICARE’s annual peak period from October  through mid-January; these CSRs are trained to handle general Medicare  inquiries.
The IVR routes callers with general Medicare or specific claims inquiries  to CSRs according to complexity. The approximately 2,600 CSRs  responding to these calls are grouped into two skill levels, or “tiers,” based  on their training and experience. (See fig. 3.)
Tier 1 CSRs, who made up the majority of CSRs as of January 1, 2008,  receive training to respond to simple inquiries about Medicare and claims.  Tier 1 CSRs handle the majority of 1-800-MEDICARE inquiries. Between  September 2007 and July 2008, Tier 1 CSRs handled over 15.1 million  calls—95 percent of the approximately 15.9 million calls handled by CSRs.  Approximately 11.8 million of these Tier 1-handled calls were general  Medicare inquiries while approximately 3.3 million were claims inquiries.
Tier 2 CSRs receive training to assist callers with more complex general  Medicare and claims inquiries. For example, callers wishing to enroll in a  Medicare Advantage plan would speak to a Tier 2 CSR. These CSRs also  can respond to calls at the Tier 1 level if needed. Between September 2007  and July 2008, Tier 2 CSRs handled about 800,000 calls—5 percent of all  calls handled by CSRs. Approximately 523,000 of these calls were general  Medicare inquiries, while approximately 273,000 were claims inquiries.
Particularly complex inquiries, about 1 percent of all calls received, may  be referred by Tier 1 or Tier 2 CSRs to a reference center staffed by CSRs  with additional training above the level of the Tier 2 CSRs.
To provide responses to callers, CSRs in Tier 1 and Tier 2 use defined  “scripts”—standard language explaining elements of the Medicare  program—that they access using desktop computer software. CSRs listen  to a caller’s inquiry and then enter related keywords into this system to  generate a list of suggested scripts that could be used to answer the  inquiry. The CSRs then select the script they consider best suited to  answer the inquiry and read either excerpts or the entire script to the  caller. CSRs may also consult other information sources if appropriate.  For example, CSRs sometimes use tools available on the Medicare Web  site to help beneficiaries select a prescription drug plan. CMS requires  CSRs to read scripts in an effort to ensure that all callers receive  consistent information from 1-800-MEDICARE—regardless of the  expertise of the CSR—and that information being shared is easily  understood by the caller.
section_title: 1-800-MEDICARE Contract and Related Contracts
paragraphs: In October 2006, CMS awarded a single performance-based contract for  the operation of its 1-800-MEDICARE contact centers valued at  approximately $496 million over the life of the contract. This contract  consisted of an initial 7-month transition period, during which the current  1-800-MEDICARE contractor assumed full responsibility for 1-800- MEDICARE help line operations, and 2 additional years, referred to as  “option years.” The contractor is reimbursed for its costs and receives a  fixed base fee. In addition, the contractor can earn an “award fee”—a  percent of the total contract amount—based on its performance in  meeting specific metric standards and indicator targets that CMS  identified as being particularly important to providing services to callers  and controlling contract costs. The current metrics and their standards  were put in place as of July 2007. Using the standards and targets, CMS  evaluates the contractor’s performance three times a year. For each  evaluation period, CMS can decide to award all, part, or none of the  available award fee amount depending on the contractor’s performance.
The current performance metrics quantify and measure the caller  experience with 1-800-MEDICARE. Several metrics are specifically related  to telephone access, such as the average amount of time callers wait after  indicating that they want to speak to a CSR until their calls are answered  by the CSR. The 1-800-MEDICARE contractor must meet the specific  standards for these performance metrics in order to be awarded up to   15 percent of the award fee. Each evaluation period is 4 months long. If  the contractor does not meet a performance metric standard during any  month in an evaluation period, that month’s portion of the award fee is  withheld at the end of that evaluation period.
CMS also has designed several performance indicators that it considers  when measuring the performance of the 1-800-MEDICARE contractor.  Several of these indicators are specifically related to telephone access,  such as the average amount of time a CSR talks to a caller. These  performance indicators do not have fixed standards against which the  contractor’s performance is measured; rather, CMS has established  performance targets and compares the contractor’s actual performance  against these targets, using a scale ranging from substandard to superior,  to determine the contractor’s award fee. According to CMS officials, the  purpose of the targets is to provide a baseline for planning and  management of contact center activities. The performance indicators,  when combined with other contract elements, account for up to   45 percent of the award fee. CMS also considers the contractor’s  performance related to program management and communication,  contract compliance, and fiscal responsibility when determining the award  fee. These elements, when combined, account for up to 40 percent of the  award fee.
In addition to the main 1-800-MEDICARE contract, CMS has awarded four  additional contracts to individual companies for other activities directly  related to the support of 1-800-MEDICARE:    A contract with a telephone company to manage the phone lines used by   1-800-MEDICARE. This company also ensures that calls to CSRs are  routed to the next available CSR with the skill set to assist the caller.
A contract to support and maintain the desktop application used by CSRs,  including software CSRs use to access scripts.
A contract to manage the NDW, a central data repository that captures,  aggregates, and integrates data on 1-800-MEDICARE from multiple  sources.
A contract—referred to as the TQC contract—to conduct activities that  include training, development of the scripts used by CSRs, and quality  assurance, such as evaluation of CSR calls.
section_title: Access to Services for Persons with LEP
paragraphs: As required by Executive Order 13166, HHS has developed a plan that  identifies the necessary steps for the department and its agencies intended  to ensure access to timely, quality language assistance services by eligible  LEP persons to its programs and activities, such as 1-800-MEDICARE. The  HHS LEP Plan, issued in December 2000, identifies seven elements  designed to help each HHS agency, program, and activity to meet the  department’s goal of providing “access to timely, quality language  assistance services to  persons.” For example, the Plan includes  elements related to oral language assistance services and efforts to assess  accessibility and the quality of language assistance activities. (See app. I  for a list of the seven LEP Plan elements.) The Plan reflects HHS’s overall  goals for improving language access for individuals and includes strategies  for improving technical assistance for language access services. HHS  officials said that the Plan provides a “road map” for addressing HHS’s  goals, while allowing individual operating divisions and agencies,  including CMS, some flexibility in implementing the Plan’s elements.
section_title: The 1-800-MEDICARE Contractor Met Most Standards and Some Targets Designed to Ensure Caller Access, but Average Wait Times under the Current Contract Varied by Type and Complexity of Inquiry
paragraphs: The current 1-800-MEDICARE contractor met most standards and some  targets for telephone access-related performance metrics and indicators— measures designed to ensure all callers’ access to services—from July  2007 through July 2008. In 10 of 13 months we analyzed, the current 1-800- MEDICARE contractor’s performance met the standards for each of the  required access-related performance metrics. Because of waivers granted  by CMS, the agency considered the contractor to have met the relevant  standards in 12 of the 13 months. While generally meeting the required  standards for the three access-related performance metrics, the 1-800- MEDICARE contractor consistently met the target for only one of the  three access-related performance indicators we analyzed. However, the  amount of time callers waited to access services has varied depending on  the type and complexity of callers’ inquiries. The amount of time callers  waited to speak with a CSR has increased since December 2005, but the  performance standards related to caller wait time also have varied over  time.
subsections: section_title: Overall, the Current 1-800- MEDICARE Contractor Met CMS Monthly Access- Related Performance Standards
paragraphs: In 10 of 13 months we analyzed (July 2007 through July 2008), the current  1-800-MEDICARE contractor’s performance met the standards for all three  telephone access-related performance metrics required under its contract  with CMS. Because of waivers granted by CMS, the contractor was  considered by the agency to have met the relevant standards in 12 of the  13 months. Implemented in July 2007, the performance metrics and their  associated standards were designed to measure, on a monthly basis, the   1-800-MEDICARE contractor’s ability to ensure callers can access services  and to determine the contractor’s award fee during each evaluation period,  which occur three times a year. The metrics, described below in table 1,  are: (1) the average wait time (also referred to by CMS as the average  speed of answer), (2) the percentage of unhandled CSR calls, and (3) the  percentage of transfers.
Average wait time. The 1-800-MEDICARE contractor met the overall  monthly average wait time performance standard—between 5 minutes and  8 minutes, 30 seconds each month—in 12 of the 13 months (from July 2007  through July 2008) we analyzed and, because of a waiver granted by CMS,  was considered by the agency to have met the relevant standard in all   13 months. (See fig. 4.) CMS granted the waiver for one month’s wait time  standard for multiple reasons, including to account for the interruption of  normal 1-800-MEDICARE contact center operations because of flooding in  the Midwest. During the 13-month period we studied, the average wait  time ranged from a low of less than 6 minutes in July 2008 to a high of  more than 8 minutes in September 2007. For the 5 months (October 2007  to February 2008) encompassing the most recent annual coordinated  election period and a portion of the open enrollment period—when call  volume to 1-800-MEDICARE typically increases—the contractor’s monthly  average wait time for all calls was between 6 minutes, 30 seconds and   7 minutes.
CMS’s monthly average wait time standard during the time period we  analyzed allowed longer wait times than were typical at two of the four  federal agencies we interviewed that use this metric for their contact  centers. These two agencies used average wait time as a performance  metric, with performance standards ranging from 4 minutes, 30 seconds to  5 minutes, 30 seconds. CMS officials said they recognized that the 1-800- MEDICARE average wait time performance standard was long, but said  that they selected it based on what could be reasonably achieved within  the current budgeted amount available for the 1-800-MEDICARE contract.  CMS officials also said that they believed that the budget would not allow  for a standard that was more comparable to standards used in the contact  center industry. However, CMS officials reported that in August 2008, they  began requiring the contractor to meet an average wait time standard of  between 1 minute and 5 minutes. CMS officials said that in order to better  serve callers, they and the 1-800-MEDICARE contractor implemented  processes and improved technologies that have increased the efficiency of  the help line. For example, CMS and the contractor implemented new  staffing initiatives to ensure that 1-800-MEDICARE has the necessary CSRs  available to answer calls.
Unhandled CSR call rate. The 1-800-MEDICARE contractor met its  unhandled CSR call rate standard, keeping the number of unhandled calls  within the required standards, in 11 of the 13 months we analyzed and,  because of a waiver granted by CMS, was considered by the agency to  have met the standard in 12 of 13 months. (See table 2 below.) The  unhandled CSR call metric provides CMS with data on the extent to which  callers abandon their calls while waiting for a CSR to answer the call, and  CMS officials said that they expect the number of abandoned calls to  decrease with shorter average wait times. CMS granted the waiver for  one month’s unhandled CSR call rate standard because of changes during  that month in its expectations of the contractor’s performance. Though the  performance metric standard was not changed, CMS encouraged the  contractor to keep its average wait time below 8 minutes. To do this, the  contractor increased the number of callbacks—instances in which callers  are called back within 48 hours rather than remaining on hold. Because  CMS includes callbacks in the unhandled CSR call metric, in this month  the contractor exceeded the unhandled CSR call standard. An expert in  federal call centers indicated that the unhandled call rate standard used by  CMS was high compared to some other federal agencies, but that these  performance standards are usually based on what level of service an  agency can afford to purchase with its contact center budget.
Transfer rate. Transfers from one CSR to another occurred for no more  than 20 percent of calls in each of the 13 months of data we analyzed,  meeting the contractually required performance standard. While CMS  officials said that they expect some transfers to occur normally, they also  said a monthly transfer rate that exceeds 20 percent may imply that CSRs  are inappropriately transferring callers. CSRs transferred nearly 13 percent  of calls in July 2007, but the transfer rate increased to just under   20 percent by October 2007. Since October 2007, the transfer rate has  generally decreased, with the lowest percentage of transferred calls of the  10 months we studied occurring in June 2008. (See fig. 5.)
CSRs can transfer calls to other CSRs for various reasons, including  transferring a call from a Tier 1 CSR to a Tier 2 CSR if the complexity of a  caller’s inquiry requires a greater degree of training. According to CMS  officials, most transfers occur between Tier 1 and Tier 2 CSRs, although  transfers can also occur between two Tier 1 CSRs. For example, a caller  may have a general Medicare inquiry answered initially by a Tier 1 CSR,  but then raise a claims-related inquiry that may be better answered by  another Tier 1 CSR with additional training.
section_title: The Current 1-800- Medicare Contractor Consistently Met Performance Targets for One of Three Monthly Access-Related Performance Indicators
paragraphs: In addition to the three required performance metrics, CMS also  established several performance indicators and associated targets for the  1-800-MEDICARE contractor to meet in order to receive a portion of its  award fee. Three of the indicators are particularly related to callers’  telephone access: (1) the average amount of time CSRs spend assisting  callers, referred to as average handle time; (2) agent occupancy—the  percentage of CSRs answering calls; and (3) forecasting of call volume  going to CSRs. (See table 3 for more information on these selected  performance indicators.)
The 1-800-MEDICARE contractor met its performance target in each of the  13 months between July 2007 through July 2008 for one performance  indicator—agent occupancy—but had varying experience in meeting its  targets for the average handle time and CSR call volume forecasting.
For agent occupancy, the 1-800-MEDICARE contractor met its  performance target—to have 80 percent or more of its CSRs answering  calls—in each of the 13 months of data we analyzed. During these   13 months, the 1-800-MEDICARE contractor’s agent occupancy ranged  from 83 percent to 89 percent.
For average handle time, the 1-800-MEDICARE contractor did not meet its  performance target—most recently set at 8 minutes—in any of the   13 months analyzed. Average handle time peaked in December 2007 at   11 minutes, 18 seconds and then decreased each month, reaching an  average handle time of 8 minutes, 59 seconds in July 2008. CMS officials  said that, because there are many factors that could affect call length, they  consider average handle time in conjunction with other metrics and  indicators to determine if the contractor is managing CSRs’ time  effectively.
The 1-800-MEDICARE contractor met its CSR call volume forecasting  target—having a variance of less than 10 percent between its forecasted  CSR call volume and actual CSR call volume—in 4 of the 13 months of  data we analyzed.
section_title: Callers’ Average Wait Times during the Current Contract Period Varied by Type and Complexity of Inquiry
paragraphs: During the current contract period, callers with claims inquiries or  complex inquiries who needed assistance from a Tier 2 CSR generally  experienced longer wait times than other callers. Although the current   1-800-MEDICARE contract does not have an average wait time metric or  indicator specifically related to the type of call, CMS’s evaluation reports  have noted that the agency expected the contractor to manage wait times  by type of call to ensure that a caller with a claims inquiry does not wait  longer than a caller with a general Medicare inquiry.
Wait times varied by type of call. Callers waited, on average, less time  to have general Medicare inquiries answered than to have calls about  claims inquiries answered in all but 1 of the 11 months we analyzed under  the current contract. During that month—December 2007—the difference  between wait times for these two types of calls was 1 second. (See fig. 6.)  During the time period we reviewed—ending July 2008—callers with  general Medicare inquiries waited between 5 minutes and 8 minutes,   30 seconds on average—a time that matches the performance standard for  all calls during that period—in 10 of the 11 months we analyzed. In  contrast, claims callers were within that range in only 5 of the 11 months  with the longest waits in the first two months of this period—almost   18 minutes in September 2007 and just over 11 minutes in October 2007. In  September 2007, about 48 percent of callers disconnected before a CSR  could answer their calls. Beginning in November 2007 and continuing  through July 2008, average wait times for callers with claims inquiries  were more closely aligned with that of callers with general Medicare  inquiries. (For more information on differences in average wait times by  type of claims call, see app. II.)
Wait times varied by complexity of calls. Between September 2007 and  July 2008, callers generally waited longer, on average, to speak with a Tier  2 CSR—a CSR with additional training to respond to more complex calls— than to speak with a Tier 1 CSR. (See fig. 7.) The average wait time for a  Tier 1 CSR was between 5 minutes and 8 minutes, 30 seconds—a time that  matched the performance standard for all calls during that period—in   10 of 11 months we reviewed. In contrast, callers waited more than   8 minutes, 30 seconds to speak with a Tier 2 CSR in 5 of 11 months we  reviewed. During the first two months of this period, the average wait time  for callers needing to speak with a Tier 2 CSR was much longer—more  than 12 minutes in September 2007 and 9 minutes in October 2007.  Beginning in November 2007 through July 2008, average wait times for  callers needing to speak to a Tier 2 CSR were more closely aligned with  that of callers needing to speak to a Tier 1 CSR. (For more information on  differences in average wait times by complexity of inquiry, see app. II.)
section_title: Since Late 2005, Callers’ Average Wait Times Have Increased
paragraphs: CMS’s performance standards for caller wait times have varied since  December 2005, and, since that time, callers have waited longer, on  average, to have their calls answered by a CSR. (See fig. 8.) The varying  performance standards have allowed for a very short caller wait time, such  as requiring 80 percent of calls to be answered in 30 seconds, while at  other times allowing for a longer wait time, such as requiring that   80 percent of calls be answered in 10 minutes. During the current contract  period, CMS’s performance standards have consistently allowed for a  longer average caller wait time. From December 2005 to October 2006,  when two contractors operated 1-800-MEDICARE, the average wait time in  8 of 11 months was below 5 minutes—the minimum average wait time  standard under the current contract period through July 2008. During the  transition period of the current 1-800-MEDICARE contract, October 30,  2006 through May 31, 2007, the average wait time ranged from a low of   2 minutes, 6 seconds to a high of 10 minutes, 22 seconds. From the end of  the transition period through July 2008, the monthly average wait times  have been at or above 6 minutes, 30 seconds in all but one month, though  they have not varied as widely as in prior periods we reviewed.
section_title: Efforts to Provide LEP Callers Access to 1-800-MEDICARE Have Led to Shorter Wait Times for Spanish-speaking Callers, on Average, but Are Not Consistent with All LEP Plan Elements
paragraphs: CMS has made efforts to provide LEP callers with access to services  through 1-800-MEDICARE by requiring the contractor to provide services  in either English or Spanish and to provide interpretation services for  callers speaking other languages. To meet these requirements, the  contractor uses CSRs who are bilingual in English and Spanish and a  telephone interpretation service to assist callers who speak other  languages. Spanish-speaking callers waited less time on average to reach a  CSR than their English-speaking counterparts in almost two-thirds of the  months we reviewed—from December 2005 through July 2008. Officials  from the Office of Beneficiary Services (OBIS)—the CMS office with  primary responsibility for 1-800-MEDICARE—said they were not aware of  the HHS LEP Plan when awarding and assigning the current 1-800- MEDICARE contract and CMS has not identified an office responsible for  acting as a point of contact for its management of the LEP Plan.  Nonetheless, steps CMS has taken to provide services to LEP callers are  consistent with some elements of the HHS LEP Plan adopted by the  agency without modification, such as the element related to oral language  assistance, but not others, such as the Plan’s element for assessing quality  and accessibility, which identifies the need for complaint mechanisms for  language issues.
subsections: section_title: 1-800-MEDICARE Provides LEP Callers with Access to Services and Spanish- speaking Callers Frequently Experience Shorter Average Wait Times to Reach a CSR than English-speaking Callers
paragraphs: As required by CMS, the 1-800-MEDICARE contractor provides callers  with service in either English or Spanish and provides interpretation  services for callers speaking other languages. The 1-800-MEDICARE  contractor uses CSRs who are bilingual in English and Spanish to provide  services to Spanish-speaking callers. As of January 1, 2008, slightly more  than 7 percent of all CSRs at 1-800-MEDICARE were bilingual. Bilingual  CSRs complete the same training required of CSRs who are not bilingual  and must successfully handle test calls in both English and Spanish prior  to answering 1-800-MEDICARE calls. Like CSRs who speak only English,  bilingual CSRs use scripts, translated into Spanish, to provide assistance  to callers.
To meet CMS’s requirement that the contractor ensure “real-time phone  translations” for callers who speak neither English nor Spanish, the 1-800  contractor subcontracts with a “language line”—a telephone interpretation  service. Through this language line, English-speaking CSRs have access to  interpretation services in more than 150 languages. According to the 1-800- MEDICARE contractor, the language line provider uses internal  certification and assessment to assure the quality of its interpreters. The  number of languages for which CSRs have requested assistance has  increased over time, from 40 languages in 2005 to 73 as of March 2008. The  language line also is used to provide interpretation services for Spanish- speaking callers if the wait for a bilingual CSR exceeds 20 minutes. In  these cases, Spanish-speaking callers are transferred to non-Spanish- speaking CSRs who then use the language line to assist these callers.  According to CMS officials, the cost of language line interpreters and the  additional length of time required to connect and handle the call using the  language line increases the costs of these calls. Calls needing Spanish  interpretation accounted for the majority of calls to the language line  during the time period we reviewed, growing from 60 percent of all calls to  the line in 2005 to 80 percent of all calls in 2007. However, while the use of  the language line for Spanish interpretation has increased, in most months  we reviewed more than 90 percent of all Spanish-speaking callers to 1-800- MEDICARE were assisted by bilingual 1-800-MEDICARE CSRs.
Spanish-speaking callers who speak with bilingual CSRs frequently  experienced shorter average monthly wait times to reach a CSR than their  English-speaking counterparts. (See fig. 9.) Spanish-speaking callers  waited less time, on average, in slightly more than 60 percent of the  months we reviewed (20 of 32), which encompassed parts of both the  prior and current contract.
While the current 1-800-MEDICARE contract does not have metrics  specifically focused on call language, the average wait time experienced  by Spanish-speaking callers under the current contract, beginning at the  end of October 2006, was consistent with CMS’s performance standard for  overall average caller wait times as of July 2008 in almost two-thirds of the  months we reviewed. However, Spanish-speaking callers have recently  waited slightly longer, on average, than their English-speaking  counterparts. In addition, while Spanish-speaking callers with simple  claims inquiries have experienced shorter average wait times than English- speaking callers, they have waited, on average, longer for all general  Medicare inquiries and more complex claims inquiries. (For more  information on differences in average wait times by caller language, see  app. II.)
section_title: CMS Did Not Consider the LEP Plan When Determining Service Provision, Although Steps Taken Are Consistent with Some Plan Elements
paragraphs: Officials from OBIS—the CMS office with primary responsibility for 1-800- MEDICARE—said they were not aware of the LEP Plan when awarding  and assigning the current contract for operation of the help line. Rather,  they relied primarily on industry best practices when determining how to  require the 1-800-MEDICARE contractor to provide LEP services. In  addition, while officials from HHS’s OCR and CMS’s OEOCR said CMS  chose to adopt the HHS LEP Plan as issued—although HHS allowed its  agencies flexibility to modify it—officials from multiple CMS offices were  unable to identify an office or official responsible for acting as the central  point of contact responsible for the agency’s management of the Plan. A  key factor in meeting standards for internal control in federal agencies is  defining and assigning key areas of authority and responsibility—such as a  point of contact for an agency-wide plan—and communicating that  information throughout the organization. Without an office or official  responsible for management of the Plan, staff lack a source of guidance  that could assist them in taking steps consistent with the Plan to provide  services to people with LEP.
Although CMS officials did not consider the LEP Plan when determining  how services for LEP callers to 1-800-MEDICARE would be provided,  steps they have taken to implement language services are consistent with  some—but not all—elements of the Plan. In particular, by requiring its  contractor to provide services to all LEP callers, CMS has taken a step  consistent with the LEP Plan element stating that “each agency, program,  and activity… will arrange for the provision of oral language assistance in  response to the needs of LEP customers, both in face-to-face and  telephone encounters.” In addition, the LEP Plan states that agencies,  activities, and programs will implement mechanisms to assess the LEP  status and needs of current and potential customers. To do this, CMS  officials said they and the contractor regularly review the frequency with  which LEP callers contact the 1-800 line to determine appropriate bilingual  CSR staffing levels. In addition, CMS officials noted that this information  could be used to determine whether CSRs who speak languages other than  English and Spanish should be made available to callers.
However, CMS has not taken steps consistent with other Plan elements  related to 1-800-MEDICARE. For example, CMS officials did not identify,  and did not require the contractor to identify, a specific official or office to  allow LEP callers to register concerns or complaints regarding language  assistance services provided by 1-800-MEDICARE, as indicated by the LEP  Plan element for assessing accessibility and quality. In addition, while  CMS considers the number and languages of LEP callers currently using   1-800-MEDICARE, consistent with the LEP Plan’s element related to the  assessment of needs and capacity, neither the number nor proportion of  Medicare-eligible or Medicare-enrolled LEP beneficiaries is specifically  considered when planning how 1-800-MEDICARE language services will  be provided. The LEP Plan also directs agencies to develop policies and  procedures for each Plan element, to designate staff responsible for  implementing these policies and procedures, and to provide staff with  training on them. However, given that CMS staff within OBIS were not  aware of the existence of the LEP Plan until our review, no uniform CMS  policies and procedures had been used to implement any elements of the  LEP Plan for 1-800-MEDICARE, nor had training specific to the LEP Plan  occurred.
section_title: CMS Uses Common Management Practices to Oversee Callers’ Access to Services and to Accurate Information from 1-800- MEDICARE
paragraphs: CMS uses all six of the management practices we identified as commonly  used by contact centers to oversee 1-800-MEDICARE callers’ access to  services and to accurate information. (See table 4 for a description of  these six common oversight practices.) These practices are addressed in  the current 1-800-MEDICARE contract and reflected in CMS’s ongoing  oversight of the help line. For example, CMS awarded some of the  available award fee to the 1-800-MEDICARE contractor for meeting certain  performance metrics and used CSR feedback to improve the oversight of  information CSRs provide to beneficiaries. In addition, CMS used  customer satisfaction surveys to identify areas for improvement, including  the IVR, and worked with the contractor to improve call volume  forecasting in an effort to ensure appropriate staffing levels to meet  callers’ needs.
Clearly defining performance metrics and indicators. The  performance metrics and indicators that CMS officials said they designed  to encourage improved performance and correct identified problems are  clearly defined in the 1-800-MEDICARE contract. The current 1-800- MEDICARE contract identifies each metric and indicator, provides a  definition for these measures, and sets a standard or target for each  measure. CMS uses these measures to evaluate contractor performance  three times a year and to provide an award fee if the contractor performs  at or above set levels. Because the contractor did not meet all standards  and targets for any evaluation period as of May 2008, CMS has awarded  only part of the possible award fee to date, in accordance with the award  guidance in the 1-800-MEDICARE contract. Award fees are based on a  scoring system, in which a percentage of the award fee is distributed  depending on CMS’s rating of the contractor’s performance, ranging from  the lowest rating, substandard, to the highest rating, superior. CMS rated  the contractor as good or very good from the start of the current contract  through May 2008.
CMS also uses the performance metrics and indicators on a continuous  basis to monitor and evaluate callers’ ability to access information from   1-800-MEDICARE. For example, CMS officials said they receive updates  from the contractor on the average wait times—a measure of caller  access—through daily e-mails. If callers’ average wait time exceeds   5 minutes, CMS officials receive e-mail notification every half hour. During  that time, CMS officials said the contractor also notifies them of actions it  is taking to improve caller wait times.
Customer satisfaction surveys. CMS officials said they use the results  of customer satisfaction surveys to gain insight into callers’ experiences  with 1-800-MEDICARE services and to identify opportunities for  improving services. In June 2008, the TQC contractor assumed  responsibility for conducting a customer satisfaction survey of 20 percent  of randomly selected 1-800-MEDICARE callers. The TQC contractor will  provide CMS with the results from this survey on an ongoing basis;  however, initial results were not available as of May 2008. Prior to June  2008, CMS required the 1-800-MEDICARE contractor to call back  randomly selected beneficiaries who contacted 1-800-MEDICARE and  administer a customer satisfaction survey developed by CMS. CMS  officials said they used the information from the surveys to make changes  to 1-800-MEDICARE. For example, based on survey participant concerns  about the IVR, which is used by 18 to 20 percent of callers to resolve their  inquiries, CMS officials indicated they made changes to the IVR prompts to  make them easier to follow. CMS officials said that they anticipate future  callers to 1-800-MEDICARE will be more willing to use technologies such  as the IVR to obtain information. However, as of November 2008, only  limited testing and focus groups had been conducted to confirm this  anticipated trend.
Ensuring accurate information. To ensure that beneficiaries receive  consistent and accurate program information, CSRs are required to use  scripts approved by the agency and CMS, and contractor officials reported  taking steps designed to make correct scripts easier for CSRs to identify  and to make scripts easier to understand. In April 2008, the TQC  contractor began developing content for 1-800-MEDICARE scripts, which  previously had been developed by the 1-800-MEDICARE contractor and  reviewed by CMS. The TQC contractor employs staff with expertise in  Medicare who develop and revise scripts as needed. CMS reviews and  approves all scripts before making them available to CSRs. According to  CMS officials, in August 2008 the TQC contractor began quarterly script  reviews for accuracy as well as legislative, program, or policy changes. In  addition to reviews conducted by the TQC contractor, CMS officials said  that they have used the results of customer satisfaction surveys and call  evaluations to assess how well scripts meet the needs of callers and how  easy scripts are for CSRs to find. CMS can also access a computer  application that captures CSR feedback on scripts, including how easy  scripts are to understand, an issue identified in previous GAO work.
Evaluating CSR interaction with callers. To assess whether callers  receive consistent and accurate information from 1-800-MEDICARE, CMS  requires both the 1-800-MEDICARE contractor and the TQC contractor to  evaluate CSRs’ interactions with callers through call monitoring. The   1-800-MEDICARE contractor listens to four calls a month for each CSR,  evaluating the CSRs’ performance on customer service skills identified by  CMS, including tone, using scripts appropriately, and completeness of  information provided. CMS officials said they designed the 1-800- MEDICARE contractor’s call evaluation process for contractor supervisors  to coach CSRs on their performance and to help improve CSRs’ ability to  use software to find appropriate scripts. The 1-800-MEDICARE contractor  has reported on the required evaluations monthly. Using these evaluation  reports, CMS officials said, they worked with the 1-800-MEDICARE  contractor to identify and correct trends or issues with scripts, software,  or CSR training. For example, CMS used the call evaluation process to  determine the reasons why callers may need to be transferred to a more  experienced CSR or place another call to 1-800-MEDICARE. This analysis  was part of the “First Call Resolution Initiative,” an effort to increase the  number of callers who have their inquiries resolved with one phone call  rather than many. However, in its evaluation of the 1-800-MEDICARE  contractor for the period ending May 2008, CMS reported that it observed  callers receiving poor service from CSRs who received perfect call  evaluation scores from the 1-800-MEDICARE contractor for those calls.  CMS noted the 1-800-MEDICARE contractor needed to improve  consistency between actual CSR call evaluation scores and the quality of  service callers receive.
In addition, since April 1, 2008, CMS has required the TQC contractor each  month to monitor and evaluate 600 randomly selected calls in English and  225 randomly selected calls in Spanish. This call sample is designed to  allow CMS to generalize trends that emerge from this sample to the call  volume of 1-800-MEDICARE as a whole. CMS officials said they anticipate  analyzing any trends identified from this call monitoring to note areas for  improvement to the 1-800-MEDICARE help line. CMS officials also said  that they will use the results of the TQC scores as part of the 1-800- MEDICARE contractor’s regular performance evaluation and resulting  award payment beginning in October 2008. In addition, CMS officials  reported monitoring calls themselves and meeting weekly with the 1-800- MEDICARE and TQC contractors to listen to and rate recorded calls as a  group. CMS officials said that these meetings help to ensure that the  contractors understand the standard of service CMS expects callers to  receive. CMS officials also planned to perform similar evaluations on calls  for which customer satisfaction survey information is available—a  practice identified by an industry expert as a method to improve contact  center service.
Capacity planning. CMS officials said they work with the 1-800- MEDICARE contractor to create short- and long-term call volume  forecasts and to determine whether systems and staffing can handle call  volume, taking into account Medicare’s annual coordinated election and  open enrollment periods when inquiries peak. CMS requires the 1-800- MEDICARE contractor to produce call volume forecasts that are accurate  within 10 percent of actual call volumes for the forecasted period. CMS  oversight of the contractor’s forecasting efforts has identified significant  differences between the long-term forecasts and actual monthly volume of  calls going to CSRs—forecasting up to 35 percent more calls than were  actually received by CSRs for the performance period ending January 2008  and causing projected staffing costs for this period to be overstated. In its  evaluation of the performance period ending January 2008, CMS notified  the contractor that performance in this area needed to improve and stated  that it wanted the contractor to identify methods of ensuring consistent  and accurate forecasts. However, CMS noted that when the forecasted call  volume was not realized, the 1-800-MEDICARE contractor adjusted its  staffing so that only the number of CSRs needed to meet the performance  standard related to average wait times were available. In its evaluation for  the period ending May 2008, CMS noted a significant improvement in long- term forecasting and indicated that the 1-800-MEDICARE contractor had a  better understanding of events that affected call volume throughout the  year.
To ensure that 1-800-MEDICARE systems, such as phone lines and  desktop software, are available to handle forecasted call volumes, CMS  requires the 1-800-MEDICARE contractor to notify the agency of systems  outage incidents that affect callers’ access. In the evaluation period ending  January 2008, CMS identified inconsistencies in the outage reporting  process, which caused key information to be omitted from reports about  systems outage incidents. In its evaluation for the period ending May 2008,  CMS noted some improvement in reporting systems outage incidents, but  indicated that the 1-800-MEDICARE contractor needed to improve the  consistency of its reporting practices in the future. CMS officials said they  are working with the contractor to address this issue and reported  finalizing a process for reporting systems outages in early November 2008.
Validation of contractor reports. CMS officials said they validate  contractor reports—many of which are used to determine contract award  fees—by analyzing data captured by 1-800-MEDICARE computer systems  and having regular meetings with their contractors. To ensure the integrity  of data collected by 1-800-MEDICARE systems, CMS collects and stores  these data in the NDW, which is managed by a separate contractor. CMS  officials compare data from the NDW on the actual call center  performance to reports submitted by the 1-800-MEDICARE contractor,  such as the long-term call volume forecasts. Using this method of  validating reports, CMS determined that the 1-800-MEDICARE contractor’s  forecasting reports were inaccurate and required the contractor to  improve in this area, which the contractor did over the next evaluation  period. In addition to validating contractor reports through the NDW, CMS  officials said they used weekly and monthly status reports, meetings with  contractors, and visits to 1-800-MEDICARE contractor sites to monitor  contractor performance between periodic evaluations.
section_title: Conclusions
paragraphs: To date, the current 1-800-MEDICARE contractor has met most of CMS’s  performance standards and some of the performance targets designed to  ensure callers’ access to services from the help line. In addition, by  employing all six commonly used management practices to oversee 1-800- MEDICARE callers’ access to services and accurate information, CMS  gains valuable data to assess the contractor’s performance and identify  areas for improvement. In particular, the new TQC contract provides CMS  with an opportunity to continue to improve both access to, and accuracy  of, information.
However, while callers with LEP can access services through 1-800- MEDICARE, CMS has not taken steps to ensure that officials throughout  the agency, including within OBIS, are fully aware of the LEP Plan, which  HHS designed to be a “road map” for providing appropriate services to this  population. By not identifying an official point of contact responsible for  management of the Plan, CMS is lacking a key internal control measure—a  clearly defined area of responsibility that has been communicated  agencywide. While CMS has taken steps to ensure access for LEP callers  to 1-800-MEDICARE, a clearly identified office or official responsible for  the Plan could provide guidance in areas where steps consistent with the  LEP Plan have not been taken and could work to ensure consistent use of  the Plan across the agency.
section_title: Recommendation for Executive Action
paragraphs: To ensure CMS offices, including those that oversee the operation of the   1-800-MEDICARE help line are aware of, and take steps consistent with,  the HHS LEP Plan when considering the needs of people with LEP, CMS  should designate an official or office with responsibility for managing the  LEP Plan.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided CMS with a draft of this report for its review and comment.  The agency provided written comments, which we addressed as  appropriate and which have been reprinted in appendix III. The current   1-800-MEDICARE contractor stated that the report was factually accurate  and provided oral technical comments, which we incorporated as  appropriate. The Social Security Administration and the departments of  Defense, Education, and Treasury told us they had no comments on the  draft report.
In responding to our draft, CMS stated that it has taken steps to implement  our recommendation. More specifically, CMS has identified an official  responsible for the development of an LEP Plan for the agency that, when  finalized, is intended to define responsibility for ensuring consistent and  reliable LEP tracking and reporting. CMS also noted that the report  identified issues related to accurate forecasts and wait times experienced  by callers for general Medicare and claims calls. The agency reiterated that  these issues were affected by the transition, completed in 2007, of claims  calls previously answered by FFS contractors to 1-800-MEDICARE. CMS  also stated that its intent is to try to fully answer callers’ questions rather  than focusing exclusively on reducing average handle time—the average  amount of time CSRs take to respond to callers’ inquiries. Additionally,  CMS stated that while it has not specifically evaluated the number or  proportion of LEP beneficiaries who are Medicare eligible and enrolled, it  continues to review demand and consider other opportunities to best  serve LEP callers. Finally, CMS noted that some information regarding the  1-800-MEDICARE contractor’s operations and contract with the agency  are considered proprietary.
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If you or your staff have any questions about this report, please contact me  at (202) 512-7114 or at kingk@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. GAO staff who made major contributions to this report are  listed in appendix IV.
section_title: Appendix I: Elements of the Department of Health and Human Services’ Limited English Proficiency Plan
paragraphs: Appendix I: Elements of the Department of  Health and Human Services’ Limited English  Proficiency Plan “Each agency, program, and activity of the HHS [Department of Health and Human  Services] will have in place mechanisms to assess, on a regular and consistent basis, the  LEP  status and language assistance needs of current and  potential customers, as well as mechanisms to assess the agency’s capacity to meet  these needs according to the elements of this  plan.”  “Each agency, program, and activity of HHS will arrange for the provision of oral language  assistance in response to the needs of LEP customers, in both face-to-face and by  telephone encounters.”  “Each agency, program, and activity of HHS will provide vital documents in languages  other than English where a significant number or percentage of the customers served or  eligible to be served has . These written materials may include paper and electronic  documents such as publications, notices, correspondence, web sites and signs.”  “Each agency, program, and activity of HHS will have in place specific written policies and  procedures related to each of the plan elements and designated staff who will be  responsible for implementing activities related to these policies.”  “Each agency, program, and activity of HHS will proactively inform LEP customers of the  availability of free language assistance services through both oral and written notice, in his  or her primary language.”  “Each agency, program, and activity of HHS will train front-line and managerial staff on the  policies and procedures of its language assistance activities.”  “Each agency, program, and activity of HHS will institute procedures to assess the  accessibility and quality of language assistance activities for LEP customers.”
section_title: Appendix II: Average Caller Wait Time by Type and Complexity of Call and Language of Caller, September 2007 through July 2008
paragraphs: This appendix provides more detailed information on the average wait  times experienced by callers depending on the type of inquiry—general  Medicare and claims—and complexity of their call or the language in  which they need assistance for the period September 2007 through July  2008 of the current contract.
subsections: section_title: Wait Times by Type and Complexity of Calls
paragraphs: Figures 10 and 11 provide information on differences in average wait times  experienced by callers depending on their type of inquiry—general  Medicare and claims—and the complexity of their inquiry. While simple  inquiries may be resolved by Tier 1 CSRs, inquiries of greater complexity  may require the assistance of a Tier 2 CSR. Figures 12 through 14 compare  the wait times for callers with simple inquiries to callers with complex  inquiries by type of claims inquiry—Medicare Part A, Part B, and, within  Part B, durable medical equipment (DME).
section_title: Wait Times by Language of Caller
paragraphs: Figures 15 through 18 provide information on differences in average wait  times experienced by callers depending on the language in which they are  assisted. The information provided compares the wait times of English-  and Spanish-speaking callers for each type of inquiry, by complexity level.
section_title: Appendix III: Comments from the Centers for Medicare & Medicaid Services
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: Acknowledgments
paragraphs: In addition to the person named above, Karen Doran, Assistant Director;  Jennie F. Apter; Hernan Bozzolo; Eleanor M. Cambridge; Emily R. Gamble  Gardiner; Barbara A. Hills; Martha R.W. Kelly; Ba Lin; Lisa S. Rogers; and  Hemi Tewarson made key contributions to this report.
section_title: Related GAO Products
subsections: section_title: Federal Contact Center Reports
paragraphs: Tax Administration: 2007 Filing Season Continues Trend of  Improvement, but Opportunities to Reduce Costs and Increase Tax  Compliance Should be Evaluated. GAO 08 38. Washington, D.C.: -- November 15, 2007.
Tax Administration: Most Filing Season Services Continue to Improve,  but Opportunities Exist for Additional Savings. GAO 07 27. Washington, -- D.C.: November 15, 2006.
Federal Contact Centers: Mechanisms for Sharing Metrics and Oversight  Practices along with Improved Data Needed. GAO 06 270. Washington, -- D.C.: February 8, 2006.
Tax Administration: IRS Improved Some Filing Season Services, but  Long-term Goals Would Help Manage Strategic Trade-offs. GAO 06 51-- Washington, D.C.: November 14, 2005. .
Social Security Administration: Additional Actions Needed in Ongoing  Efforts to Improve 800-Number Service. GAO 05 735. Washington, D.C.: -- August 8, 2005.
Immigration Services: Better Contracting Practices Needed at Call  Centers. GAO 05 526. Washington, D.C.: June 30, 2005. -- Tax Administration: IRS Improved Performance in the 2004 Filing  Season, But Better Data on the Quality of Some Services Are Needed.  GAO 05 67. Washington, D.C.: November 15, 2004. -- Tax Administration: IRS Needs to Further Refine Its Tax Filing Season  Performance Measures. GAO 03 143. Washington, D.C.: November 22, -- 2002.
IRS Telephone Assistance: Limited Progress and Missed Opportunities  to Analyze Performance in the 2001 Filing Season. GAO 02 212. -- Washington, D.C.: December 7, 2001.