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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. The questions and answers we used to test the accuracy of carrier call center responses to physician inquiries are shown in table 4. 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. Donald Kittler, Victoria Smith, Christi Turner, and Margaret Weber made key contributions to this report.

Summary: 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.