CMS develops regulations and policies to implement the statutory provisions governing the Medicare program, and it communicates the information to providers primarily through its Medicare contractors. The contractors share information with providers through their Web sites, written bulletins, and carrier call centers. To respond to inquiries from providers, carriers operate 34 call centers. Most of the carrier call centers—31 of 34—are “blended,” that is they respond to inquiries from beneficiaries as well as from providers. In most cases, CSRs at “blended” call centers answer calls from both providers and beneficiaries. More than 21 million inquiries were made to carrier call centers in fiscal year 2003. The vast majority of these were “status-oriented” calls. Typically status-oriented calls are relatively simple to answer and involve inquiries concerning the status of a claim or confirmation of an individual’s eligibility for Medicare. Such calls generally do not require CSRs to provide callers with complex information. On the other end of the spectrum are “policy-oriented” questions, which involve more complicated issues, such as billing rules, covered services, and medical policies. The remaining calls include elements of both status-oriented and policy- oriented inquiries. For example, a provider may call to learn why a claim was denied. In some instances, the explanation may be simple, such as the claim form omitted necessary information. In others, the reason for the denial may be more complex and involve an assessment of whether the particular circumstance required to obtain Medicare payment was met. Although CMS requires that carriers report data that categorize calls by type, these categories are not standardized, and carriers differ in the criteria they use to define call type. CMS officials estimate the volume of calls received by CSRs involving policy-oriented questions to have been approximately 500,000 in fiscal year 2003. In fiscal year 2001, CMS required that all carrier call centers install automated voice response systems. The interactive voice response (IVR) unit allows providers to use their telephone keypads to respond to automated prompts and obtain status-oriented information without speaking to CSRs. Use of the IVR has been growing, and in fiscal year 2003, the automated system handled more than 52 percent of provider inquiries answered at carrier call centers. CSRs are available to respond to inquiries that providers believe are beyond the capability of the IVR, including policy-oriented calls. Generally, calls to CSRs are electronically routed by the carriers’ automated systems based on CSR availability. The routing process does not consider the nature and complexity of the question or the expertise of the CSRs. Despite the diversion of many calls to the IVR, CSRs recently experienced an increase in the number of calls that they answer. According to CMS, the number of calls CSRs answered increased from 9 million in fiscal year 2002 to 10 million in fiscal year 2003. CSRs responding to status-oriented calls can typically access the relevant claims or enrollment information to respond to the inquiry. In addition, to assist CSRs, carriers have developed scripted responses to answer standard questions from beneficiaries, such as how to enroll in Medicare. To respond to inquiries from providers, CSRs may use FAQs posted on their carriers’ Web sites. In addition, they may search a variety of other sources, including CMS’s Web sites. If CSRs cannot locate information to respond to a provider’s question, they may arrange to contact the provider—after conferring with a specialist. In addition, CMS requires each carrier to analyze provider inquiry data and develop a list of questions most frequently asked and areas of concern or confusion for providers. They must also tally problem areas identified when providers submit erroneous claims for payment. Each quarter, carriers report the 10 most frequent inquiries and claim submission errors to CMS and update the list of FAQs on their own Web sites. Because the nature of calls may vary by carrier, the types of questions posted on these Web sites may also vary. In addition, some carrier Web sites only list FAQs that are policy related, while others list routine questions about the mechanics of claims submissions and correcting billing errors. Carriers are required to monitor their own call centers and report to CMS on their performance, such as the average time that calls wait before being connected to a CSR and the percentage of provider calls that are abandoned before they reach a CSR. Carriers are also required to listen to, and rate, a selection of CSR calls on customer and knowledge skills, such as the manner in which they greet callers, conduct the call, offer additional assistance at the conclusion of the call, and whether their responses are correct and complete. Through CPEs, CMS also evaluates call center compliance with performance measures it establishes. Recently, CMS piloted remote call monitoring, which allows CMS staff to listen in on provider calls. CMS’s administration of the Medicare program will undergo significant changes over the next several years as the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) is implemented. MMA provides CMS with increased flexibility in contracting with new entities to assist it in operating the Medicare program. Instead of primarily relying on the claims administration contractors to perform most of the key business functions of the program, the law authorizes CMS to enlist a variety of contractors to perform these tasks. For example, the MMA will allow CMS to use new contractors to communicate program information to its providers and deliver provider education and training. CMS is just beginning to develop plans to implement MMA’s contracting reform provisions. Phase-in of certain provisions may begin as early as October 2005, and all carrier and fiscal intermediary contracts are scheduled to end by October 1, 2011. After this date, new contracts must be based on CMS’s new authority. The agency expects to issue its implementation plan for contracting by October 1, 2004. CSRs at the carrier call centers we tested rarely provided correct and complete answers to our policy-oriented questions. Only 4 percent of the responses we received from CSRs were correct and complete. Our test suggested several factors that may account for poor performance, including fragmented information scattered among a variety of sources, confusing information that may be difficult for CSRs to understand and interpret, and difficulties in retaining CSRs. CMS is developing two initiatives that may improve CSRs’ access to information; however, neither of these new tools is designed to provide a comprehensive source of information to support the CSRs who respond to providers’ policy- oriented questions. We found that CSRs provided incorrect, partially correct, or incomplete responses to 96 percent of the 300 policy-oriented test calls we made to carrier call centers. The four questions we posed concerned a variety of circumstances on the proper way to bill Medicare in order to be paid for services rendered. Our questions specifically addressed the following topics: billing for beneficiaries transferred from one hospital to another, billing for services delivered by therapy students, billing for multiple surgeries on the same day, and billing for an office visit and services on the same day. The results of our test, which CMS Medicare coding and policy experts validated, are shown in table 1. Our analysis of CSR responses to test questions and discussions with CMS officials identified several factors that contributed to CSRs’ errors. They include the following: Fragmentation of information: When responding to Medicare inquires from providers, CSRs rely on fragments of information from multiple electronic sources. In addition, many CSRs use printed Medicare program information, including policy changes, which CMS estimates at about 200 per year. For example, at one carrier call center, we observed that CSRs relied on electronic information from CMS and carrier Web sites, along with paper documents, including the Medicare carrier manual, program memorandums, and carrier bulletins. Further, CMS officials told us that the agency does not prepare scripted responses to follow when answering questions from providers as it does for CSRs responding to beneficiaries’ inquiries. During the site visit, we also asked one CSR to demonstrate the process that would typically be followed to answer our four policy-oriented questions. In responding to one of our questions, we observed that this CSR did not have a source of comprehensive information that she could easily access to find the answer to our question. Instead, she accessed multiple information sources, including both electronic materials and paper documents, in an attempt to respond to our question. We further noted, as we toured the call center, that other CSRs also had access to, and appeared to be using, both paper and automated resources as they responded to calls. According to CMS and carrier officials, CSRs have to learn to operate multiple information systems, including CMS’s claims information processing system and carrier developed information system. They also must access other sources, such as carrier or CMS Web sites, to respond to policy-oriented questions. Although CMS required that all CSRs have access to the Internet in fiscal year 2003, some CSRs continue to rely heavily on paper documents because of their familiarity with these materials. During our 300 test calls, CSRs referred us to a total of 13 different information sources when answering our second question regarding billing for services delivered by therapy students. Twelve of the references were either incorrect or did not include all of the information needed to give a correct and complete answer. Our review of the 13th document, which was structured in a question and answer format, included our specific test question but without the complete answer. Fragments of the answer, however, were located earlier in the document. We also found other parts of this answer on a different page, attached to a different but related question. It was evident to us that without reading the entire document, it would be plausible for the CSR to have read the test question and mistakenly given the caller the wrong answer, while assuming that the response given was correct and complete. Confusing information: Some of the information that CSRs must access to respond to policy-oriented questions is difficult to interpret. CMS officials acknowledged that some policies contain complex language.