Have a Medicare policy question? Carriers usually give wrong answers

Washington Medicare carrier call centers could become the last place physicians want to go to have their billing questions answered after a recent government report showed that the centers' already dismal accuracy rate has dropped over the past couple of years.

Physicians, many of whom feel that federal officials constantly look over doctors' shoulders for any Medicare claims that hint of fraud or abuse, are unlikely to find solace in the Government Accountability Office's findings.

For the study, the GAO posed four questions to Medicare carrier phone banks about how to bill the program properly. In the 300 test calls, customer service representatives gave correct and complete responses only 4% of the time, and more than half the time the answers were simply wrong.

"While the Medicare call centers' inability to correctly answer physicians' questions is troubling, sadly it is not surprising," said J. James Rohack, MD, chair of the American Medical Association Board of Trustees.

The report follows up on a survey conducted almost two years ago that found call centers answered questions correctly only about 15% of the time.

"It's a well-known fact that they're often wrong," said Mary Jean Sage, a practice management consultant with Sage Associates in Arroyo Grande, Calif.

The problem of wrong answers appears to be so persistent and pervasive that most physicians have given up on the call centers, some experts said.

The report states that both the Centers for Medicare & Medicaid Services and the carriers are doing a poor job of monitoring the call centers. CMS officials have been actively seeking anecdotal information as part of efforts to reform the centers but have been unable to find examples of bad billing advice.

That is because only 5% of the 21 million calls fielded during fiscal year 2003 and the estimated 28 million in fiscal 2004 involve policy questions. This makes assessing the quality of call centers' policy answers difficult to do in a systematic way, CMS said.

The other 95% of calls the phone banks receive are to check on Medicare beneficiaries' eligibility or the status of claims. Those queries are simple enough that in 2001 CMS required call centers to automate the process. More than half of those types of questions are now handled by interactive voice response computers.

But when talking to human operators, physicians are less likely to receive satisfaction for questions related to billing rules, covered services and medical policies. Finding out exactly why a claim was rejected is also hit or miss, the GAO concluded.

"The GAO report confirms longstanding complaints from physicians about the lack of clear and reliable guidance on complex Medicare policy questions," Dr. Rohack said.

Investigators found several other reasons why the call centers had such low accuracy rates.

For example, CMS comes under criticism for providing call takers with a fragmented mix of computerized and paper documents to search through for answers. Agency officials, however, respond that the materials have improved over the last couple of years and continue to get better.

The GAO also found that operators are prone to trying to apply, usually unsuccessfully, generic responses to specific questions.

"You can tell when you call, some of these people just don't have a clue about the Medicare program," Sage said. The call centers might be where new employees start out to gain basic experience about the business, she added.

Turnover is high, either because qualified customer service representatives are promoted or resign for a better job, the report states.

A jargon barrier also exists, Sage said. Physicians might be asking the wrong question, or even asking the right question the wrong way.

If operators don't have the right keywords, they might not be experienced enough to know how to look up the relevant information, Sage added.

CMS' reaction

In a response to the report, CMS acknowledged that the low accuracy rate is a problem. Agency officials also said they were taking steps to implement recommendations contained in the report.

The agency plans to create a triage-like system so that billing policy and other technical questions are automatically routed to supervisors or other more experienced call takers who are more likely to be able to answer them correctly.

The agency is also in the process of developing electronic documentation that will be searchable and give operators more reliable and comprehensive access to reference materials.

In addition, after the triage system is implemented, CMS will increase monitoring requirements.