Medicare's no-help line: Doctors not getting good answers

A report saying Medicare carrier call centers rarely give the correct answer to billing questions highlights the need for Congress to protect physicians from overzealous fraud investigators.

Posted Oct. 4, 2004.

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For years, the AMA has called on Congress to halt abusive enforcement practices by the federal government and refocus its investigations to traditional definitions of fraud rather than inadvertent billing errors. Although the Centers for Medicare & Medicaid Services has assured physicians that their confusion over billing is not a major target for Medicare fraud investigations, honest mistakes are still actionable under the False Claims Act and subject to a civil monetary penalty.

So when it's time for physicians to bill Medicare, it would make sense to clear up any confusion by contacting Medicare call centers to ask for advice, lest a miscoded claim be construed as fraud. Except that, according to a Government Accountability Office study, physicians have only a 4% chance of getting a correct and complete response to their question.

That means 96% of time -- as happened when the GAO ran 300 test calls posing four questions on Medicare billing -- customer service representatives gave answers that were incomplete, only partially correct or completely wrong. That last category -- completely wrong -- made up half of those botched answers, according to the GAO.

Not that this is a new problem. A similar survey two years ago put the correct-answer rate at 15%, which looks downright reliable compared with the current 4%. No wonder AMA Board of Trustees Chair J. James Rohack, MD, responded to the news by saying, "While the Medicare call centers' inability to correctly answer physicians' questions is troubling, sadly, it is not surprising."

Dr. Rohack, in his response to the GAO report, added it "confirms longstanding complaints from physicians about the lack of clear and reliable guidance on complex Medicare policy questions."

In response to the GAO report, CMS says it is going to take some steps to improve its call centers. One such move the CMS plans is to create a triage-like system that would allow customer service representatives to transfer billing questions to a supervisor or a more experienced call-taker. Another move the CMS says it plans is to create a searchable database that customer service representatives can use to find the exact answer to a physician's question, rather than, as often happens, giving a generic response to a complicated query.

While it's laudable that CMS intends to work on these problems, the agency's move would not address the culture of fear that has physicians calling Medicare to make sure they're not unwittingly committing a fraudulent act. Nor, as some consultants say, does it speak to the exasperation from phone system hassles that have physicians not calling Medicare and hoping they didn't unwittingly commit fraud.

Doing away with the culture of fear would require Congress passing a measure that would allow physicians to be exempt from civil penalties if there is no evidence of fraud, or if the physician was given incorrect guidance from CMS. A bill, S 1332, that does just those things is in committee. Intentional and willful fraud is a terrible thing, but it is different than a physician unintentionally miscoding a form.

It's enough of a hassle for physician to have to take time out to call an insurer to check on billing. It's an even bigger hassle, one that veers well into the absurd, when that insurer is almost incapable of giving a precise answer to a physician's question. And it goes beyond hassle and into a threat to livelihood when the inability to give a precise answer could end up getting a physician under federal investigation.

Physicians need protection to make sure an innocent mistake, and an incorrect answer, doesn't turn into a case of fraud.

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