Government

Medicare carriers to answer faster, better

New CMS rules require contractors to have automated voice response for simple queries and a triage system for tougher ones.

By David Glendinning — Posted Feb. 7, 2005

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Washington -- Physicians who feel that federal officials are too focused on how accurately doctors bill Medicare may be gratified to learn that the government has started taking a closer look at how well its contractors are helping in this process.

As of Jan. 1, Medicare carriers must have in place a "provider customer service program" designed to give the best answers to the myriad types of physician queries that come their way. Congress included the mandate in its 2003 Medicare reform measure after the American Medical Association and other groups complained that program participants too often were having a tough time getting quick, accurate information from contractors.

The first step in solving this problem lies in taking care of the easier questions without involving too much effort from either party, the Centers for Medicare & Medicaid Services states in a September 2004 instruction manual explaining the new requirements. Carriers now must have an automated voice response system set up on their telephone lines that allows physicians to check on the status of a claim, determine eligibility for a patient or obtain definitions for certain types of codes.

For the harder issues, carriers must establish a triage system that quickly routes inquiries to staffers who will be able to give an accurate answer. The more complex questions about Medicare coverage, coding and payment will be directed to specialists who have advanced training in program policy.

If the issue at hand involves a potentially substantial federal reimbursement, however, doctors may want to submit the query in writing so that they receive a written response. Under a separate provision in the Medicare law, participants receiving overpayments based on bad written advice from contractors must still return the overage but are no longer subject to penalties or interest.

Written responses may come back to physicians more quickly than they have in the past under the new requirements. Even the most complex of questions must prompt a full carrier answer within 45 business days.

To give more assistance to smaller physician practices, CMS is requiring carriers to provide special education and outreach to groups with fewer than 25 full-time equivalent employees. In addition, firms must hold quarterly "Ask the Contractor" teleconferences designed to share vital program information and to receive feedback from Medicare participants.

Serious business

Medicare experts who counsel program participants on how to navigate the system are confident that the mandate will bring about tangible improvements in what is often a frustrating process.

"CMS is serious about this," said Dennis M. Barry, a health care attorney with Vinson & Elkins in Washington, D.C. "And when CMS is serious about something, the contractors tend to get the message."

But physicians should not lose sight of the responsibilities that they continue to hold, Barry said.

"Contractors shall educate providers that the [carrier staff members are] not an extension of or a replacement for billing staff," CMS states in its instructions. "The straightforward pure coding questions should be answered with referrals to the correct organizations, such as the American Medical Association and the American Hospital Assn.'s Coding Clinic."

Barry said doctors have the best chance of protecting themselves under the new system if they submit detailed inquiries in writing. In addition to covering the physicians' financial liability if the carriers' information proves to be wrong, such a tactic also helps ensure that no ambiguity exists about what questions the contractors are answering.

Even a modest upswing in the accuracy of information coming from the carriers likely will be a welcome start. The Government Accountability Office reported last August that roughly 96% of telephone inquiries on Medicare billing policy to carrier call centers received incomplete or inaccurate responses.

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External links

Centers for Medicare & Medicaid Services instruction manual to contractors on its provider customer service program, in pdf (link)

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