CMS help lines, bulletins offer little help, GAO says

Medicare carriers often provide inaccurate or incomplete responses to physician queries.

By Markian Hawryluk, amednews staff. March 18, 2002.

Washington -- Physicians frustrated with their inability to get straight answers from Medicare can at least take heart that a government watchdog agency feels their pain.

A new report from the General Accounting Office concluded that information given to doctors by Medicare carriers is often difficult to use, out of date, inaccurate or incomplete.

Communication breakdown
Links

"Physicians cannot rely on carrier bulletins, call centers or Web sites to meet their information needs," the GAO said in the report.

Carriers, with whom the Centers for Medicare & Medicaid Services contracts to administer the Medicare program, generally rely on bulletins to communicate program information to physicians. But those bulletins are poorly organized and contain dense language, GAO said.

Carriers are required to issue the bulletins at least quarterly but have wide latitude in how those documents are structured. GAO found that many did not have a table of contents and did not categorize instructions by subject matter, forcing physicians to scan bulletins typically in excess of 50 pages.

In several instances, the documents gave notice of new requirements after their effective date or with too little advance warning for physicians to meet implementation deadlines, the GAO found.

Many physicians have complained about the complexity of the Medicare bulletins and the difficulty of finding the relevant information.

"The bulletin is really not very helpful," said Amilu Rothhammer, MD, a surgeon in Colorado Springs, Colo., and a member of the Dept. of Health and Human Services' Practicing Physicians Advisory Council. "I would guess that one bit of communication that comes by mail is hardly even read by most of the physicians."

Agents without answers

Physicians seeking help from customer service representatives at carrier call centers fared no better. Investigators found that 85% of phone responses were either inaccurate or incomplete. Many physicians told GAO they were frustrated that carriers will not always provide information on how to properly code certain claims.

The report said the contractors had differing policies on providing coding information. Some carriers indicated that their customer service representatives lack the medical expertise to make appropriate coding decisions, or they don't have the physician's clinical documentation in front of them to understand the procedure in its proper context.

In many cases, the carriers ultimately refer doctors to other sources, such as bulletins or regulation numbers, for more specific coding information.

"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," the GAO said.

Some call centers even lacked the basic technology needed to be able to search a database for the issue in question. At those sites, representatives said they relied heavily on their more experienced colleagues for answers, the report stated.

While all carriers now have Web sites, investigators also found that the sites lacked "logical organization and navigation tools." GAO found that only two of the 10 sites examined complied with all CMS requirements.

The GAO blamed much of the problem with carrier communications on insufficient management and oversight by CMS. The agency has established few standards to guide communication efforts, the report noted.

The GAO recommended that CMS adopt a national bulletin for physicians in addition to its plans for a quarterly compendium of new regulations. Carriers could be responsible for preparing supplements to the national bulletin to reflect local medical policy issues, the report said.

CMS should also create new call center performance standards that emphasize providing complete and accurate answers, the GAO suggested. New Web site standards would promote consistency, accuracy and user-friendliness, the report said.

Plans for improvements

Agency officials concurred with a majority of the report's findings and attributed the low level of oversight to a lack of funding.

"We agree that improvement is needed in this area for the agency," CMS Administrator Tom Scully said in a written response to the report. "Many of the observations and suggestions contained through the report represent initiatives CMS would gladly undertake if it had the resources to do so."

The agency already has taken several actions to address physician communication troubles, particularly after the GAO reported similar problems last year. CMS officials said they were taking steps to disseminate through the bulletins articles of national interest. The agency also has instituted new performance standards designed to provide more effective oversight and evaluation of carrier communications.

Physician groups said the report simply bolstered their claims about Medicare's regulatory complexity.

"Medicare holds physicians responsible for deciphering more than 110,000 pages of policies, rules and regulations," said Richard F. Corlin, MD, president of the American Medical Association. "Physicians are held to standards of accuracy that the program's carriers can't begin to meet themselves."

The AMA and other physician organizations said the report underlines the need for the Senate to pass the Medicare regulatory reform bill passed unanimously by the House last year.

"The report substantiates the numerous inadequacies in Medicare carrier communications that are experienced daily by [physician] practices," said William F. Jessee, MD, president and CEO of the Medical Group Management Assn.

Dr. Jessee said the administrative burden that physicians face forces them to divert limited resources from patient care to meet the program's requirements.