Medicare:

Communications with Physicians Can Be Improved

GAO-02-249: Published: Feb 27, 2002. Publicly Released: Feb 27, 2002.

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Unlike other federal programs that make expenditures under the direct control of the government, Medicare constitutes a promise to pay for covered medical services provided to its beneficiaries by about one million providers. Given this open-ended entitlement, it is essential that appropriate and effective rules and policies be specified so that only necessary services are provided and reimbursed. Congress and the Centers for Medicare and Medicaid Services (CMS) have promulgated an extensive body of statutes, regulations, policies, and procedures on what shall be paid for and under what circumstances. Information that carriers give to physicians is often difficult to use, out of date, inaccurate, and incomplete. Medicare bulletins that carriers use to communicate with physicians are often poorly organized and contain dense legal language. Similarly, other means of communicating with physicians, such as toll-free provider assistance lines and websites, have problems with accuracy and completeness. Although all carriers issue bulletins, operate call centers, and maintain websites, each carrier develops its own communications policies and strategies. This approach results in a duplication of effort as well as variations in the quality of carrier communications. CMS provides little technical assistance to help carriers develop effective communication strategies. Neither CMS carrier oversight nor self-monitoring by the carriers is comprehensive enough to provide sufficiently detailed information that could either pinpoint specific communication problems or identify poorly performing carriers. CMS is working to improve its physician communications by consolidating new instructions and regulations and issuing them on a more predictable schedule to lessen the burden of frequent policy changes that physicians cannot anticipate. CMS is also enhancing its education programs for both physicians and carrier staffs and expanding its efforts to obtain physician feedback. Finally, CMS is improving its national website and intends to develop a single web-based source of information for physicians.

Recommendations for Executive Action

  1. Status: Closed - Not Implemented

    Comments: In 2006, CMS reported that it had completed implementing this recommendation by standardizing web site requirements and providing contractors with real-time satisfaction surveys on their web sites. However, CMS's response did not describe what aspects or elements of the web site requirements were standardized. It was also silent on its efforts to provide technical assistance to contractors to promote the quality, consistency, timeliness, and user friendliness of contractor websites. CMS did not provide an update on this recommendation in 2007. We therefore remain unclear as to what aspects or elements of the web site requirements were standardized or the status of its efforts to provide technical assistance to contractors. CMS considers its response to be complete, but did not clarify the specific actions taken in response to our recommendation. Consequently, we will close this recommendation as not implemented.

    Recommendation: In order to improve its assistance to, and oversight of, its Medicare carriers' physician communications efforts, the administrator of CMS should adopt a standard approach that would promote the quality, consistency, and timeliness of Medicare communications while also strengthening CMS's management and oversight. Specifically, CMS should set standards and provide technical assistance to carriers to promote consistency, accuracy, and user-friendliness of carrier Web sites, which should be limited to local Medicare information and should be designed to link to CMS's Web site for national program information.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

  2. Status: Closed - Not Implemented

    Comments: CMS reported that in fiscal year 2004 it implemented this recommendation by establishing call center performance standards for timeliness, accuracy, adherence to the Privacy Act, and other skills. However, our recent report "Medicare: Call Centers Need to Improve Responses to Policy-Oriented Questions from Providers" (GAO-04-669, July 16, 2004) suggests that any actions taken by CMS to date have not been successful. Our tracking of the recommendations made in this more recent report therefore supersedes the need to monitor this previous recommendation separately.

    Recommendation: In order to improve its assistance to, and oversight of, its Medicare carriers' physician communications efforts, the administrator of CMS should adopt a standard approach that would promote the quality, consistency, and timeliness of Medicare communications while also strengthening CMS's management and oversight. Specifically, CMS should establish new performance standards for carrier call centers that emphasize providing complete and accurate answers to physician inquiries. Carriers' monitoring of their carrier call center operations should also be expanded to assure that these performance standards and policies are followed.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

  3. Status: Closed - Implemented

    Comments: CMS reported that in fiscal year (FY) 2003, it continued to study the practicality of establishing a national source of information to be included in provider bulletins while also allowing for the inclusion of local contractors' concerns. Its "Alternative Distribution of Bulletin Information Initiative," is examining a variety of paperless ways to make such information available to providers and suppliers. CMS said it planned to evaluate the success of this initiative in FY2004. In 2005, CMS reported that it implemented "Medlearn Matters...Information for Medicare Providers." These articles are designed to help providers understand new or changed Medicare policy, beginning in February 2004. These national educational articles are located at www.cms.hhs.gov/medlearn/matters by issue date, and replace the individual articles previously developed by each Medicare contractor when program updates are issued from CMS. According to CMS, feedback from the Medicare provider community has been extremely positive, and has stressed significant improvements in the understandability, consistency, and timeliness of communications from CMS. This initiative has replaced the development of a national provider bulletin, thereby bringing this item to completion.

    Recommendation: In order to improve its assistance to, and oversight of, its Medicare carriers' physician communications efforts, the administrator of CMS should adopt a standard approach that would promote the quality, consistency, and timeliness of Medicare communications while also strengthening CMS's management and oversight. Specifically, CMS should assume responsibility for the publication of a national bulletin for physicians, in addition to issuing a quarterly compendium of regulations. Carriers would be responsible for preparing supplements to CMS's national bulletin regarding local medical policy issues.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

  4. Status: Closed - Not Implemented

    Comments: CMS agreed that expert teams of reviewers would be the best tools for ensuring substantive contractor evaluations of provider communications, but noted that such teams would require a core of dedicated staff. Given its workload and resources, CMS said it is unable to devote staff to these reviews. In fiscal year 2003, CMS reported that its performance standards for carrier call centers have been updated, and that routine call monitoring has shown that the vast majority of provider calls are handled accurately and completely. CMS reported that this recommendation has been fully implemented. However, our recent report "Medicare: Call Centers Need to Improve Responses to Policy-Oriented Questions from Providers" (GAO-04-669, July 16, 2004) suggests that any actions taken by CMS to date have not been successful. Our tracking of the recommendations made in this more recent report supersedes the need to monitor this previous recommendation separately.

    Recommendation: In order to improve its assistance to, and oversight of, its Medicare carriers' physician communications efforts, the administrator of CMS should adopt a standard approach that would promote the quality, consistency, and timeliness of Medicare communications while also strengthening CMS's management and oversight. Specifically, CMS should strengthen its contractor evaluation and management process by relying on expert teams to conduct more substantive contractor performance evaluation reviews on all physician communications activities.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

 

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