Medicare:

Accuracy of Responses from the 1-800-MEDICARE Help Line Should Be Improved

GAO-05-130: Published: Dec 8, 2004. Publicly Released: Dec 8, 2004.

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In March 1999, the Centers for Medicare & Medicaid Services (CMS) implemented a telephone help line--1-800-MEDICARE--to provide information about program eligibility, enrollment, and benefits. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) directed GAO to examine several issues related to this 24-hour help line and the customer service representatives (CSRs) who staff it. In this report, GAO evaluated (1) the accuracy of the information the help line provides, (2) the training given to CSRs, and (3) CMS's efforts to monitor the accuracy of information provided through the help line.

The 1-800-MEDICARE help line provided accurate answers to 61 percent of the 420 calls we made and inaccurate answers to 29 percent. We were not able to obtain any answers for the remaining 10 percent of our calls at the time we placed them. Most of these calls were not answered because they were transferred to other contractors responsible for processing Medicare claims that were not open for business at the time we called or these calls were inadvertently disconnected. To facilitate accurate responses, the 1-800-MEDICARE help line provides CSRs with written answers--called "scripts"--that CSRs use during a call. When CSRs provided inaccurate information, it was largely because they did not seem to access and effectively use a script that answered our questions. CMS and its contractor do not routinely pretest the scripts to ensure that they are understandable to CSRs or potential callers. The training for CSRs meets CMS's requirements, but it is not sufficient to ensure that CSRs are able to answer questions accurately on the help line. Before handling calls, CSRs must complete about 2 weeks of classroom training; accurately answer two simulated calls consecutively out of six; and score at least 90 percent on a written exam. In addition, all CSRs receive ongoing training. However, the results from our calls indicate that the testing and simulated call answering did not sufficiently measure whether CSRs were prepared to answer questions accurately. CMS delegates most accuracy monitoring to one of its contractors and reviews the results. The bulk of the monitoring focuses on how accurately individual CSRs answer questions. However, this monitoring does not systematically track questions answered inaccurately by CSRs as a group, which could help target training and script improvement. Through two smaller studies that measured how accurately specific questions were answered, CMS was able to identify areas to improve scripts and training.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: In August 2005 CMS wrote that its main 1-800-Medicare contractor had amended its quality assurance process of having an independent contractor re-review 200 calls to require the contractor to categorize and trend quality assurance results. The 1-800-Medicare contractor will use these results to identify opportunities to improve accuracy by targeting specific scripts for review or topics for refresher training. In 2006 CMS indicated that it had established a CSR Script Review Committee to review the new scripts and provide feedback and recommendations to improve them based on their experience interacting with callers.

    Recommendation: In order to improve the accuracy of responses made on the 1-800-MEDICARE help line and callers' ability to have their questions answered, the CMS Administrator should supplement current monitoring efforts to include a systematic review of the accuracy of information provided by the CSRs as a group for the most frequently asked questions and use the results to modify scripts or provide more training, as needed.

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

  2. Status: Closed - Implemented

    Comments: In March 2005 CMS indicated that it was adjusting its training protocol to spread the testing of the customer service representatives' (CSR) ability to handle calls over the length of their training period and to focus on categories of calls, particularly those that constitute the most frequently asked questions. In 2006, a CMS official indicated that the 1-800 MEDICARE contractors now review monthly data that indicate which topics CSRs most commonly seek help to answer. The topics are then reviewed during regular CSR trainings or in weekly CSR meetings. Second, the contractors review the most commonly asked questions for each week and information to answer the questions are shared with CSRs in weekly meetings and trainings. Third, the contractors use call monitoring to assess the accuracy of CSR responses and provide specific training to CSRs whose accuracy rates are low.

    Recommendation: In order to improve the accuracy of responses made on the 1-800-MEDICARE help line and callers' ability to have their questions answered, the CMS Administrator should enhance testing of CSRs' skills in accurately answering the most commonly asked questions using scripts and, if needed, provide additional training to improve the accuracy and completeness of their responses.

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

  3. Status: Closed - Implemented

    Comments: In March 2005 CMS reported that it had several processes in place to get suggestions for improving scripts. These include a feedback system for its customer service representatives (CSR) to suggest improvements, conducting focused feedback sessions to solicit CSRs' reactions to complex scripts, and having CSRs participate in the development of scripts. In addition, CMS indicated that it was implementing an editorial board to review words and phrases used in scripts to ensure that they are easily understood.

    Recommendation: In order to improve the accuracy of responses made on the 1-800-MEDICARE help line and callers' ability to have their questions answered, the CMS Administrator should assess the current scripts for the most commonly asked questions to ensure that they are understandable to CSRs and potential callers and if not, revise them as needed and pretest new and revised scripts to ensure that CSRs can effectively use them to accurately answer callers' questions.

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

  4. Status: Closed - Implemented

    Comments: CMS reported that 1-800-MEDICARE had changed its call routing protocol so that calls were no longer transferred to call lines that were not open for business at the time of the call.

    Recommendation: In order to improve the accuracy of responses made on the 1-800-MEDICARE help line and callers' ability to have their questions answered, the CMS Administrator should revise routing procedures and technology to ensure that calls are not transferred or referred to claims administration contractors during nonbusiness hours.

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

 

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