Medicare: Communications with Physicians Can Be Improved

Medicare: Communications with Physicians Can Be Improved
(27-FEB-02, GAO-02-249).

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give to physicians is often difficult to use, out of date,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.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-02-249
ACCNO: A02823
TITLE: Medicare: Communications with Physicians Can Be Improved
DATE: 02/27/2002
SUBJECT: Agency missions
Communication
Data integrity
Health insurance
Information resources management
Physicians
Strategic planning
Web sites
Medicare Program

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GAO-02-249

United States General Accounting Office

GAO

Report to Congressional Requesters

February 2002

MEDICARE

Communications With Physicians Can Be Improved

GAO-02-249

Contents

Letter

Results in Brief
Background
Carrier Communications Are Often Difficult to Use, Out of Date,

Inaccurate, and Incomplete CMS's Management and Oversight of Communications
With

Physicians Are Insufficient CMS is Making Efforts to Improve Physician
Communications Conclusions Recommendations for Executive Action Agency
Comments and Our Evaluation

4 5

13 16 18 19 19

Appendix I Scope and Methodology

Appendix II Call Center Accuracy Test Questions

Appendix III Results of Communications Collection from Seven Physician
Practices

Appendix IV Comments from the Centers for Medicare and Medicaid Services

Appendix V GAO Contact and Staff Acknowledgments

Tables

Table 1: Timeliness of 10 Carriers' Publication of Program

Memorandums (PMs) 9 Table 2: Summary of the Accuracy of Responses by
Question 10 Table 3: Compliance with Fiscal Year 2001 BPR Content

Requirements by 10 Carrier Web Sites 13 Table 4: Questions and Answers for
Test of Carrier Call Centers 26 Table 5: Summary of Communications Included
and Excluded by

Physician Practices 28

Table 6: Percentages of Medicare Communication Subjects and Sources
Collected by Seven Physician Practices from February 1, 2001 through April
30, 2001

Abbreviations

BFE business function expert
BPR budget and performance requirement
CMS Centers for Medicare and Medicaid Services
CPE contractor performance evaluation
CSR customer service representative
FAQ frequently asked questions
HCFA Health Care Financing Administration
HHS Department of Health and Human Services
LMRP local medical review policy
PM program memorandum
PRIT Physicians' Regulatory Issues Team

United States General Accounting Office Washington, DC 20548

February 27, 2002

The Honorable Jim Nussle
Chairman
Committee on the Budget
House of Representatives

The Honorable Nancy L. Johnson
Chairman
Subcommittee on Health
Committee on Ways and Means
House of Representatives

The Honorable Saxby Chambliss
House of Representatives

Medicare, serving nearly 40 million beneficiaries, is the nation's largest
health insurer and second largest federal program. 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 1 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. To accomplish this, the Congress and the Centers for
Medicare and Medicaid Services (CMS)1-the federal agency within the
Department of Health and Human Services (HHS) that administers
Medicare-have promulgated an extensive body of statutes, regulations,
policies, and procedures regarding what shall be paid for and under what
circumstances. CMS, which relies on the assistance of about 50 claims
administration contractors2 to operate the Medicare program, is charged

1On June 14, 2001, the secretary of Health and Human Services announced that
the name of the Health Care Financing Administration (HCFA) had been changed
to the Centers for Medicare and Medicaid Services. In this report, we will
refer to HCFA where our findings apply to operations that took place under
that organizational structure and name.

2Medicare consists of two parts-A and B. Contractors that process Part A
claims-those covering inpatient hospital, skilled nursing facility, hospice,
and certain home health services-are known as fiscal intermediaries.
Contractors processing Part B claims- covering physician services,
diagnostic tests, and related services and supplies-are referred to as
carriers.

with communicating this information to medical providers, including
physicians, so that they can bill the program properly.

Recently, physicians and their representatives testified at congressional
hearings that their participation in Medicare is becoming increasingly
burdensome. Among other things, they reported being inundated with large
volumes of complicated, unclear, and inconsistent information from the
Health Care Financing Administration (HCFA) and its carriers about Medicare
program requirements. They also expressed concern that, because rules change
frequently, their understanding of billing rules may be obsolete and
incorrect, which could lead to inadvertent billing errors.

This report responds to your request, which recognized both the need for
HHS, and particularly CMS, to routinely communicate regulations,
instructions, and guidance to physicians, and the concerns of physicians
regarding the quality of the materials they receive. Specifically, you asked
us to examine several aspects of Medicare communications, including (1) the
quality of Medicare information provided to physicians by HHS, and CMS and
its carriers, (2) the quality of CMS's management and oversight of carrier
communications, and (3) current CMS efforts to enhance the communication
process.

To understand physicians' concerns regarding Medicare communications, we
first solicited the views of individual physicians from several specialties
and representatives from relevant professional organizations. As part of
this effort, we obtained the cooperation of seven physician practices of
varying sizes that provided us with information on the volume and type of
Medicare communications they received during a 3-month period. These
practices were located in different areas of the country and received
information from different carriers. They also provided us with excerpts
from documents they received and shared their views on the usefulness of the
information they received during that time frame. In addition, we
interviewed officials at several carriers and HCFA. We also

met with officials at other HHS agencies to discuss their communications
with physicians participating in the Medicare program.3

On the basis of this information, and because the vast majority of Medicare
communications are issued by carriers on behalf of CMS, we focused on the
information carriers provide to physicians. We then conducted an evaluation
of the quality of the three main methods carriers use to provide information
to physicians-bulletins they publish and mail to physicians, telephone call
centers that respond to physician questions, and Internet Web sites to serve
participating physicians. Specifically, to assess bulletins we reviewed
recently issued bulletins from 10 carriers to determine whether they
organized material in ways that would help readers locate information. We
evaluated the timeliness and completeness of these bulletins by examining
them to determine when certain CMS-issued memorandums, which were relevant
to physicians, were included. To assess the quality of information provided
to physicians calling carriers with questions, we telephoned 5 of the 37
provider assistance call centers with frequently asked questions (FAQ) taken
from carrier Web sites. With CMS's assistance, we scored the completeness
and accuracy of these responses. We also visited 3 carrier call centers to
observe their operations and to study the carriers' approaches to monitoring
the performance of the customer service representatives who are responsible
for responding to physician inquiries. To assess carrier Web sites we
examined 10 such sites to determine if they complied with requirements
established by CMS, as well as to assess whether the information presented
on those Web sites was accurate, complete, and timely. We did not evaluate
communications issued by all Medicare carriers; our findings are limited to
those carriers we reviewed and cannot be projected to other carriers.

To evaluate the quality of CMS's management and oversight of carriers'
communications activities, we identified relevant requirements that CMS
imposes on carriers regarding their communications with physicians. We also
examined CMS's allocation of key resources devoted to communication
activities. In addition, we observed CMS officials conduct

3In addition to CMS, other HHS agencies generate information and guidance
that are relevant to certain physicians or specialties that may affect their
care of Medicare beneficiaries. For example, the Food and Drug
Administration publicizes information on recalls of drugs or medical
devices. The Centers for Disease Control and Prevention issues disease
prevention guidance and manages a national surveillance system for
approximately 60 infectious diseases. The Office of Inspector General issues
Medicare-related fraud alerts and compliance guidance for specific provider
types, including physicians.

Results in Brief

an on-site performance evaluation of one carrier's call center. To identify
CMS's efforts to improve Medicare communication to physicians, we spoke with
officials from CMS, carriers, medical associations, physicians and their
practice administrators, and reviewed related documentation. We identified
recent initiatives CMS has undertaken to improve physician communications
and also explored its plans for future enhancements.

Appendix I contains more information regarding the scope and methodology of
our work. A more detailed description of our review of carrier call centers
is contained in appendix II. Appendix III summarizes the amount and types of
information the seven physician practices received from both governmental
and nongovernmental sources from February 1, 2001, through April 30, 2001.
CMS provided comments on a draft of this report. These comments are
reproduced in appendix IV.

Our work was conducted from December 2000 through January 2002 in accordance
with generally accepted government auditing standards.

Information given to physicians by carriers is often difficult to use, out
of date, inaccurate, and incomplete. Medicare bulletins that carriers use as
the primary means of communicating with physicians are often poorly
organized and contain dense legal language. They are sometimes incomplete,
failing to include information about upcoming program changes, and are not
always timely in communicating CMS-issued information. Similarly, carriers'
other principal means of communicating information to physicians-toll-free
provider assistance lines and Web sites-also proved to be problematic in
terms of accuracy and completeness. Customer service representatives rarely
provided appropriate answers to questions, answering only 15 percent of our
test calls completely and accurately. In addition, only 20 percent of the
carrier Web sites we reviewed contained all of the information required by
CMS, and many lacked common features that allow Web sites to be used
effectively, such as site maps and search functions. Although all carriers
issue bulletins, operate call centers, and maintain Web sites, 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.

Although CMS is tasked with assuring that carriers are responsive to
physicians, the agency has established few standards for carriers to meet in
their physician communications activities. CMS provides little technical
assistance to help carriers develop effective communication strategies.

CMS officials told us that they do not have enough staff to effectively
monitor and assist carriers in their communications with physicians. Neither
CMS carrier oversight nor self-monitoring by the carriers is comprehensive
enough to provide sufficiently detailed information that could either
pinpoint specific communications problems or identify poorly performing
carriers.

CMS is working to improve its physician communications in a number of ways.
For example, the agency announced that it would consolidate new instructions
and regulations and issue them on a more predictable schedule to help lessen
the burden of frequent policy changes that physicians have no way to
anticipate. CMS is also enhancing its education programs for both physicians
and carrier staffs and expanding its efforts to obtain physician feedback.
In addition, CMS is improving its national Web site and intends to develop a
single Web-based source of information for physicians. These and other
improvements are potentially valuable; however, many are in the early stages
of planning or implementation, and we could not assess their ultimate
effectiveness.

We are making recommendations to the CMS administrator to further improve
the timeliness, consistency, and quality of Medicare communications to
physicians. CMS agreed that it needs to improve these communications and
described some of its ongoing and planned improvements.

The complexity of the environment in which CMS operates the Medicare program
cannot be overstated. CMS manages Medicare, the nation's largest health
insurer, in a challenging and complex environment in which medical providers
and beneficiaries form a vast network of stakeholders with differing
priorities. The agency is charged with developing regulations and policies
that implement the statutory provisions of the Medicare program. The program
is operated by CMS with the assistance of approximately 50 carriers and
fiscal intermediaries-generally health insurance companies-that annually
process about 900 million claims submitted by nearly 1 million providers and
private health plans. Medicare is estimated to have spent nearly $240
billion in fiscal year 2001 for services provided to approximately 40
million elderly and disabled beneficiaries.

In order to receive reimbursement from Medicare, CMS requires physicians to
submit claims that identify the services they have performed by using the
agency's national uniform procedure coding system. Like

Background

other Medicare providers, physicians are responsible for billing Medicare
correctly for services performed and informing beneficiaries of the level of
Medicare coverage at the time of service. To do this they need reliable
information on Medicare coverage, claims coding and documentation
requirements, claims submission instructions, program changes, and carrier
policies.

CMS communicates information describing its billing requirements, as well as
other relevant regulations and policies, to physicians primarily through its
carriers. The carriers communicate with physicians in several ways. They
send physicians bulletins periodically to update them on new rules and
program changes, provide toll-free lines to call centers so physicians can
obtain answers to questions, and maintain Web sites that include postings
of, among other things, new Medicare developments and carrier-sponsored
training. CMS and its carriers also sponsor a variety of provider education
activities, such as workshops and on-line training courses, to help
familiarize physicians with billing rules and other aspects of the program
and to update them on program changes.

Physicians have become increasingly vocal about the timeliness and quality
of the Medicare information CMS and its carriers provide. For example, last
year, in congressional testimony, physicians and their representatives
reported frustration because carrier communications are often unclear and do
not always provide them with advance notice of program changes. They also
charged that, when they seek clarification, carrier personnel often give
them incorrect answers to their questions.

CMS establishes carrier requirements, including some related to
communications, in its annual budget and performance requirements (BPR). For
example, the BPRs require carriers to communicate with physicians about
local medical review policies (LMRP)4 and claims submission procedures. CMS
is responsible for monitoring the performance of its carriers to ensure that
they accurately and efficiently fulfill their requirements and properly
implement Medicare policies. Much of CMS's oversight is accomplished through
its periodic evaluations of

4LMRPs specify under what circumstances a carrier will or will not provide
Medicare payment for a type of service. LMRPs are developed by carriers to
reflect their interpretation of Medicare coverage and to enhance or clarify
national Medicare guidance. Because carriers may differ in how they assess
the reasonableness and necessity of services provided, one carrier might pay
for services that would not be paid for by another carrier.

Carrier Communications Are Often Difficult to Use, Out of Date, Inaccurate,
and Incomplete

carrier performance. In addition, the agency also requires carriers to
routinely submit evidence of their own self-monitoring activities.

Medicare information provided by carriers for physicians is often difficult
to interpret and use, out of date, inaccurate, and incomplete. Our analysis
of the three main methods that carriers use to communicate information to
physicians-printed bulletins, provider assistance call centers, and Web
sites-revealed problems with all three types of communication.

Carrier Bulletins Can Be Difficult to Use and Lack Current Information

Carrier bulletins contain important information for physicians but present
this information in formats that may be difficult for them to use. In
addition, critical information, including changing program requirements, may
be late in reaching physicians who need to take steps to implement these
changes.

CMS relies heavily on carrier bulletins-which each carrier is required to
issue at least quarterly-to give physicians official notice of their
responsibilities and requirements under Medicare law, regulations, and
guidelines. Carriers have discretion regarding the bulletins' format and
organization, but they are required to reprint certain CMS-provided
information verbatim. For example, carriers receive and reproduce CMS-issued
guidance-known as program memorandums (PM)-which convey details about
upcoming program changes scheduled to become effective in the next few
months.

Our review of bulletins issued from March through July 2001 by 10 randomly
selected carriers5 showed that there are several aspects of the bulletins,
including their organization and length, which hinder their usefulness. As a
result of carriers' freedom to develop their own bulletins with little
direct CMS guidance, there was considerable variation in the organization
and format of the bulletins we reviewed. While bulletins issued by 6 of the
10 carriers organized information by subject matter or

5Carriers vary in how frequently they issue bulletins. The carriers we
sampled issued from two to five bulletins each during the 5-month period.

specialty, the others provided only an alphabetical key word index instead
of a table of contents to assist the user. Providing only a key word index
makes it difficult to identify information relevant to different physician
practices. Some carriers that serve physicians in several states issued a
single bulletin for all their states. Some of these bulletins had
information for each state contained in a separate insert or section. Other,
less helpful, multistate bulletins only noted state differences within
individual articles, requiring physicians or their staffs to scan each
article to determine whether it was relevant and applicable to their
practices. In addition, the bulletins were typically over 50 pages in length
and several exceeded 80 pages, making them lengthy documents to search.

In several instances, bulletins were late, or provided little advance
notice, in communicating HCFA-issued program changes to physicians. To test
the timeliness of carrier bulletins in communicating information, we
selected four PMs that HCFA issued from February through April 2001
concerning program changes that physicians would need to be aware of in
billing for certain services. We then reviewed the bulletins issued from
March through July by the 10 carriers we sampled, to determine when the four
PMs were included in the carriers' bulletins. In 11 instances, PMs were
either not communicated through carriers' bulletins until after their
scheduled implementation dates, or they did not appear at all in the
bulletins we reviewed, as shown in table 1. In 11 additional instances,
bulletins communicated the memorandums less than 30 days prior to the
implementation date, giving physicians little advance notice to help ensure
their compliance with Medicare rules.6 Overall, 6 of the 10 carriers did not
communicate at least one of the four PMs before its scheduled
implementation.

6CMS has no standard for the amount of advance notice providers should
receive before program changes are implemented. However, it does require
that providers receive a 30-day notice before fee schedule or other payment
changes are to take effect.

Table 1: Timeliness of 10 Carriers' Publication of Program Memorandums (PMs)

Number of carriers that had not included PM

in the bulletins as of 30 days after

PMs (topic and number) Number of carriers that included the PMs implementation
in their bulletins
At least 30 days Less than 30 days
before before 1 to 30 days after
implementation implementation
implementation
Claims for drugs and
biologicals, 10
PM: B-01-10
Coverage for verteporfin,a 6 2 1
PM: AB-01-37
Levels of physician supervision 1 3 5
required for diagnostic tests,
PM: B-01-28
Billing codes for splints and
casts, 1 6 3
PM: AB-01-60

aVerteporfin is a light-sensitive drug used in laser treatments of the eye.

Source: GAO analysis, based on PMs obtained from CMS and bulletins obtained
from selected carriers.

Carrier Call Centers Often Provide Inaccurate and Incomplete Information and
Lack Standard Policies and Sufficient Resources

Customer service representatives (CSR) at carrier call centers we tested
rarely provided appropriate answers to questions we posed. Eighty-five
percent of the responses we received from CSRs from 5 carrier call centers
were inaccurate or incomplete.

To assess the accuracy of responses provided by CSRs, we made 61 calls to
the provider inquiry lines at call centers and asked three questions from
the FAQ pages on carriers' Web sites concerning the appropriate way to bill
Medicare in circumstances commonly encountered by physicians.7 When calling,
we identified ourselves as GAO representatives and asked the CSRs to answer
our questions as if we were physicians. CSR responses were recorded verbatim
and submitted to a Medicare coding expert at CMS along with the text of the
questions and answers used. We used the following questions when making our
calls:

7Although carrier officials told us that the majority of physicians' calls
concern the status of claims, we were not able to ask for information about
specific claims due to concerns about beneficiary confidentiality.

1. If a physician provides critical care for 1 hour and 15 minutes, how
should the services be reported? Should code 99292 (for an additional 30
minutes) be reported? Should the reduced services modifier be used?

2. What is the proper way to bill for an office visit on the same day as a
surgical procedure?

3. Can code 99211 be reported if a nurse in the physician's office provides
instruction on self-administering insulin?

Appendix II provides the answers that appear on the Web sites.

The results of the test, which were validated by the coding expert, showed
that 32 percent of the answers were inaccurate, 53 percent were incomplete,
and only 15 percent were complete and accurate. These results are
illustrated in table 2. There was little variation among the carriers in the
overall accuracy and completeness of their answers.

Table 2: Summary of the Accuracy of Responses by Question

Inaccurate response

Incomplete response

Accurate and complete response Nonresponsea

Question 1:
Critical care coding 8 6 6 1
Question 2:
Office visits and
surgical procedure 6 10 3 1
Question 3:
Nurse providing
instruction 5 15 0 0
Number of call
center responses 19 31 9
Percentage of call
center responses 32% 53% 15% N/A

aNonresponses omitted from the sample.

Source: GAO analysis of carrier call center responses.

Many physicians we spoke to expressed frustration that CSRs will not always
provide information on how to properly code certain claims. Carrier call
centers had varying policies about providing physicians with specific coding
information. Knowing the appropriate code for a medical service is essential
to properly billing Medicare. Although CMS does not

have a policy preventing them from doing so, managers at the carrier call
centers we visited reported that it is not their policy to provide
information to callers on how to code a specific claim. Carriers reported
that they are reluctant to provide specific codes because the CSRs lack the
medical expertise to appropriately make coding judgments, and they do not
have the physician's clinical documentation at the time of the calls to
understand the procedure or service in context.

During our test of call center accuracy, we noted that CSRs followed
different procedures regarding coding-related inquiries and frequently did
not adhere to the carriers' stated policy. While in 19 cases the CSRs
provided neither a code nor referral to a source of coding information,
specific codes were given in 24 instances. Specific referral to a bulletin
issue or to a regulation number was given in 16 other cases, but for 7 of
these cases the information was too vague to enable someone to locate the
coding rules. 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.

Our visits to 3 call centers also revealed that there is no uniformity or
standardization across carriers in the types of technological resources
available to CSRs. For example, 1 call center we visited had an on-line
searchable database of LMRPs that facilitated quick retrieval of the
appropriate information by the CSRs. Representatives at the 2 other call
centers used hard copy bulletins or bulletins posted on their Web sites in a
nonsearchable format. CSRs without easily searchable tools told us that they
relied heavily on their more experienced colleagues, in the absence of more
authoritative sources, for answers.

The lack of technological resources at call centers can affect centers'
abilities to monitor the performance of their CSRs. One call center we
visited was able to record calls from providers and the computer screens
accessed by CSRs to determine whether their responses were accurate and
complete, while the other two call centers could only record the telephone
calls. Two call centers we visited were able to electronically observe each
CSR's phone line activity to track the length and origin of calls; however,
another call center had no electronic information and could only monitor
lines and identify the type of caller by listening to the calls as they took
place.

Carrier Web Sites Not Easy to Use and Often Did Not Meet HCFA-Mandated
Requirements

Most of the 10 carrier Web sites we reviewed did not contain features that
would allow physicians to quickly and directly obtain the information they
needed. The Web sites frequently lacked logical organization and navigation
tools and search functions that increase a site's usability and value. Only
4 of the 10 Web sites we examined contained site maps. Only 6 contained
search functions and in two instances, the search functions did not work.
Three sites had neither search functions nor site maps, making them
difficult to navigate to access information. Furthermore, the Web sites
often contained out-of-date information. Nine of the 10 sites included the
required schedule of upcoming workshops or seminars but 5 of these sites
were out of date. Only 1 site contained a potentially useful "What's New"
page, but the page contained a single document of regulations that went into
effect 8 months prior to the date of our Web site review.8

Although HCFA's 2001 BPRs contain specific requirements for carrier Web
sites, most of the sites we reviewed did not meet all of these standards.
Only 2 of the 10 sites complied with all 11 of the BPRs' content
requirements,9 as shown in table 3. In addition, other requirements, such as
a federally mandated privacy statement outlining the type of information the
site collects on visitors and a section containing FAQs were not
consistently met. Five Web sites contained the privacy statement, and 5
contained a link to FAQs.

8We did not review HCFA's own Web site during our review. In 2001, a
consultant to the agency completed a needs assessment and design plan for
the Web site, and the agency is working to improve the site's usability.

9Additional BPRs, not related to Web site content, focus on copyright
guidelines for billing codes developed by the American Medical Association.

Table 3: Compliance with Fiscal Year 2001 BPR Content Requirements by 10
Carrier Web Sites

Total carriers meeting requirement

Carrier

HCFA Web site
requirement 1 2 3 4 5 6 7 8 9 10
Recent
bulletins �� �� �� �� ��
Compatibility
with multiple �� �� �� �� ��
browsers
Schedule of
training � �� �� �� ��
sessions
Link to
HCFA.gov �� � �� �� �
Link to
HCFA's
Medicare � �� � � ��
Learning
Networka
Search
function � � �� � �
Privacy
policy �� � ��
published
FAQs �� � � �
Link to
Medicare.gov �� � � �
E-mail
support � � ��
Register for
events � � �
Percentage of
BPR
requirements 55 46 82 64 46 100 55 55 100 55
met

Legend: � indicates that the Web site met the HCFA standard.

aThe Medicare Learning Network is a Web site featuring information on
training resources for physicians.

Source: GAO analysis of carrier Web sites.

Although CMS has set standards for carrier Web sites, each carrier
independently develops its own Web site. This has resulted in duplication of
effort and variations in the usability and complexity of the information
provided.

CMS is ultimately responsible for managing and overseeing carrier
performance to ensure that carriers supply physicians with consistent and
accurate information. However, the agency's standards and technical
assistance to guide carriers in physician communications activities are not
sufficient to produce consistent, high-quality products and effective
communication strategies. The lack of standard approaches to communication
by carriers makes consistent oversight more challenging for CMS. Neither of
the two principal oversight tools used by CMS- contractor performance
evaluations (CPE)10 and carrier self-monitoring

CMS's Management and Oversight of Communications With Physicians Are
Insufficient

10Teams of CMS staff annually conduct CPEs, reviewing the performance of
some contractors in selected functions.

and reporting-provide enough information to reveal problems carriers may
have in providing quality communications.

CMS's Communications Management Lacks Sufficient Standards and Resources

CMS has established few standards to guide carriers' primary communication
activities, including publishing bulletins, providing telephone assistance
to callers, and establishing and maintaining Web sites. The BPRs only
require carriers to issue bulletins at least quarterly. There is no
substantive guidance regarding content or readability.11 Carrier call
centers are instructed to perform "quality monitoring" no more than 10 times
a quarter for each CSR, but CMS's definition of what constitutes accuracy
and completeness in call center responses is neither clear nor specific. For
example, CMS defines accuracy as not being inaccurate-as opposed to
providing necessary and complete information to allow physicians to
correctly bill the program. In the case of Web-based communication, the BPRs
contain few requirements about the clarity or timeliness of information.
Instead, they generally focus on legal issues- such as measures to protect
copyrighted material-that, while important, do not enhance physicians'
understanding of, or ability to correctly implement, Medicare policy.

CMS officials acknowledged that physician communications have received less
support and oversight than other aspects of carrier operations and
attributed this, in part, to a lack of resources. CMS's regional offices,
which are most directly responsible for carrier oversight, provide
assistance to carriers through business function experts (BFE) whose
principal method of oversight is participation on CPE teams. A CMS official
told us that there are not enough BFEs to provide direct technical
assistance to all carriers in all areas of communication. Furthermore, a
lack of budgetary resources limits BFEs' travel to carrier sites. One
regional BFE we interviewed handles four functional areas, including
provider education and provider phone inquiries, for 6 separate Medicare
carriers. The BFE interviewed noted that little hands-on technical
assistance is provided. Despite the fact that bulletins are a key means of
physician communication, and Web sites are growing in importance, some
regions have not been allocated any BFEs for these functions. Moreover, no
region has a full-time equivalent staff member dedicated to these

11As of fiscal year 2001, the only BPR requirement relating to content was
that bulletins must include a statement that they should be shared with all
health care practitioners and managers of the provider staff.

critical forms of communication, leaving carriers to solve problems
independently.

CMS's efforts to assist carriers in sharing successful approaches are also
limited. The agency's annual conference for call center managers provides a
forum for sharing information and strategies. However, similar opportunities
do not exist for carrier staff members working with bulletins and Web sites.
CMS collects and posts on-line a carrier BestPractices Handbookrelating to
provider communications and education, but as of January 2002, the
information had not been updated in a year. Further, the handbook contains
little detail about how to implement the strategies for improving
communications.

The lack of specific standards, sufficient technical assistance, and best
practice guidance creates an environment in which, as one CMS business
function expert said, each carrier must develop its own communication
strategies, resulting in duplication of carriers' efforts and variations in
the quality of their service to physicians. At the time of our review, CMS
did not have any efforts that would be implemented in the near future to
develop more standardized carrier communications to physicians.

Monitoring of Carriers Is Not Sufficient to Ensure Quality and Accuracy in
Physician Communication

HCFA has not traditionally undertaken comprehensive evaluations of the
quality or usefulness of carriers' bulletins or Web sites. For 21 years, the
agency has conducted on-site evaluations to directly monitor carriers'
performance in a variety of areas. However, the agency is just beginning to
focus CPEs on provider communications. In 2001, it expanded the focus of its
call center CPEs to include call centers that serve providers, including
physicians. Previously, these reviews had been limited to beneficiary call
centers.

We observed one CPE team as it evaluated the operations of a provider call
center. This team focused mainly on performance standards that address
procedures, such as how long a caller is kept on hold or whether the CSR had
given an appropriate greeting, rather than whether information provided was
complete and accurate. In order to evaluate the carrier's performance in
monitoring its CSRs, the CPE auditor listened to 10 prerecorded calls that
had been evaluated by the carrier at an earlier date. However, the CPE
auditor did not access the claims information to evaluate whether the
information being provided to the callers was correct. While assessing
procedural performance is important, helping ensure that callers receive the
correct information is essential.

In addition to CMS's evaluation of call centers through CPEs, the agency
requires carriers to evaluate the performance of their call center CSRs.
Carriers must monitor up to 10 calls for each CSR each quarter- amounting to
about 90 of the more than 30,000 provider inquiries received by a given
carrier each quarter. Carriers we visited agreed with one call center
industry expert12 that this level of monitoring is far short of what is
necessary to thoroughly evaluate quality. Accuracy and completeness are a
relatively small component (40 percent of the total score) in the overall
performance evaluation of a CSR. The remaining components focus on CSR
attitude and helpfulness.

CMS's oversight beyond the CPE process and carrier self-monitoring consists
principally of CMS staff reviewing carriers' self-reported data, with little
direct feedback from the regional BFEs. Carriers submit monthly reports
summarizing certain call center data, such as how long callers were kept on
hold and the number of calls abandoned. They also submit quarterly activity
reports on communications. The reports include items such as the number of
provider training sessions offered and the questions most frequently asked
by providers. Feedback from CMS is geared toward correcting specific
problems, such as lengthy caller waiting times, rather than identifying ways
to improve performance on a broader scale.

Through the feedback it has received from the physician community, CMS is
aware of a need to improve Medicare communications. It is working to issue
new Medicare rules and regulations on a more consistent and predictable
schedule, expand information resources available to physicians, and obtain
more physician feedback relating to Medicare policies and communications.
However, most of these efforts are in early stages of planning or
implementation; therefore, we could not assess their ultimate impact.

In June 2001, CMS announced plans to reduce the burden on providers of
frequent and irregularly occurring Medicare program changes by issuing and
communicating regulations on a more consistent schedule. CMS plans to
institute a new, Web-based quarterly compendium of program changes,
including all regulations that it expects to publish in the coming quarter,
as

CMS is Making Efforts to Improve Physician Communications

12 This expert was a featured speaker at HCFA's 2001 Telephone Customer
Service Conference.

well as references or electronic links to regulations published in the
previous quarter. By doing so, CMS hopes to make physicians aware of program
changes and provide them with sufficient lead time to implement them. The
compendium was originally to be introduced in October 2001, but according to
a CMS official, as of January 2002 the compendium's format was still being
developed.

CMS is attempting to improve the consistency of information that carriers
provide to physicians and has both short-term and long-term projects under
way. Currently, the agency is establishing a new on-line training program
for carrier call center CSRs, and over the past year it has provided
in-person training to carrier staffs. Installation of satellite dish
technology at Medicare carriers was recently completed so that CMS could
broadcast training to carrier staffs. In addition to these shorter-term
initiatives, agency officials told us that they are developing some
longer-term projects to enhance carriers' communications. For example, they
are developing a standard template for carrier bulletins. In 2001, CMS also
awarded a contract for the design of a standardized computer system that
would be used by CSRs at all carrier call centers to improve CSRs' access to
information as they respond to telephone inquiries. A CMS official told us
this will be tested first at a durable medical equipment contractor this
spring, but had no estimate of when it would be installed at carrier sites.

CMS is also addressing information that it provides directly to the
physician community. In November 2001, CMS mailed the physician edition of
Medicare and You 2002to physicians participating in Medicare, which was the
first issuance of a physician-oriented version of their annual Medicare
andYoubeneficiary handbook. This physician information includes a summary of
recent Medicare program changes, an overview of physician concerns that CMS
is currently addressing, and guidance on contacting carriers or CMS for
claims submission and billing information. The agency is also focusing on
improving its national Web site. Plans include installation of a new
navigational system to make information on CMS's Web site more accessible
and consolidation of all information relevant to providers in a single
Web-based source-a project that will take several years to complete.

In recent years, CMS has also increased efforts to obtain feedback from
physicians regarding communications and training. In response to the
physician community's concerns, the agency established the Physicians'
Regulatory Issues Team (PRIT) in 1998. PRIT has collaborated with the
physician community to identify Medicare requirements, procedures, and
communications that cause the most problems for physicians, and is

working to address the most significant of them. In July 2001, the
administrator of CMS announced the formation of "open door" policy
committees, including one focused on physicians, consisting of top CMS staff
members and provider group representatives that would meet regularly to
discuss regulations that are troubling to providers. Finally, in the fall of
2001, CMS sent out two surveys to obtain the views of physicians and other
providers on their Medicare education needs and their experiences with CMS's
program integrity efforts.

Conclusions

The scope and complexity of the Medicare program make complete, accurate,
and timely communication of program information vital to physicians who need
up-to-date knowledge of Medicare requirements in order to serve their
patients and bill correctly for the services they provide. Although CMS has
delegated this responsibility to carriers, our work demonstrates that
physicians cannot rely on carrier bulletins, call centers, or Web sites to
meet their information needs. In addition, CMS's lack of standard
requirements for carrier communications results in carriers developing their
own approaches to convey information, leading to duplication of effort and
varying degrees of timeliness, accuracy, and completeness.

CMS has initiated a number of efforts, although some are just getting
underway, to improve the way its carriers communicate with physicians and,
in doing so, has acknowledged that improvements are needed. However, these
efforts focus on the individual methods of communication and do not consider
more fundamental matters such as whether the current, and almost complete,
reliance on carriers to communicate with physicians is in the best interest
of the program. We believe it is important for CMS to initiate a more
comprehensive and standardized approach to physician communications through
coordination, leadership, and management of CMS's carrier-based
communications. This approach should focus on communicating timely,
accurate, and complete information in formats that physicians find easy to
use. It should include meaningful performance standards for carrier
communications, enhanced requirements for carrier self-monitoring, effective
monitoring and feedback by CMS's staff, and more substantive periodic CPE
reviews of carrier communications.

Recommendations for Executive Action

In order to improve its assistance to, and oversight of, its Medicare
carriers' physician communications efforts, we recommend that the
administrator of CMS adopt a standardized approach that would promote the
quality, consistency, and timeliness of Medicare communications while also
strengthening CMS's management and oversight. Specifically we recommend that
CMS take the following actions:

* 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.

* 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.

* Set standards and provide technical assistance to carriers to promote
consistency, accuracy, and user-friendliness of all 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.

* Strengthen its contractor evaluation and management process by relying on
expert teams to conduct more substantive CPE reviews on all physician
communications activities.

Agency Comments
and Our Evaluation

In written comments on a draft of this report, CMS agreed that improvement
is needed in its communications with physicians participating in Medicare
and recognized that providing them with the best possible information is
integral to successfully serving Medicare beneficiaries. CMS described its
current efforts to develop a comprehensive customer service plan and
elaborated on several efforts to improve communications that the agency
currently has under way. For example, CMS pointed out that it is enhancing
its services to physicians by establishing a new program to disseminate
information at professional conferences and by instituting its "Open Door
Forums" where physicians can meet with CMS officials and share their views
on Medicare program rules. We have reprinted CMS's letter in appendix IV.
CMS also provided us with technical comments, which we incorporated as
appropriate.

In addressing our first recommendation to assume responsibility of a
national bulletin for physicians, CMS pointed out that it is taking steps to
"nationalize" information contained in these bulletins. It said it is
already including articles of national interest regarding Medicare issues in
carrier

bulletins. CMS also said it is planning a National Provider Bulletin Project
to study the practicality of establishing a national source for the
information included in these bulletins as well as potential changes to the
publication and distribution process.

In response to our second recommendation that new performance standards be
established for carrier call centers, CMS described a variety of initiatives
it has under way to help enhance the quality of these communications. CMS
agreed that providing timely, correct, and consistent answers to physicians'
questions is imperative. The agency stated that it has instituted a new
program of performance standards that features more effective oversight and
evaluation and that includes new quality call monitoring procedures.
Although this new plan appears to contain key components of an effective
communication strategy, CMS's description of this effort does not contain
sufficient detail for us to fully assess its usefulness. We believe such a
plan ultimately needs to incorporate specific performance measures for which
the carriers could be held accountable. Although CMS indicated it plans to
devise ways of objectively measuring carrier performance, it said that it
does not yet have such measures in place.

In response to our third recommendation to set standards and provide
carriers with additional technical assistance to enhance carrier Web sites,
CMS outlined the requirements that carriers must meet. CMS indicated it was
satisfied with carriers' performance in this area, pointing out that an
examination of Web sites was part of this year's annual CPE reviews.
According to CMS, none of the carriers have been deficient in their
compliance with CMS requirements, and CPE reviewers found most of the Web
sites to be user-friendly. Although these CPE reviews may not have detected
deficiencies at carrier Web sites, as we have noted most of the Web sites we
reviewed did not comply with some of CMS's requirements. CMS has agreed to
reexamine its Web site monitoring efforts.

Regarding out fourth recommendation, CMS agreed that utilizing expert teams
to conduct CPE reviews would be the best means of ensuring substantive
evaluations. However, CMS said that it believed that implementing our
recommendation would require the agency to establish a team of dedicated
review staff, which would not be feasible given the agency's available
resources. Although CMS said it could not implement our recommendation at
this time, it indicated that it will nonetheless try to continue building
the expertise of its review staff. According to CMS, many of the staff
members that performed these reviews last year will

perform them this year as well. In addition, CMS said it will continue to
provide relevant training to these staff members.

Officials of the American Medical Association and the Medical Group
Management Association also reviewed a draft of this report. In oral
comments, officials from both organizations said they generally agreed with
our findings and recommendations and offered technical comments, which we
incorporated as appropriate.

We are sending copies of this report to the secretary of Health and Human
Services, the administrator of CMS, and other interested parties. We will
make copies available to others upon request.

If you or your staffs have any questions about this report, please call me
at (312) 220-7600. An additional GAO contact and other staff members who
made major contributions to this report are listed in appendix V.

Leslie G. Aronovitz Director, Health Care-Program Administration and
Integrity Issues

Appendix I: Scope and Methodology

To develop an understanding of physicians' concerns about the Medicare
communications they receive, we obtained the cooperation of seven physician
practices. These practices were of varying sizes, were located in different
geographic regions, and were served by three different Medicare carriers.
Each practice agreed to send us the Medicare-related information that it
received during the 3-month period from February 1 through April 30, 2001.
Besides participating in this communications collection effort,
representatives from these practices shared their views on the quality of
the information they received during this period. We also discussed these
matters with representatives from the following 10 professional
associations:

* American Academy of Family Physicians,

* American Academy of Professional Coders,

* American College of Emergency Physicians,

* American College of Physicians-American Society of Internal Medicine,

* American Health Information Management Association,

* American Medical Association,

* Health Care Billing Managers Association,

* Health Care Compliance Association,

* Medical Group Management Association, and

* Professional Association of Health Care Office Managers.

Because the majority of Medicare communications to physicians are issued by
carriers on behalf of CMS, we focused on the three main methods these
carriers use to communicate with physicians-carrier bulletins, carrier
provider assistance call centers, and carrier Web sites. We did not review
communications from every Medicare carrier. Our findings are limited to the
carriers we reviewed and cannot be projected to other carriers. The scope of
our work did not permit us to examine provider education efforts such as
seminars and training sessions except in the form of documents submitted by
physician practices and conversations with agency and carrier officials. In
addition to assessing the quality of carrier communications, we also
reviewed the agency's oversight of physician communications and its plans to
improve these communications. Finally, we interviewed officials from other
agencies within HHS to discuss their communications with physicians
participating in the Medicare program.

Quality of Carrier To evaluate the quality of carrier bulletins, we randomly
selected 10

Medicare Communications carriers and reviewed the bulletins they issued from
March through July 2001. We reviewed the bulletins from the standpoint of
whether their

Appendix I: Scope and Methodology

format and organization facilitated a reader's ability to locate
information. To test the bulletins' timeliness and completeness in
communicating required information, we identified approximately 40
PMs-issued by HCFA from February 1 through April 30, 2001-that addressed
program changes relevant to physicians. We then selected four of these
memorandums and reviewed the bulletins issued by the sampled carriers to
determine when, or whether, the memorandums were published.

To evaluate the accuracy and completeness of responses given on
carrier-operated provider inquiry lines, we made calls to five call centers
operated by 3 carriers for a total of 59 usable responses (two nonresponses
were eliminated from the sample). We selected call centers operated by the 3
carriers that serve the geographic areas where the seven physician practices
participating in our data collection were located. The three test questions
were selected from FAQs posted on carrier Web sites, to represent common
physician billing concerns. The questions and answers are listed in appendix
II. Our methodology was to ask each of the three questions, four times, at
each of the five call centers, for a total of 12 test calls to each center
and 20 test calls for each question. Calls were placed at different times of
day and different days of the week from early May through June 2001.

HCFA officials were aware of our test. Call center managers were also
informed that their CSRs would be receiving test calls from us. When
calling, we identified ourselves as GAO representatives and asked the CSR to
answer our question as if we were physicians. Prompts were only given if the
CSR probed for more specific information or gave conditional responses that
depended upon different circumstances. In those situations, we asked the CSR
to provide the correct answer for each set of circumstances (such as,
whether the office visit was related or unrelated to the surgical
procedure). Following the response, we asked the CSR if there was any
additional information he or she would like to provide. CSR responses were
recorded verbatim and submitted to a Medicare coding expert at CMS along
with the text of the questions and answers used. The coding expert verified
our results using the following criteria.

* Correct and complete: The answer provided enough information to correctly
bill, including (1) a correct explanation of how to apply the billing policy
and (2) correct billing codes or a referral to specific documentation that
provides coding information.

* Partial or incomplete: The answer referred to material, but (1) did not
provide assistance in interpretation or warn about special circumstances

Appendix I: Scope and Methodology

that would affect billing, or (2) provided interpretation but no directions
to specific documentation, or (3) was correct but not complete.

* Incorrect: The answer contained fully or partially incorrect information,
such that a physician might incorrectly bill or not file a claim for a
billable service.

* Nonresponse: The CSR refused to answer the question. (Nonresponses
occurred because CSRs would not answer questions for callers who were not
physicians.)

To test the usefulness of carriers' electronic communications with
physicians, we randomly selected 10 carrier Web sites for review. We
investigated Web sites to determine whether they were in compliance with the
content requirements for electronic media as detailed in HCFA's 2001 budget
and performance requirements and in the contractor Web site standards and
guidelines posted on the agency Web site. To identify best practices for
effective, user-friendly Web sites, we interviewed four individuals familiar
with Web site development, including the Web master for HHS and two private
Web designers. We used information from these sources to evaluate the 10
carrier Web sites for their accessibility, privacy, format, content, ease of
navigation, organization, contact information, appearance, and use of
graphics.

HCFA Oversight of Physician Communications

We identified HCFA requirements for carrier bulletins, call center
operations, and carrier Web sites, and discussed the agency's oversight and
monitoring of carriers' communications with both headquarters and regional
office officials. We researched call center standards used in private
industry through conversations with an industry expert and the manager of a
large call center, and visited three carrier call centers to discuss
technology, standards, best practices, and support from HCFA. We also
observed carrier call centers' monitoring of calls for quality at the three
call centers we visited. In addition, we observed a contractor performance
evaluation-the agency's independent review of "at-risk" contractor
activities-conducted at one of the carrier call centers in our review.

Improving Medicare Throughout this review, as we met with HCFA and carrier
officials and

Communications representatives of the physician practices participating in
our communications collection, we solicited their views on problems with the
Medicare communications process and potential best practices. Agency
officials also identified their current and planned efforts to improve its
process for communicating with Medicare providers. In addition, we

Appendix I: Scope and Methodology

discussed related issues in our conversations with representatives from
professional associations.

Other HHS Agencies' Communications to Physicians

HHS is the principal federal department responsible for protecting the
health of Americans and providing other essential health services. Although
the focus of our work was Medicare communications that originated with CMS,
we were also asked to identify the quantity and type of communications that
physicians receive from other HHS agencies. Based on our review of
background information and discussions with HHS officials, we identified
nine HHS offices and agencies, other than CMS, as potential sources of
information or instructions for practicing physicians. These include the
Office of the Secretary, Office of the Inspector General, Agency for
Healthcare Research and Quality, Centers for Disease Control and Prevention,
Food and Drug Administration, Health Resources and Services Administration,
Indian Health Service, National Institutes of Health, and Substance Abuse
and Mental Health Services Administration.

We contacted officials in these offices and agencies and reviewed
information available through their Web sites to determine whether they
issued instructions or requirements that affected practicing physicians.
Compared to CMS, the other HHS agencies we contacted issue relatively few
requirements for practicing physicians and rarely communicate instructions
or information directly to the physicians, as does CMS through its Medicare
carriers. Generally, officials we contacted indicated that these agencies
rely primarily on posting information to their Web sites to communicate with
the medical community and the general public. Many of the HHS agencies also
offer subject-specific e-mail notification of new Web postings to physicians
and others who register to receive this service. Some agencies have
newsletters or publications to which physicians and others can subscribe or
they provide specific information upon request.

Appendix II: Call Center Accuracy Test Questions

The questions and answers we used to test the accuracy of carrier call
center responses to physician inquiries are shown in table 4.

Table 4: Questions and Answers for Test of Carrier Call Centers

Question Answer

If a physician provides critical care for 1 Code 99291, Critical care, first
hour. Should be used to report the services of a hour and 15 minutes, how
should the physician providing constant attention to a critically ill
patient for a total of 30 minutes to services be reported? Should code 99292
1 hour on a given day. If the total duration of critical care provided by
the physician on a (for an additional 30 minutes) be reported? given day is
less than 30 minutes, the appropriate evaluation and management code Should
the reduced services modifier be should be used. In the hospital setting, it
is expected that the level 3 subsequent used? hospital care code (99233)
would most often be used.

Code 99292, critical care, each additional 30 minutes. Should be used to
report the services of a physician providing constant attention to the
patient for 15 to 30 minutes beyond the first hour of critical care on a
given day.

What is the proper way to bill for an office If the office visit is
unrelated to the surgical procedure, separate payment can be visit on the
same day as a surgical allowed by applying the "25" modifier to the office
visit procedure code. Medicare will procedure? not pay separately for a
visit on the same day as a minor surgery or endoscopic

procedure unless other significant, separately identifiable services are
performed in addition to the procedure. If other significant evaluation and
management services are performed on the same day, the physician may bill
for the visit with modifier "25."

Can code 99211 be reported if a nurse in Yes. If a physician's employee
performs a limited service, a physician may use this the physician's office
provides instruction code to report services that may not require personal
performance.a The definition of on self-administering insulin? code 99211 is
as follows: office or other outpatient visits for the evaluation and

management of an established patient that may not require the presence of a
physician. However, this code should not be reported in addition to other
evaluation and management services performed by the physician on the same
day.

aCMS advised us that the following sentence should be inserted for this
answer to be accurate: "All of the requirements for an `incident to' service
must be met."

Source: Frequently asked questions and answers posted on carrier Web sites.

Appendix III: Results of Communications
Collection from Seven Physician Practices

To identify the quantity and sources of Medicare information received by
physicians, we enlisted the assistance of seven physician practices to
collect communications that related to their practices and were received
during the 3-month period from February 1 through April 30, 2001. A 3-month
period was selected so that practices would receive at least one carrier
bulletin. HCFA representatives and participating practices reported that the
period selected was typical in relation to the release of Medicare
regulations and information. The participating physicians represented both
urban and rural practices and were located in four states served by three
carriers and three HCFA regional offices. They also varied in size and
specialty and included

* a 600-physician multispecialty group;

* a 450-physician teaching hospital-based group;

* a 43-physician network of small internal medicine/family practice groups;

* a 10-physician internal medicine, obstetrics/gynecology, and pediatric
group;

* a 4-physician multispecialty group;

* a 4-physician internal medicine group; and

* a 4-physician ophthalmology group.

The practices collected and submitted full copies or excerpts of
practice-related communications received by mail, fax, or e-mail, or
downloaded from the Internet, regardless of the source, during this period.1
We asked the practices to omit certain items from their collection due to
lack of relevance or privacy issues. Material the practices were asked to
include and exclude from their submissions to us is shown in table 5.

1In the case of the three largest practices, we collected documents from
only some of their departments. Due to the size of some of these documents,
we often received excerpts containing the front page, table of contents, and
a description of the document.

Appendix III: Results of Communications Collection from Seven Physician
Practices

Table 5: Summary of Communications Included and Excluded by Physician
Practices

Communications included Communications excluded

* Written communications containing information that the * Internal practice
communications or communications with physician, or his or her practice, was
required to comply with patients.

a) to participate in or submit claims to Medicare, other * Statements and
correspondence as part of the routine claims federal or state programs, or
private payers; or processing cycle, including claims denials and
documentation

b) to legally operate his or her practice. requests.

* Written communications that the physician was not required * Marketing and
advertising information.

to comply with, but had to review in order to determine that * Information
on conferences or educational opportunities (other compliance was not
required. than compliance training).

* Information that was not compliance-related but was relevant *
Communications from agencies such as the Internal Revenue

to the practice, such as professional journals, newsletters or Service; the
Occupational Safety and Health Administration; or public health alerts.

other federal, state, or local government entities that have no

direct bearing on medical practice.

* Subpoenas, demand letters, or similar legal communications.

We collected 947 documents from the physician practices. Based on the table
of contents or section titles of these documents, we categorized them as (1)
directly related to Medicare, (2) unrelated to Medicare but involving some
other requirement relevant to the physician practice, and (3) information
relevant to the physician practice that did not include any requirement the
practice needed to act upon. We also classified communications by their
source, including HCFA or its carriers, other HHS agencies, state and local
government agencies, insurance companies and managed care plans, and all
other sources, such as professional journals, newsletters, or other
information sent to physicians. We could not independently verify that the
physician practices submitted all relevant communications they received, nor
could we reliably distinguish between communications that the practice
requested and those that were unsolicited. Most of the documents submitted
by the practices had some Medicare content, indicative of the pervasiveness
of the Medicare program. Frequently appearing topics included Medicare fraud
and abuse, Medicare coding issues, contractor audits, and the Medicare
appeals process.

The information that was submitted by the seven physician practices shows
that while Medicare-related information accounts for much of this material,
a relatively small portion of the documents came from HCFA, its carriers, or
other governmental sources. About half of the documents we received from the
physician practices contained mostly Medicare information. We found that a
relatively small amount of all documents- about 10 percent-was sent by HCFA
or its carriers. Material from other HHS agencies accounted for less than 3
percent of all documents the physician practices collected. The majority of
the information came from

Appendix III: Results of Communications Collection from Seven Physician
Practices

other organizations, such as consulting firms and medical specialty or
professional societies.

Table 6 shows the source and subject of all documents collected and
submitted by the participating physician practices.

Table 6: Percentages of Medicare Communication Subjects and Sources
Collected by Seven Physician Practices from February 1, 2001 through April
30, 2001

Subject of the Communication Source of communication

Medicare Information

Practice information not related to Medicare Information not required for
Medicare or medical

practice Totala

HCFA 9.9 0.2 0
All HHS other than HCFA 1.5 0.8 0
All government other than HHS (federal, state, and local)b 0.3 2.3 0.5a 3.2
Private insurance 0.1 6.2 0.1 6.4
Private sector other than insurance 36.0 19.1 22.8
Totala 47.8 28.7 23.4

aSome columns and rows do not equal the total percentage shown because of
rounding.

bCategory includes local public health department warnings and proposed
legislation at all levels of the government. Category does not include
communications from agencies such as the Internal Revenue Service, the
Occupational Safety and Health Administration, or other federal, state, or
local government entities that have no direct bearing on medical practice.

Source: GAO analysis of 947 documents collected from seven physician
practices.

The number of Medicare-related documents and number of pages submitted by
each practice was generally related to the size of the practice. This was
true both of documents from HCFA and from the private sector. Three of the
smaller practices sent us fewer than 5 documents that they received from
HCFA. In one case, the 3 documents submitted by a small practice totaled 217
pages. The largest practice, a multispecialty clinic, sent 57 HCFA documents
totaling 704 pages. A small rural practice sent 3 private-source documents
totaling 12 pages, while the multispecialty clinic sent 148 documents
totaling 1,174 pages. The number of documents received by a practice may be
influenced by the practice's breadth of specialties and participation in
professional organizations.

Appendix IV: Comments from the Centers for Medicare and Medicaid Services

Appendix V: GAO Contact and Staff Acknowledgments

GAO Contact Geraldine Redican-Bigott, (312) 220-7678

Staff Acknowledgments Donald Kittler, Victoria Smith, Christi Turner, and
Margaret Weber made key contributions to this report.

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