GAO Faults Medicare Insurers For Poor Communication With M.D.s

Physicians who complain about problems in getting information about Medicare reimbursement policies and procedures have gained a valuable ally: the U.S. General Accounting Office (GAO).

In September Leslie G. Aronovitz, director of the Health Care Program Administration and Integrity Issues at GAO, said, “Our ongoing work. . . shows that physicians often do not receive complete, accurate, clear, and timely guidance on Medicare billing and payment policies. We found shortcomings in print, electronic, and telephone communications that Medicare contractors use to provide information to physicians and respond to their questions.”

Those comments were part of her testimony before the Subcommittee on Health of the House of Representatives’ Ways and Means Committee, which was considering the Medicare Regulatory and Contracting Reform Act of 2001 (MRCRA, HR 2768; Psychiatric News, December 7).

Aronovitz described a series of specific shortcomings in the performance of claims-administration contractors who are responsible for providing information and education to health personnel and beneficiaries, as well as paying claims. GAO staff examined the communications activities of 10 of the 20 contractors that administer Part B claims.

• Review of quarterly bulletins that provide information to health personnel revealed them to be “unclear and difficult to use.” Articles were “written in dense language and printed in small type.”

• Only two of the 10 Web sites complied with all 11 content requirements established by the Centers for Medicare and Medicaid Services (CMS). Most did not contain features, such as navigation tools, that would allow physicians and others to obtain information they need. Five of the nine sites that had a required schedule of CMS workshops or seminars were out of date.

• A test of five call centers established to provide information about Medicare billing showed that only 15 percent of the answers were complete and accurate. Fifty-three percent were incomplete, and 32 percent were entirely incorrect.

According to Aronovitz, CMS “has established few standards to guide the contractors’ communication activities. For example, the agency requires that bulletins be issued quarterly, but requires little in terms of content or readability. Similarly, requirements for Web-based communication do little to promote the clarity or timeliness of information.”

APA’s Help Line Director Karen Sanders said, “It is clear from the calls we receive from our members that they have been having great difficulty getting answers from their carriers. When APA Medicare specialist Ellen Jaffe makes follow-up calls to carriers, she encounters the same problems. But she finds going directly to the carriers’ medical directors to be effective.”

Edward Gordon, M.D., chair of APA’s Medicare Advisory Committee, said, “The bulletins issued by carriers are dense and lack any indices or systems for organizing material by medical specialty. The material relevant to psychiatrists often is buried in a 40-page document.”

GAO relates the inability of CMS to improve the work of its contractors to faulty procedures in granting contracts for claims administration.

• There is no full and open competition for the contracts. The Medicare statute exempts CMS from competitive contracting requirements. Instead, participation has been limited to entities with experience processing Medicare claims, most frequently health insurance companies.

• CMS uses cost-based reimbursement contracts that prevent the use of financial incentives to reward contractors for performance.

• Contracts generally cover the full range of claims processing and related activities. Functional contracting, in contrast, would permit the granting of specialized contracts with multiple entities that have expertise in different areas.

In early October the House Committee on Ways and Means approved MCRA, and on October 31 the House Committee on Energy and Commerce approved a similar bill, HR 3046, the Medicare Regulatory, Appeals, Contracting, and Education Reform Act (RACER; Psychiatric News, December 7). RACER, which has been strongly supported by APA, includes provisions that would “improve efforts to educate physicians and other health professionals and providers to reduce errors and improve compliance with coding and other requirements” and that would require “prompt written responses from Medicare contractors,” according to Jay Cutler, director of APA’s Division of Government Relations.

Cutler said, “Differences between the two bills will be narrowed before they head to the House floor. Action seems all but certain before Congress adjourns for the year.”

APA’s Web site has a summary of RACER at www.psych.org/pub_pol_adv/dgrupdate11201.cfm and MRCRA at www.psych.org/pub_pol_adv/medicareregreform10901.cfm. Aronovitz’s testimony, Report GAO-01-1141T, is posted at www.gao.gov. ▪