American College of Physicians: Internal Medicine — Doctors for Adults ®


Medicare revamps how it answers physician questions

From the July-August ACP Observer, copyright 2005 by the American College of Physicians.

By Kerry Hunt

Q: I've heard that Medicare contractors are now required to offer better service when responding to inquiries from physicians. What kinds of changes can I expect?

A: Section 921 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 requires Medicare contractors to implement provider customer service programs to help educate and answer questions from health care professionals and suppliers.

Medicare contractors must offer increased education and outreach to the provider community, specifically to small practices. In January of this year, contractors began creating customer service programs to answer physician inquiries in an accurate, consistent and timely manner.

Q: What exactly are provider customer service programs?

A: Medicare requires all contractors to create provider customer service programs that include several different components: self-service technology, contact centers, and outreach and education. Here's an overview of each of those components:

  • Self-service technology. Medicare contractors must set up systems that allow providers to get some of the information they need without having to talk to a staff member or customer service representative.

    Physicians should use their contractors' interactive voice response system for all simple inquiries on claims status and beneficiary eligibility, and for the top 100 remittance advice code definitions.

    The law also requires Medicare contractors to create Web sites that give providers information on how to subscribe to local contractors' provider Internet discussion groups, get electronic copies of provider bulletins, and access provider education and outreach information. These Web sites also provide a link to the main Web page of the Centers for Medicare and Medicaid Services, along with lists of frequently asked questions and an up-to-date, complete glossary of remittance advice code sets.

  • Contact centers. At the same time, Medicare contractors must create provider contact centers to respond to providers' general telephone and written inquiries. At those centers, customer service representatives will handle telephone inquiries that cannot be answered via the interactive voice response system, including straightforward claims denial questions, Medicare secondary payer status inquiries and more complicated eligibility status questions. They will also respond to written inquiries.

    Medicare contractors must use a tiered staffing system to make sure physician inquiries are handled by staff with appropriate expertise. All contact centers, for instance, must have first- and second-level customer service representatives.

    Second-level representatives have more experience and knowledge than first-level representatives and will handle more difficult or complicated inquiries, such as questions about local coverage determinations that don't require referral for medical review. (They are also charged with calling back providers whose telephone questions cannot be answered by first-level customer service representatives—and must call back within five business days of the original inquiry.) Note that contact center representatives are not supposed to field questions—such as appeals, fraud or Medicare secondary payer disputes—that are handled by other units within the contractor.

    Contact centers must answer written inquiries within 45 business days. If a question cannot be answered within that time frame, an interim response must be issued explaining the cause of the delay. Interim responses to provider inquiries cannot account for more than 5% of all written responses.

    If a second-level customer service representative can't adequately address a complex inquiry or if a question requires substantial research, the customer service representative will route the question to a provider relations research specialist.

    Research specialists have more experience with Medicare payment and coverage policies than customer service representatives do. In addition, Medicare contractors are required to have at least one certified coder on their team of relations research specialists to make sure coding inquiries related to Medicare coverage issues are satisfactorily addressed.

    Unless otherwise requested, provider relations research specialists will respond to all inquiries in writing. They must make a final response to inquiries within 10 business days for at least 75% of the inquiries referred from customer service representatives and within 20 business days for at least 90% of inquiries. They must respond to all inquiries within 45 business days.

  • Outreach and education. The 2003 Medicare law requires contractors to improve provider outreach and education efforts through several initiatives. Those efforts include enhanced use of the Internet through contractor Web sites, "ask-the-contractor" teleconferences, training geared specifically to small providers, training tailored to reduce claims error rate, and communication about self-service technology options. Physicians should already be receiving information from their contractors about education and outreach efforts.

Q: Will Medicare contractors keep track of inquiries?

A: Contractors must maintain a tracking and reporting system for all inquiries. (Contractors' Web sites and a toll-free contact center directory are online. That tracking system must include the type of inquiry, which staff member responded, the disposition of the inquiry and the timeliness of the response. Reports generated by these tracking systems will be used to identify areas for additional customer service representative training and opportunities for provider education. Provider feed back will also be considered should contractors reapply for their Medicare contracts in the future.

Kerry Hunt is a Senior Analyst in ACP's Washington office.


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