The U.S. Government, as of Jan. 1, 2005, is requiring all Medicare carriers to have in place a "provider customer service program" designed to give the best answers to physician queries. The program was mandated by Congress in its 2003 Medicare Reform measure after the American Medical Association and other groups complained that program participants were getting slow, inaccurate information from contractors.
As a result, the Centers for Medicare & Medicaid Services issued an instruction manual in Sept. 2004 requiring all carriers to have an automated voice response system on their telephone lines allowing physicians to check claim status, determine patient eligibility or obtain definitions for specific code types. To handle more challenging questions posed, carriers must create a triage system which quickly routes inquiries to more experienced staffers. The most difficult questions regarding coverage, coding and payment are being deferred to advanced specialists with special training in program policy.
Physician requests of potentially substantial federal reimbursement are to be submitted in writing so a written response can be reciprocated and documented.
Medicare carriers are also being required to provide special education and outreach to smaller physician practices with fewer than 25-full-time equivalent employees. Straight-forward coding questions will be referred to other organizations such as the American Medical Association and the American Hospital Association's Coding Clinic. Detailed inquiries should be submitted in writing to stand the best chance of physician protection.
Enhanced customer service enforcement comes on the heels of the GAO's Aug. 2004 report citing approximately 96 percent of Medicare billing policy telephone inquiries to carriers received incomplete or inaccurate responses. For a complete instruction manual on CMS' new "provider customer service program", visit http://www.cms.hhs.gov/manuals/pm_trans/rll30tn.pdf