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December 2004


Legislative Watch

By George G. Olsen, JD, and Rebecca A. Reisinger

Here to Help You

CMS attempts to become provider friendly

The old saw "I'm from the government and I'm here to help you" never fails to evoke a derisive response from those whose businesses must deal frequently with the federal government. But maybe, just maybe, the adage might prove to be true, at least in part, in the case of the Centers for Medicare and Medicaid Services (CMS). Section 921 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) requires the Secretary of Health and Human Services to coordinate activities through its Medicare contractors to maximize the effectiveness of education efforts for providers and suppliers. Congress also directed the Secretary to implement a series of initiatives designed to assist Medicare providers and suppliers including the creation of incentives for contractors to establish effective education and outreach programs, adoption of processes for ensuring access to and prompt responses from Medicare contractors, and increased training activities for providers and suppliers regarding billing and coding as well as to improve the accuracy, consistency, and timeliness of contractor responses to provider inquiries.

These legislative directives dovetail nicely with the mind-set of CMS Administrator Mark B. McClellan, MD, PhD, who has been an advocate of improving the working relationship between Medicare contractors and providers and suppliers. Under his direction, CMS issued a transmittal notification on September 10, 2004, to all Medicare contractors outlining the requirements for a new Provider Customer Service Program (PCSP).1

Pursuant to this transmittal, each Medicare contractor must establish an integrated PCSP comprising the following three elements: (1) provider self-service technology, (2) a provider contact center, and (3) provider outreach and education. PCSPs must be in place by January 1, 2005. There follows a description of each of these program requirements.

PROVIDER SELF-SERVICE TECHNOLOGY
There are several components to the Provider Self-Service (PSS) Technology requirement:

Interactive Voice Response Units (IVRs) for Telephone Inquiries. IVRs must provide information about "claims status, beneficiary eligibility, and the top one hundred remittance advice code definitions." In so doing, they must respect medical privacy requirements. The CMS notice makes clear that provider telephone customer service representatives (CSRs) are not to answer caller questions where the questions may be answered by the IVR; instead, they must refer all such callers to the interactive voice response unit. In addition, contractors must proactively identify and contact providers who "repeatedly call customer service representatives for information available on the IVR" in order to assist the provider in learning how to use the system.

Contractor Web Site Requirements. The following elements must be available on every contractor's Web site: links to the CMS Web site, frequently asked questions (FAQ), a glossary of remittance advice code sets, and local contractor information. Contractors must assign a Webmaster to be responsible for maintaining and updating the provider portions of the Web site.

Electronic Copies of Provider Bulletins. Bulletins must be clearly written, published at least quarterly, and posted on the Web site.

PROVIDER CONTACT CENTER
Medicare contractors must establish a Provider Contact Center (PCC), which must include a provider call center and a general written inquiries unit. The center will serve as the "backbone for assuring a positive business relationship" between contractors and providers. The PCC shall not apply to inquiries handled by other units within the contractor-eg, sections handling appeals, fraud, and Medicare secondary payor issues. Provider toll-free numbers installed for Part A and Part B are not to be used for other business purposes beyond answering general questions for each of those functions.

Inquiry Triage Process. The contact center must be able to route general inquiries within the PCC to the person best equipped to respond with a minimal number of transfers. Contractors must organize dedicated provider telephone customer service representatives into a minimum of two levels to handle questions of varying complexity. The most complex inquiries will be routed to Provider Relations Research Specialists (PRRSs). The program should be implemented in a way that creates promotion pathways for customer service representatives.

Staffing. The contact center must be staffed with individuals whose sole task is to respond to provider inquiries. Contact center staffing will be divided on the basis of telephone and written inquiries. Complex inquiries-both written and verbal-will be channeled to the provider relations research specialists.

Telephone inquiry staff must include at least two levels of customer service representatives. First level CSRs will respond to basic questions that cannot be answered using the IVR mechanism and that do not involve substantial research. Contractors will determine what types of inquiries are best answered by first level customer service representatives. The CMS transmittal provides the following examples of questions appropriate for first level CSRs: "(1) eligibility, claims status or Medicare Secondary Payer status inquiries; (2) straight-forward claim denial questions; and (3) questions with well-documented, nationally consistent and easily accessible answers." Second level customer service representatives must have more "experience and expertise." They may serve as "consultant subject matter experts for first level CSRs" and are not always required to speak directly to a provider. "Second level customer service representatives may also handle callbacks." All callbacks must be completed within five business days of the original inquiry. Contractors may limit the number of inquiries per provider telephone call to three. Contractors must monitor five calls for every customer service representative every month.

Contractors must develop triage mechanisms to quickly identify complex inquiries in need of a provider relations research specialist. CMS expects the volume of written inquiries to increase substantially over time and reminds contractors that all written inquiries must be responded to in final within 45 business days. Where written inquiries cannot be answered in final within 45 business days, contractors must issue an interim response explaining the reason for the delay. However, interim responses may not comprise more than 5% of all written responses. Final responses shall be issued within five business days of receipt of the information necessary to complete the response. The 45-business day time frame begins the day the inquiry is originally received and date-stamped by the contractor and ends the day the contractor sends the response from the mailroom.

Complex inquiries that cannot be answered by the telephone or written inquiries staff and require significant research shall be referred to the provider relations research specialists. Although the PRRSs are not charged with responding to local provider education and training initiative inquiries, contractors may choose to use this model to fulfill the requirement that there be a mechanism to monitor and improve the accuracy of the contractor staff's responses to specific inquiries identified through a progressive corrective action process.

All responses from provider relations research specialists will be written, unless the provider has requested a callback or the inquiry is best handled with a provider callback. For PRRS inquiries closed using a telephone callback, the response must be documented in the tracking system. PRRS staff must provide written answers within 10 business days for at least 75% of cases referred by the telephone customer service representatives and within 20 business days for 90% of the cases referred by the telephone CSRs. All cases must be closed within 45 business days.

The provider relations research specialists must include at least one certified coder to ensure adequate coding expertise. Coding questions appropriately answered by the PRRS are those regarding underlying Medicare payment or coverage policy. Contractors are required to educate providers about the fact that the PRRS is not an extension of or replacement for billing staff. The PRRS does not provide coding guidance.

Answers given by provider relations research specialists will be considered for provider "job aids" enabling customer service representatives to answer similar inquiries in the future. Job aids should serve as talking points for CSRs. CMS will be increasing the number of national job aids provided to contact centers. The PRRS will serve as the point of contact for Medicare Advantage plans about Medicare program coordination issues.

Contractors must maintain a tracking and reporting system that identifies the following: (1) type of inquiry; (2) person responsible for answering the inquiry; (3) category of the inquiry using CMS-provided categories; (4) the disposition of the inquiry; and (5) the timeliness of the response. The tracking system must not include any beneficiary-identifiable information. Data from the system shall be used to "analyze the number and types of inquiries in order to generate website frequently asked questions, identify areas for telephone CSR training, and identify areas for broader provider education." The system will also be used to generate quarterly reports for CMS use.

Contractors are responsible for training customer service representatives. The provider relations research specialists should be involved in developing training materials for the general inquiries staff. PRRS staff will be trained in the use of the CMS Internet-Only Manual, CMS and contractor Web sites, and pertinent laws and regulations in order to respond to complex inquiries.

PROVIDER OUTREACH AND EDUCATION
Areas of provider outreach and education embraced by a new provider outreach and education program (POE) include the following: (1) training tailored for small providers; (2) enhanced use of the Internet; (3) "Ask-the-Contractor" Teleconferences; (4) training tailored to reduce the claims error rate; and (5) marketing of self-service technology.

Small providers are defined by law as providers with fewer than 25 full-time equivalent employees or suppliers with fewer than 10 such employees. Contractors are not required to identify and validate providers meeting the statutory definition. By April 1, 2005, contractors must offer to all providers a minimum of two educational programs tailored to small provider/supplier needs. Thereafter, contractors must offer at least one small provider educational event per quarter and a minimum total of six events per state per fiscal year. Education may include the provision of no-cost technical assistance; such assistance need not be a face-to-face activity. Technical assistance may include "educational seminars for groups of providers identified as having similar problems with their billing systems or internal controls."

Contractors should encourage providers to use the Web sites and to sign up for Listservs offered by both the CMS and contractors. By January 1, 2005, all contractors must have at least one Internet educational offering and offer at least one per quarter thereafter with a minimum total of six events per fiscal year. Contractors must find solutions for providers who lack Internet access and demonstrate a need for such solutions; contractors may charge providers modest amounts to defray expenses associated with making such solutions available.

Contractors shall organize toll-free ask-the-contractor teleconferences to complement, but not replace, the work of the provider/supplier communications advisory group(s). The teleconferences shall be offered at least once every quarter.

Contractors shall design and implement a provider education methodology based on analysis of the comprehensive error rate and the provider compliance error rate. Education activities shall "focus on those areas of the error rate that represent high dollar impact to the Medicare program." CMS will review every contractor's error rate reduction plan and CERT (comprehensive error rate testing) data to ensure contractors are effectively implementing targeted provider education under this requirement.

Contractors must take every opportunity to educate and encourage providers to use self-service technology where appropriate.

CMS will create an education article outlining the Provider Customer Service Program. The article, set to be available in November 2004, shall be "the basis for all provider education about the new program by both CMS and the contractors."

CONCLUSION
The new provider service program outlined in CMS' transmittal is a significant first step in improving the relationship between CMS, Medicare contractors, and providers and suppliers. As the mechanisms described above come online, providers should seize the opportunity and exercise best efforts to maximize the effectiveness of these initiatives. A good faith effort by all stakeholders in the process might well result in a federal agency that really is "here to help you."

George G. Olsen, JD, is an attorney with the law firm of Williams & Jensen, PC, Washington, DC; and Rebecca Reisinger is a law clerk with the firm.

REFERENCE
  1. One-Time Notification: Transmittal 113. Centers for Medicare and Medicaid Services. CMS Manual System-Pub 100-20. September 10, 2004.

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