Contact Center Operations

4.3.2.1 – Contact Center Operations (Rev. 11032; Issued: 09-30-21; Effective: 10-12-21; Implementation: 11-10-21) The Contact Center Operations (CCO) is a CMS managed contact center which provides beneficiaries with personalized Medicare information and accepts both inquiries and complaints regarding a variety of topics including, but not limited to, billing errors, the provision of services/tests, and coverage guidelines. The Customer Service Representatives (CSRs) at the CCO shall try to resolve as many complaints or inquiries as possible with data available in their desktop systems. The following are some scenarios that a CSR may receive and resolve in the initial phone call rather than refer to the MAC for additional screening (this is not an all-inclusive list): • Lab Tests - CSRs shall ask callers if they recognize the referring physician. If they do, remind callers that the referring physician may have ordered some lab work for them. The beneficiaries usually do not have contact with the lab because specimens are sent to the lab by the referring physician office. (Tip: ask if they remember the doctor withdrawing blood or obtaining a tissue sample on their last visit). • Anesthesia Services - CSRs shall check the beneficiary claims history for existing surgery or assistant surgeon services on the same date. If a surgery charge is on file, explain to the caller that anesthesia service is part of the surgery rendered on that day. • Injections - CSRs shall check the beneficiary claim history for the injectable (name of medication) and the administration. Most of the time, the administration of the injection is not payable, as it is a bundled service under Part B only. There are very few exceptions to pay for the administration. • Services for Spouse - If the beneficiaries state that services were rendered to their spouse and the HICNs are the same, with a different suffix, the CSR shall initiate the adjustment and the overpayment processes. • Billing Errors - If the beneficiaries state that they already contacted their provider/supplier and the provider/supplier admitted there was a billing error but a check is still outstanding, the CSR shall follow the normal procedures for resolving this type of billing error. • Services Performed on a Different Date - The beneficiaries state that a service was rendered, but on a different date. The CSR shall review the beneficiary claim history to determine if there are multiple dates billed for this service. If not, an adjustment to the claim may be required to record the proper date on the beneficiaries’ file. • Incident to Services - Services may be performed by a nurse in a doctor’s office as “incident to.” These services are usually billed under the physician’s provider/supplier transaction access number (PTAN) (e.g., blood pressure check, injections). These services may be billed under the minimal evaluation and management codes. • Billing Address vs. Practice Location Address - The CSR shall check the practice location address where services were rendered. Many times the Medicare Summary Notice will show the billing address, causing the beneficiaries to think the billing might be fraud. The CSRs shall use proper probing questions and shall use claim history files to determine if the complaint or inquiry needs to be referred to the MAC for additional screening. Any provider/supplier inquiries regarding potential fraud, waste, and abuse shall be referred immediately to the MAC for handling and screening. Immediate advisements (IA) shall be referred immediately to the MAC for handling and screening. These advisements include inquiries or allegations by beneficiaries or providers/suppliers concerning kickbacks, bribes, or a crime by a federal employee (e.g., altering claims data or manipulating them to create preferential treatment to certain providers/suppliers; improper preferential treatment collecting overpayments; or embezzlement). Indicators of contractor employee fraud shall be forwarded to the CMS Compliance Group.