HCFA sets new rules on evaluating contractors

Speed, customer service among criteria

Providers can expect better service from Medicare contractors as a result of a new set of carrier performance evaluation standards issued by the Health Care Financing Administra tion in Baltimore. Under the new performance standards, contractors will be evaluated based on the following criteria:

1. Claims processing.

Contractors will be evaluated based on how fast they process claims, accuracy of explanations of Medicare benefits, percentage of electronic claims paid, and percentage of bills HCFA has to pay interest on because of delays in getting clean claims.

2. Customer service.

HCFA will look at the completeness of the service to provider customers based on such standards as the rate of cases reversed by an admin istrative law judge, timeliness of intermediary reconsideration cases, accuracy and timeliness of carrier reviews, and hearings, accuracy, and timeliness of carrier replies to beneficiary telephone inquiries.

During the year 2000, HCFA also will ask providers for feedback about where it can improve operations in such areas as beneficiary relations, provider education, appropriate telephone inquiry responses, and the tone and accuracy of all correspondence.

3. Payment safeguards.

Hoping to further reduce inappropriate payments, HCFA will pay extra close attention to carrier performance when it comes to medical review/necessity and Medicare secondary payer issues.

Other specific areas of performance interest include:

— accuracy of decisions on skilled nursing facility demand bills;

— timeliness of processing the Tax Equity and Fiscal Responsibility Act target rate adjustments, exceptions, and exemptions;

— core standards for medical review and benefit integrity.

4. Fiscal responsibility.

HCFA will evaluate how well contractors manage Medicare funds when it comes to benefit payments and administration, institution of proper financial and budgetary controls, and adherence to the Chief Financial Officers Act.

5. Administrative activities.

HCFA will measure how efficiently and effectively contractors manage their operations to ensure constant improvement in the way they do business; HCFA also will check systems security, automated data processing maintenance, and disaster recovery plans.