Cover Story -- December 2001
By Walt Borges
The genesis for this article was personal.
A few months ago, my physician sent me a bill for an office visit that was clearly covered by my health insurance but which remained unpaid four months later. I called my doctor's billing specialist to complain.
She apologized immediately and said the intent of the bill was not to ask me to pay for the services but to enlist me to call the insurer about the bill. I surely would be able to get through quickly, the specialist told me. She and others in the office already had made numerous phone calls to the provider customer service number and had not been able to speak to a customer service representative.
I had heard consistent griping from doctors about the amount of time they and their staff spend on the telephone trying to resolve claims problems, so I agreed to call the insurer. I asked for the number the office had called, dialed it, and sat on hold for 15 minutes before I gave up. I called again and realized from the prompts that I had been given a number for physicians to call. I found the correct patient number, dialed it, and was speaking to a customer service representative in less than a minute. With the claims information and check number I was provided, my physician's billing staff was able to reach a provider claims representative by telephone in less than two minutes and quickly resolve the problem. (The check had been sent to the wrong address, but that's another story.)
New communication technologies may offer many opportunities to improve the exchange of information between physicians' offices and insurance claims processors, but to hear doctors tell it, experiences with insurers' telephone systems are more about systematic delay and mounting frustration than about speed and efficiency.
For many physicians, particularly those who do their insurance billings in-house instead of contracting out the billing services, telephone problems can be a drag on office economics, requiring additional staff or longer hours for existing staff. In the Texas Medical Association's 2000 survey of physicians, telephone hold times and repeated busy signals were the two greatest concerns of physicians dealing with third-party payers.
Chasing down claims can cost a practice time and money, says Robert T. Gunby Jr., MD, chair of TMA's Council on Socioeconomics. "Telephone hold times are a part of that," Dr. Gunby said.
"Telephone problems present a significant problem for physician offices," Dr. Gunby explained. "If you call at the wrong time, you can stay on hold for 30 minutes or an hour."
Particularly frustrating are systems that allow a physician or staff member to hold for 10 minutes or longer; then, an automated prompt suggests that the physician call back and the call is terminated, Dr. Gunby says.
Texas Medical Association's Hassle Factor Log is one of the main tools that TMA staff use to collect and analyze member complaints concerning reimbursement hassles. The problems identified through the log are then used by TMA officials and staff as discussion items during meetings with insurers and for preparing reports and policy recommendations addressing the problems.
Hassle factor reports are accepted from TMA members on a standard form available from TMA's Health Care Financing Department. Forms and guidelines for preparing the reports can be obtained by calling TMA at (800) 880-1300, ext. 1414, or (512) 370-1414; or visiting the TMA Web site.
TMA compiles a database of physician problems with insurers, known as the Hassle Factor Log, and the severity of the telephone problems for physicians is reflected in the number of complaints relating to the telephone systems of insurers.
The Hassle Factor Log shows that 42 percent (2,547) of the 6,105 complaints submitted during the 13-month period ending Sept. 30, 2001, concerned phone issues. Of those calls, 965 were related to busy phones and hold times, with the remaining 1,582 complaints concerning repeated and numerous telephone calls.
No one knows exactly how many times physicians or their staff called insurer customer service representatives during that period or how many physicians received prompt answers to their questions. But the anecdotal evidence in the Hassle Factor Log suggests that some insurers do better than others when it comes to service over the telephone line.
In selecting phone systems to study, Texas Medicine analyzed a one-year period ending May 1, 2001. During that period, TMA's Hassle Factor Log program received 165 complaints about UNICARE related to telephone hold times and busy signals, 137 complaints about United HealthCare, and 103 complaints about Blue Cross and Blue Shield of Texas (BCBS). No other insurer or third-party administrator had more than 42 complaints lodged against it for busy signals and hold times (see Table 1 ).
TMA on Hold
To see if the anecdotes were supported by a pattern of behavior, TMA staff members conducted a mini-survey of the three worst offenders in the complaint category and two others with better records, Humana and Aetna U.S. Healthcare. A series of three phone calls were placed to the insurers' customer service numbers for claims problems at different times during Oct. 15-19, with calls being placed to both patient and physician service lines at the same time. Although all the insurers urged callers to use automated information systems to obtain claims information, the use of such systems would require tax identification numbers and patient Social Security numbers that would have violated privacy standards. Instead, TMA surveyors were instructed to record the time it took to get a live person on the line who could handle a claims problem.
The mini-survey found that United HealthCare averaged the longest hold times on lines used by physicians and patients (see Table 2 ). It took an average of five minutes and 20 seconds for callers to reach a customer service representative on United's patient number, and eight minutes and 20 seconds for a customer service representative to pick up the line at the provider service number.
The response times for UNICARE were better, averaging about four minutes on the patient line, and four minutes and 40 seconds on the physician line. Calls to the BCBS patient line took two minutes and 20 seconds to reach a live person, but calls to the physician line required seven minutes to reach a claims representative.
Calls to the Humana patient line averaged almost three minutes to negotiate menus and hold for a representative, but calls to the physician line needed only two minutes and 40 seconds to reach a live claims representative.
Aetna set the benchmark for performance, with patient line calls requiring a little more than a minute to be connected, and physician line calls being answered in an average of one minute and 40 seconds.
As an additional check, each insurer's physician line was called on Monday morning, Oct. 22, to see if response times were extended in what physicians' staff consider to be one of the highest traffic times of the week. With the exception of BCBS, response times were better than the average from the previous week. BCBS's response time of 14 minutes was twice its average.
Busy signals were not a problem. Only once was a busy signal recorded, necessitating a redial. However, one call resulted in a message within the insurer's telephone queue that indicated the line was not available because of high caller volume. The message suggested the caller try again later and then disconnected the caller. Together with the repeated call, total time for that attempt on United's physician line was 10 minutes.
Doctors Do It Longer
One finding the mini-survey highlighted was that physicians generally will wait longer than patients to speak with a customer service representative.
"There is a perception among some physicians that physicians are the low men on the totem pole when it comes to phone calls," Dr. Gunby said.
That perception is given weight by a policy correction that came to light in a recent meeting between TMA staff and PacifiCare. According to TMA participants, PacifiCare informed them that it had been shifting the customer service representatives answering physician calls to take patient calls when volumes were high on the patient lines. Concerned that this tactic contributed to increased wait times for doctors, TMA officials said they were told that PacifiCare not only banned the practice but also shifted the physician customer service operations to a separate location.
Tony Salters, a PacifiCare spokesperson, said later that the company would keep its call center and continue to shift its personnel to meet demands of call volumes. However, PacifiCare recognized the need to provide more service for physicians and established regional call centers to handle physician calls in each major Texas market.
PacifiCare rolled out its new North Texas provider relations team on Oct. 24 with a new toll-free number, (877) 847-2862. Customer service representatives are available to North Texas physicians from 8 a.m. to 5 p.m. on weekdays and will handle both claims and preauthorization questions. PacifiCare planned to set up other provider relations teams to serve Houston and San Antonio, with operations set to go into effect last month.
But other insurers said personnel shifts similar to the now defunct PacifiCare system do not exist in their shops.
At BCBS, "dedicated units of customer service representatives are staffed to handle only calls from physicians," Ray Angeli, senior vice president for health operations, said in written comments. Staff schedules are adjusted during the day to "accommodate fluctuating call volumes and [to] minimize hold times," Mr. Angeli said.
To follow up on the Hassle Factor Log and the mini-survey, the five insurers were asked to discuss the structure of their phone system and to explain how physicians could best use it.
UNICARE officials refused to talk about their phone system and to respond to written questions.
Larry Bryant, director of corporate communications for UNICARE, did issue a written statement saying, "UNICARE is committed to continually improving service to all physicians, hospitals and other health care providers by investing in new technologies and streamlining processes. In addition, UNICARE works directly with our contracted physicians and physician groups to resolve issues and create an atmosphere conducive to a long-term partnership."
The Hassle Factor Log is used to formulate physicians' concerns. Among the complaints involving UNICARE are:
- A staff member for a Houston obstetrics-gynecology practice complained in January that a claims call to UNICARE resulted in 10 minutes of busy signals. "After dialing for 10 minutes and hearing only a busy signal, I got through to UNICARE [and was on] hold from 11:05 to 11:55. The patient was in the lobby and was forced to wait while I was on hold," the staff member reported.
- Another Houston physician's staff member who attempted to precertify a patient's hospital stay on Jan. 9, 2001, reported that she was on hold for two hours with UNICARE's preferred provider organization for Compaq Corp. When the doctor's staff finally got through, UNICARE's representative was unable to precertify the hospital stay.
- Baytown and LaPorte physicians reported hold times of 30 to 50 minutes in December 2000 and January 2001 when calling UNICARE.
Marjorie Thomas, office manager for David Rogers, MD, an Allen gynecologist who sits on TMA's Council on Socioeconomics, recalls a February 2001 attempt to verify coverage with UNICARE and to obtain preauthorization for hospital surgery.
"I spent 55 minutes on the phone," Ms. Thomas reported. "I called at 2:38 p.m. to verify coverage. At 2:55 p.m., I called medical management and was on hold until 3:10, a full 15 minutes. [The claims representative] at UNICARE said that was good because the usual hold time was 45 to 60 minutes. I did not feel especially lucky.
"She then transferred me to the nurse for clinical review, and I was on hold until 3:33 p.m. and no clinical information was required," Ms. Thomas wrote. "What a waste of time!"
Ms. Thomas said that it is unusual to face that kind of delay in the seven to 10 claims follow-up phone calls she makes each week, but she says the preauthorization and claims calls can tax the resources of doctors and staff in small practices.
United HealthCare Chief Executive Officer Bob Sheehy and Reed Tuckson, MD, senior vice president for consumer health and medical care advancement for United HealthCare Group, say United has not been satisfied with the performance of its communication systems.
"I was disappointed where we were early this year" with phone response times, Mr. Sheehy said, explaining that the growth of United's business in Texas had the insurer scrambling to keep up with staffing needs.
Dr. Tuckson and Mr. Sheehy say United is in the process of making three changes that should make it easier for physicians to get the information they need in a timely manner.
The first step, Mr. Sheehy says, is to reduce the number of computer systems used by United to conduct business for its numerous plans. The multiple computer systems were inherited by United in the course of acquiring other health care companies, United officials say.
"United used to have 14 individual computer systems but we are down to two key systems," Mr. Sheehy said. "We are in the midst of rolling out a desktop system that links the two systems together. … We hope to be down to one system before long. Our goal is to give physicians one number to call to get their problems resolved."
The second and third changes involve uses of technology to reduce the load on United customer service specialists, Dr. Tuckson says. United has introduced a free Web-based physician portal that allows physicians to check eligibility, submit claims, and check claims status without using the phones. The system has been rolled out to 40,000 physicians nationwide, including those in the Houston area, and the remainder of Texas could be online within months, Dr. Tuckson says.
As the third leg of its improvement program, United is ramping up its voice recognition technology to provide answers to basic questions from physicians and office staff. "A vast majority of our calls involve basic questions about eligibility and benefits, so let's answer those with technology and deal with the complex stuff with our personnel," Mr. Sheehy said.
For those physicians who must call, Mr. Sheehy advises that Mondays and Tuesdays are the worst days to get through. United customer service representatives are trying to reduce the traffic on those days by scheduling telephone conferences with regular physician callers on Thursday and Friday, the current low-volume days, Mr. Sheehy says.
BCBS, Phone Home
n his written response, Mr. Angeli said BCBS has made numerous changes to its phone system to improve communication with physicians. "As a result, [BCBS] does not hear of significant hold time complaints," he said.
BCBS urges physicians to use its voice response unit that resolves 50 percent of daily contacts with less than three seconds of hold time.
"A longer wait time may be experienced by those physicians who choose to speak to a service representative, but staffing is managed to keep the hold time to a minimum," Mr. Angeli said.
He said BCBS sorts its physician calls according to plan. HMO physicians call (877) 299-2377, while physicians serving members of other types of plans call (800) 451-0287.
Entering a patient identification number sorts the call to customer service units serving preferred provider organizations (PPOs) and point-of-service plans, federal employee programs, state of Texas programs, or individual products.
Although the BCBS voice interaction unit operates all the time, the HMO unit does not have a claims status function, necessitating a call to a customer service representative. HMO representatives are available from 7 a.m. to 7 p.m. on weekdays; for PPO and other plans, the representatives are available from 8 a.m. to 8 p.m.
BCBS says its low-volume times include Friday afternoons, and from 8 to 9 a.m. and from 1 to 2 p.m. on weekdays.
Humana's phone system is set up differently, said Humana officials who participated in a group interview. Both patients and physicians call a single customer service number (800) 4HUMANA ( 448-6262), which routes calls to teams of customer service representatives who handle both physician and patient problems.
Samantha Champagnie, director of the San Antonio customer service center, suggested that physicians use Humana's Web site to get as much information on a claim before attempting to call the customer service associates, who are available from 8 a.m. to 6 p.m. weekdays.
Associates often will ask for the name of the patient, the patient's Social Security number, a tax number for the physician, the date of service for the treatment, and the charge amount when dealing with claims questions, the Humana official said.
Ms. Champagnie says Humana's system has excellent phone response time that exceeds the company's goals, but the Humana officials declined to say what their internal studies showed as the average. Such information is proprietary, a company spokesperson said.
Ms. Champagnie also suggests physicians avoid the peak hours for call volume in the Humana system, which are 11 a.m. to 2 p.m.
Making It Work
Aetna's phone system, which performed best in the mini-survey, uses a single HMO number for physicians, (800) 245-1206, sorting telephone calls to regional call centers by area code, says Joe Cheek, MD, the regional medical director. For PPO members, the correct numbers for customer service are best taken off member cards, he says.
"We have a sophisticated system that tracks the calls on a real time basis," Dr. Cheek said. "It redistributes calls as volumes increase."
While the volume of calls on physician lines may accumulate in one call center, the customer service representatives serving physicians are cross-trained so that, for example, physicians calling from Dallas can be handled by Houston call center representatives if the Dallas center is jammed.
Dr. Cheek says the industry standard for customer service calls -- answering 75 percent of incoming calls within 45 seconds -- is not the standard Aetna uses for physicians. "We expect our patient management staff to answer 80 percent within 30 seconds," Dr. Cheek said.
Aetna spokeswoman Karen Michlewicz says that a majority of the calls received by Aetna from physicians are patient management calls designed to check eligibility or obtain preauthorization for treatment. Recognizing that precertification is an issue with physicians, Aetna revised the list of services requiring precertification, Dr. Cheek says.
"When we reduced the precertification list, it reduced the volume of precertification calls to approximately 30 percent," Dr. Cheek said. Problems in that area now often stem from office staff who must rely on information "that is not well articulated in the physician's notes," he said.
"We also recognize that the equipment is only as good as the people who use it," Dr. Cheek said. "That means we try to give our people the knowledge and the power to address physician problems. We try to empower them so they don't have to run up the line to get answers from someone else."
Walt Borges can be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; or by e-mail at email@example.com. There is no waiting time on hold.
Table 1. Hassle Factor Log Complaints Related to Busy Signals and Hold Times, May 1, 2000-May 1, 2001 .
Insurer No. of Complaints
United HealthCare 137
Blue Cross and Blue Shield 103
Heritage Southwest 40
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Table 2. Average Time (in minutes) To Reach a Customer Service Representative.
Simultaneous calls were made by TMA staff to patient and physician customer service lines for each insurer. The calls were placed at 10 a.m., Wednesday, Oct. 17; 2 p.m., Thursday, Oct.18, and 3 p.m., Friday, Oct. 19.
Monday (Oct. 22) -- Provider Lines Only
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