HI 00208.040 District Office Contacts with Providers of Services

A. General

DO’s have a special responsibility in the area of health services because of their unique insights into the problems, failures, and successes of programs and instructions within their service areas. In order to fulfill this responsibility, DO’s have been selected as community focal points. They are responsible for; (1) establishing a routine visit and report program involving only Medicare providers of services; (2) reviewing and transmitting public complaints about any medical facility. In addition, DO’s refer information about obvious substandard conditions observed by a DO representative while conducting regular Social Security business at a facility, whether it is certified for title XVIII or not (see HI 00208.045). If the report concerns substandard or safety conditions in a certified provider or supplier, submit the original to the HSQ RO and a copy to AC Field.

B. DO role before CMS signs the agreement

DO’s may receive inquiries about the certification process. These questions may deal with general or specific conditions of participation, utilization review, transfer agreements, physician certification and recertification, etc. These are technical matters about which the DO may have only general knowledge. Generally, DO’s should refer the inquiry or the inquirer to either the State agency or to the CMS RO.

C. DO rule after CMS signs the agreement

1. Initial contact

As soon as possible after learning that a provider has been certified, the district manager or the assistant district manager should make a personal contact with the provider. This contact is important in fostering effective cooperation among all of the participants in the Health Insurance program.

Discussion should cover such items as the role and services of the DO, with specific mention of assistance available with health insurance claim number problems. Another subject, particularly with hospitals, is the application procedure discussed in section 308 of the Hospital Manual (see GN00204.005). Discussions with direct dealing facilities should, of course, establish local arrangements for DO receipt of hospital admission notices.

If the hospital’s administrator raises questions or comments about billing procedures, reimbursement, or related problems, refer him to the intermediary. Report promptly to the CMS RO any significant questions or problems encountered. (This could include significant questions or comments which the provider intends to direct to the intermediary.)

2. Continuing contacts

Participating provider contacts should be based on request or need, e.g., problems are identified by the news media or there is a beneficiary complaint. Persons making these visits should be experienced and knowledgeable about the program and fully aware of the sensitive relationships involved. They should take a low-key approach, and avoid giving the impression that they are “investigators.” This point cannot be overemphasized. At the conclusion of the visit, a report should be prepared and the original submitted to the CMS Bureau and a copy to the AC Field.

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HI 00208.040 - District Office Contacts with Providers of Services - 09/12/2003
Batch run: 04/07/2015