If you’re like most family physicians, you occasionally have a question or concern related to Medicare reimbursement that you try to resolve by talking with the Medicare carrier in your area. And if you’re like most physicians, you occasionally run into the proverbial brick wall. You try every avenue you know at that level to resolve your concerns, to no avail. Next time this happens to you, try contacting your Health Care Financing Administration (HCFA) regional office.¹ The Medicare carriers are HCFA contractors, and the HCFA regional offices are their front-line supervisors. As such, the regional office has some clout with the carrier that you don’t have and, therefore, may be in a position to influence or settle a dispute between you and your Medicare carrier.

Contacting the regional office

You shouldn’t make the regional office your first point of contact. The Medicare carrier is in the best position to solve your problem expeditiously, so you should begin by working with them. (see “Working with Your Medicare Carrier,” FPM, October 1993, page 120, for suggestions.) The time to think about contacting the regional office is when you’ve made a good faith effort and have not received a satisfactory response from the carrier.

Your best bet is to begin by calling the HCFA regional office, identifying yourself as a physician and indicating that you are calling about a problem you are having with your Medicare carrier. (Phone numbers and addresses are listed below.) You may also want to indicate what state you are calling from and the general nature of your problem. This will help the person answering the phone to direct your call to the person in the best position to address your concern and help you establish a point of contact for follow-up inquiries. Usually this person will be someone who works for the Associate Regional Administrator for Health Plans and Providers, since responding to physicians’ concerns generally falls under that person’s responsibility.

When you reach that contact person, calmly share the facts of your case, ask and answer questions and be certain to end the conversation with a clear understanding of the next steps on both ends of the line. Then, follow up in writing and provide any necessary documentation.

Next, you’ll need to be patient. It may take time for the regional office staff to research your concern, clarify the relevant policy and follow up with the Medicare carrier. While the problem may be an ongoing one for you, it is potentially new to staff in the regional office, and they will need some time to address it. Thirty days is usually a reasonable amount of time to allow the regional office to respond, unless they indicate some other time frame. If you don’t hear from the regional office after a reasonable wait, then feel free to follow-up by phone or in writing.

Communication strategies

You’re more likely to get a successful outcome if you keep the following strategies in mind:

• Be kind and keep cool. As the old proverb says, you will catch more flies with honey than with vinegar. If you stay calm and speak and write professionally, you are more likely to get the answers you seek, distinguish yourself (in a positive way) from all the other folks calling or writing to complain and build a relationship that will be helpful in the future as well as the present.

• Stick to the facts. Opinion and conjecture tend to confuse and muddle matters and don’t usually contribute to a successful resolution. Be prepared to tell who, what, when and where. The more facts you have at your disposal, the easier it will be for the regional office staff to research your case and address your concerns. Any documentation you can provide to support your facts is also helpful.

‘I’m from the government, and I’m here to help’

Of course the HCFA regional office may not be able to resolve every issue to your satisfaction. Sometimes national HCFA policy will supersede the regional office’s ability to act in your favor, and sometimes you may encounter a brick wall in the regional office (e.g., if your point of contact there is unresponsive). In that case, you may need to look to the supervisor of the person you’ve been working with or go even further up the chain of command. If necessary, you may need to contact your congressional representative, state medical association, the AAFP, your state Academy or other resource for help.

The quote, “I’m from the government, and I’m here to help,” is more often seen as a punch line than a promise. But the HCFA regional office is there to help you with any problems you cannot resolve with your Medicare carrier, and you may find it worthwhile taking advantage of that resource.