Form Approved
OMB Number 0935-0118
Expiration Date 01/31/2013
MEDICAL EXPENDITURE PANEL SURVEY
MEDICAL PROVIDER COMPONENT
EVENT FORM
FOR
HOME CARE - NON-HEALTH CARE PROVIDERS
FOR
REFERENCE YEAR 2012
OMB
(Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to complete the survey.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:
AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0118) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850)
DCS: READ THIS ALOUD ONLY IF REQUESTED BY RESPONDENT.
PRESS NEXT TO CONTINUE IN THIS EVENT FORM
PRESS BREAKOFF TO DISCONTINUE
BILLING
Did you bill for the services provided in (PATIENT NAME)’s home during the calendar year 2012 by month, by 60-day period, or by week?
BY MONTH ........................................................................................... = 1
BY 60-DAY PERIOD ............................................................................. = 2
BY SOME OTHER PERIOD?
(USE THIS RESPONSE ONLY IF PROVIDER ABSOLUTELY CANNOT CALCULATE COSTS BY MONTH)........................................................................................... = 3
BY WEEK ............................................................................................... = 4
(IF SOME OTHER PERIOD: What was that?)
DK/REF/RETRIEVABLE – CONTINUE TO D1
VISIT DATE
D1. During calendar year 2012, what (was the (first/next) month/were the begin and end dates of the (first/next) 60-day period/were the begin and end dates of
the (first/next) OTHER PERIOD/were the begin and end dates of the (first/next) weekly period) during which your records show that services were provided in (PATIENT NAME)’s home?
REFERENCE PERIOD – CALENDAR YEAR 2012
MONTH:
Month:_____
Day:________
Year:_______
OR
BEGIN DATE:
Month:_____
Day:________
Year:_______
END DATE:
Month:_____
Day:________
Year:_______
SERVICES/CHARGES
D2. I need to know which type or types of persons provided services at (PATIENT NAME)’s home (during (MONTH)/from (BEGIN DATE) through (END DATE)) and either the number of hours or the number of visits for each type.
SELECT ALL THAT APPLY
EXPLAIN IF NECESSARY: By type of person I mean a housekeeper, therapist, nurse aide, yard worker, and so forth.
- HOME HEALTH AIDE
HOURS/MINUTES_____ OR VISITS_____
- HOMEMAKER
HOURS/MINUTES_____ OR VISITS_____
- I.V./INFUSION THERAPIST
HOURS/MINUTES_____ OR VISITS_____
- NURSE/ NURSE PRACTIONER
HOURS/MINUTES_____ OR VISITS_____
- NURSE’S AIDE
HOURS/MINUTES_____ OR VISITS_____
- OCCUPATIONAL THERAPIST
HOURS/MINUTES_____ OR VISITS_____
- PERSONAL CARE ATTENDANT
HOURS/MINUTES_____ OR VISITS_____
- PHYSICAL THERAPIST
HOURS/MINUTES_____ OR VISITS_____
- RESPIRATORY THERAPIST
HOURS/MINUTES_____ OR VISITS_____
- SOCIAL WORKER
HOURS/MINUTES_____ OR VISITS_____
- SPEECH THERAPIST
HOURS/MINUTES_____ OR VISITS_____
- YARD WORKER
HOURS/MINUTES_____ OR VISITS_____
- DRIVER
HOURS/MINUTES_____ OR VISITS_____
- BABYYSITTER
HOURS/MINUTES_____ OR VISITS_____
- Any other home care personnel?
YES ..... 1
NO ...... 2
D2 - DK/REF/RETRIEVABLE – CONTINUE TO D3
D3 – DK/REF/RETRIEVABLE – CONTINUE TO C2
D3. I need a description of the services provided (during (MONTH)/from (BEGIN DATE) through (END DATE)).
CLEANING OR YARD WORK
YES=1, NO=2
TRANSPORTATION
YES=1, NO=2
SHOPPING
YES=1, NO=2
EMOTIONAL SUPPORT PERSON OR
ONE-ON-ONE BUDDY
YES=1, NO=2
SUPPORT GROUPS
YES=1, NO=2
CHILD CARE
YES=1, NO=2
OTHER (SPECIFY):____________
YES=1, NO=2
C2. What were the charges for the services provided to (PATIENT NAME) (during (MONTH)/from (BEGIN DATE) through (END DATE))?
IF NO CHARGE: Some facilities that don’t charge for each individual service do associate dollar amounts with services for purposes of budgeting or cost analysis. This is sometimes called a “charge equivalent”. Could you give me the charge equivalents for these services?
VERIFY: IS THIS THE TOTAL CHARGE FOR (THIS/THESE) SERVICE(S)?
IF NOT, RECORD TOTAL CHARGE.
NOTE: WE NEVER ENTER $0 FOR A CHARGE
TOTAL CHARGES: $________.____
C2 - DK/REF/RETRIEVABLE – CONTINUE TO C4a
SOURCES OF PAYMENT
C4a. From which of the following sources did your organization receive payment for the charges (for (MONTH)/from (BEGIN DATE) through (END DATE)) and how much
was paid by each source? Please include all payments that have taken place between (MONTH/BEGIN DATE) and now for this care.
SELECT ALL THAT APPLY
[DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO, PROBE: And is that Medicare, Medicaid, or private insurance?
OTHER SPECIFY: PROBE FOR SOURCE OF FUNDS AND TYPE OF PLAN.
IF THE ONLY PAYMENT FOR THIS EVENT WAS A LUMP SUM, ANSWER “NO” HERE.
- Patient or Patient’s Family ....... $__________.____
- Medicare ............................... $__________.____
- Medicaid ................................ $__________.____
- Private Insurance ................... $__________.____
- VA/Champva ......................... $__________.____
- Tricare .................................. $__________.____
- Worker’s Comp; ..................... $__________.____
- Or something else? ................. $__________.____
(IF SOMETHING ELSE: What was that? __________)
C5. I show the total of all payments received for (MONTH) / (BEGIN DATE) through (END DATE)) as [SYSTEM WILL COMPUTE AND DISPLAY TOTAL]. Is that correct?
IF NO, CORRECT PREVIOUS ENTRIES AS NEEDED.
YES ..... 1
NO ...... 2
[If C4 is DK/REF/RETRIEVABLE – CONTINUE TO C5.
If C5 is RETRIEVABLE – CONTINUE TO BOX 1.]
BOX 1
DO TOTAL PAYMENTS EQUAL TOTAL CHARGES?
YES, AND ALL PAID BY PATIENT OR PATIENT’S FAMILY................. – 1 (GO TO LSPCHECK)
YES, OTHER PAYERS........................................................................ - 2 (GO TO C5a)
NO, PAYMENTS < CHARGES ............................................................ - 3 (GO TO PLC1)
NO, PAYMENTS > CHARGES ............................................................ - 3 (GO TO Q6_EXCEEDED)
C5a. I recorded that the payment(s) you received equal
I recorded that the payment(s) you received equal the charge(s). I would like to make sure that I have
this recorded correctly. I recorded that the total payment is [SYSTEM WILL DISPLAY TOTAL PAYMENT FROM C5]. Does this total payment
include any other amounts such as adjustments or discounts, or is this the final payment?
IF NECESSARY, READ BACK AMOUNT(S) RECORDED IN C4a.
YES, FINAL PAYMENTS RECORDED IN C4 AND C5.......... = 1 (GO TO LUMP SUM PAYMENT QUESTION)
NO ............................................................................ = 2 (GO BACK TO C4a)
PAYMENTS LESS THAN CHARGES
PLC1. It appears that the total payments were less than the total charge. Is that because...
- There were adjustments or discounts ..... YES=1 NO=2
- You are expecting additional payment .... YES=1 NO=2
- This was charity care or sliding scale ..... YES=1 NO=2
- This was bad debt ................................ YES=1 NO=2
[If a=1 then show C6_adjustments.
If b=1 then show C6_additional.
If [a=1 and b=1 ] or [a=2 and b=2 and c=2 and d=2] then show both C6_adjustments and C6_additional.
If both c=1 and d=1 with no other selection, show neither C6_adjustments or C6_additional.
If both c=1 or d=1 with no other selection, show neither C6_adjustments or C6_additional.]
DIFFERENCE BETWEEN PAYMENTS AND CHARGES
C6. It appears that the total payments were (less than/more than) the total charges. What is the reason for that difference? Please include all adjustment activity that has taken place between (MONTH/BEGIN DATE) and now for this care.
ENTER YES FOR ALL REASONS MENTIONED.
C6_adjustments
PAYMENTS LESS THAN CHARGES:
Adjustment or discount
- Medicare limit or adjustment? ................ YES=1 NO=2
- Medicaid limit or adjustment? ................. YES=1 NO=2
- Contractual arrangement with insurer or managed care organization? ............... YES=1 NO=2
- Courtesy discount? ............................... YES=1 NO=2
- Insurance write-off? ............................. YES=1 NO=2
- Worker’s Comp limit or adjustment? ...... YES=1 NO=2
- Eligible veteran? .................................. YES=1 NO=2
- Something else? .................................. YES=1 NO=2
(IF SOMETHING ELSE: What was that? _______________)
C6_additional
Expecting additional payment
- Patient or Patient’s Family? ................... YES=1 NO=2
- Medicare? ........................................... YES=1 NO=2
- Medicaid? ............................................ YES=1 NO=2
- Private Insurance? ............................... YES=1 NO=2
- VA/Champva? ..................................... YES=1 NO=2
- Tricare? .............................................. YES=1 NO=2
- Worker’s Comp? ................................. YES=1 NO=2
- Something else ................................... YES=1 NO=2
(IF SOMETHING ELSE: What was that? _______________)
It appears that the total payments were more than the total charges. What is the reason for that difference?
Please include all adjustment activity that has taken place between [DATE] and today.
Was it (a)
IF THE ONLY PAYMENT FOR THIS VISIT WAS A LUMP SUM, ANSWER “NO” TO ALL OPTIONS.
Do the charges exceed payments because of
Q6_exceeded
- Charity care or sliding scale?.............. YES=1 NO=2
- Bad debt?......................................... YES=1 NO=2
Q6_extra
PAYMENTS MORE THAN CHARGES:
- Medicare adjustment?...................... YES=1 NO=2
- Medicaid adjustment?...................... YES=1 NO=2
- Private insurance adjustment?.......... YES=1 NO=2
- Something else?.............................. YES=1 NO=2
(IF SOMETHING ELSE: What was that? _______________)
It appears that the total payments were more than the total charges. What is the reason for that difference?
Please include all adjustment activity that has taken place between (DATE) and today. Was it (a)
[After C6 - GO TO LUMP SUM PAYMENT QUESTION]
DK/REF/RETRIEVABLE – LUMPSUM PAYMENT QUESTION
LUMP SUM PAYMENTS
LSPCHECK WAS THIS EVENT COVERED BY A LUMP SUM?
YES ..... 1
NO ...... 2
DK/REF/RET ALLOWABLE and SKIP TO END OF EVENT FORM
FINISH SCREEN
PRESS VALIDATE TO COMPLETE THIS EVENT FORM.