Form Approved
OMB Number 0935-0118
Expiration Date 12/31/2015

MEDICAL EXPENDITURE PANEL SURVEY

MEDICAL PROVIDER COMPONENT

CONTACT GUIDE

FOR

HOMECARE PROVIDERS

FOR

REFERENCE YEAR 2013

(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.)

A1. Hello, have I reached [PROVIDER]?

PHONE NUMBER: [PROVIDER TELEPHONE NUMBER]

[IF A1 = 1 GO TO A2b,IF A1 = 2 GO TO CONTACT BLOCK,
IF A1 = 3 GO TO EXIT]

A2b. (READ IF HOSPITAL: Hello, have I reached the home care department?) I have [an] authorization form[s] for the release of billing and payment records and would like to speak to the person that can help me with that process.

• IF RECORDS ARE KEPT BY AN EXTERNAL BILLING SERVICE, ASK TO SPEAK WITH THE PERSON IN THE OFFICE WHO DEALS WITH THE EXTERNAL BILLING SERVICE.

[IF A2b= 1 GO TO B1,
IF A2b=2, GO TO CONTACT BLOCK
IF A2=3 GO TO EXIT SCREEN]

B1. My name is (YOUR NAME).

I am calling on behalf of the U.S. Department of Health and Human Services. We are conducting MEPS which is a study about how people in the United States use and pay for health care. For quality assurance and training purposes, this call may be monitored.

POC: [POC NAME]

READ IF NECESSARY: I have [an] authorization form[s] for the release of billing and payment records and would like to speak to the person that can help me with that process.

• IF THIS PERSON CANNOT HELP, ASK TO BE TRANSFERRED TO SOMEONE WHO CAN.

[IF B1=1, GO TO B2,
IF B1=2, GO TO CONTACT BLOCK]

B2 First, can you confirm that this is a home care organization?

[IF B2 = 1 GO TO B3a
IF B2 = 2 OR 3 GO TO B2a]

B2a Does your organization include a home care unit or department?

[IF B2a = 1 GO TO B3a
IF B2a = 2 GO TO B2b]

B2b. Does your organization ever make arrangements for other organizations or individuals to provide some kind of assistance to people in their homes?

[IF B2b = 1 GO TO B3a
IF B2b = 2 GO TO B3]

B3.Does your organization provide any kind of assistance to people in their homes?

[IF B3 = 1 GO TO B3a
IF B3 = 2 GO TO EXIT]

B3a. Are your services provided to persons who need in-home assistance for health reasons?

EXPLAIN IF NECESSARY: Health reasons can include either physical or mental health conditions.

[IF B3a = 1 GO TO B4
IF B3a = 2 GO TO B3b]

THIS IS WHERE HOME CARE HEALTH AND NON HEALTH SHOULD BE CREATED. IF B3a=1, THEN THE CASE SHOULD BE LABELED AS A HOME CARE HEALTH FOR EVENT FORM DATA COLLECTION. IF B3a=2, THE CASE SHOULD BE HOME CARE NON-HEALTH.

B3b. What kind of services does your organization provide to people in their homes? SELECT ALL THAT APPLY.

[IF any response in B3b = 1, 2, 3, 4, 5, 6 GO TO B4
IF B3b = 7 GO TO EXIT
IF B3b = 7 provide text box to record response.]

B4. At this time, [NUMBER FROM PATIENT LIST] patient[s] identified [PROVIDER] as a source of health care during 2013. [The/Each] patient signed an authorization form allowing us to contact you for information about the cost of the care they received from [PROVIDER] in 2013. {IF B3A=2, FILL “We need information about the services provided to the persons in our study and about the charges and payments for those services.”, ELSE FILL “We are collecting information about the in-home services provided to the persons in our study and about the charges and payments for those services.”} Much of the information we need is within the billing and payment records. Are the billing and payment records maintained in your office, or is an external billing service used?

[IF B4 = 1 GO TO B4b,
IF B4 = 2 GO TO B4_1]

B4_1. Are you the person who deals with the external billing service?

[IF B4_1 = 1, GO TO C2,
IF B4_1 = 2, GO TO B4a]

B4a. I’ll need to collect the name and telephone number for the person in your office who deals with the external billing service.

PRESS “NEXT” TO GO TO THE CONTACT BLOCK. ADD THE NEW POC TO THE CONTACT BLOCK AND CALL THEM USING SECTION C: IDENTIFY BILLING SERVICE.

[NEXT BUTTON TAKES USER TO CONTACT BLOCK]

B4b. I would like to fax the authorization form[s] to you, along with additional information explaining the study I need to be sure I have the correct information for the package. Should I direct it to you?

• READ IF THE PERSON ON THE PHONE WOULD LIKE TO PROVIDE THE DATA PRIOR TO RECEIVING AUTHORIZATION FORM(S): In order to remain HIPAA compliant, I need to send you the authorization form[s] first. Once you have received the form[s], then we can arrange for the collection of the data.

[GO TO CONTACT BLOCK]

B5. Can you please provide the name and number for the person who needs to receive the courtesy packet/needs to receive the forms to approve the release of data?

[IF B5 = 1 GO TO CONTACT BLOCK,
IF B5 = 2 GO TO EXIT SCREEN.]

C1. Hello, my name is (YOUR NAME).

I am calling on behalf of the U.S. Department of Health and Human Services. We are conducting MEPS which is a study about how people in the United States use and pay for health care. For quality assurance and training purposes, this call may be monitored.

POC: [POC NAME]

READ IF NECESSARY: I have [an] authorization form[s] for the release of billing and payment records and would like to speak to the person that can help me get in touch with the external billing service that maintains your billing and payment records.

• IF THIS PERSON CANNOT HELP, ASK TO BE TRANSFERRED TO SOMEONE WHO CAN.

[IF C1=1, GO TO C2,
IF C1=2, GO TO CONTACT BLOCK]

C2. READ IF NECESSARY: At this time, [NUMBER FROM PATIENT LIST] patient[s] identified [PROVIDER] as a source of health care during 2013. [The/Each] patient signed an authorization form allowing us to contact you for information about the cost of the care they received from [PROVIDER] in 2013.)

We should be able to get all of the information we need from the billing service.
We can also fax you a copy of the authorization form[s] for your files.

I need to be sure I have the correct information for the package. Should I direct it to you?

• READ IF THE PERSON ON THE PHONE WOULD LIKE TO PROVIDE THE DATA PRIOR TO RECEIVING AUTHORIZATION FORM(S)]: In order to remain HIPAA compliant, I need to send you the authorization form[s] first. Once you have received the form[s], then we can arrange for the collection of the data.

[GO TO CONTACT BLOCK]

C3. Can you please provide the name of the billing service, the name of a contact person, their telephone number and title?

• IF THIS PERSON CANNOT HELP, ASK TO BE TRANSFERRED TO SOMEONE WHO CAN AND RESTART THIS SECTION.

[IF C3 = 1 GO TO CONTACT BLOCK,
IF C2 = 2 GO TO EXIT SCREEN.]

D1. Have I reached [BILLING SERVICE]?

PHONE NUMBER: [BILLING SERVICE TELEPHONE NUMBER]

• IF THE PERSON ON THE PHONE SAYS NO, VERIFY THAT YOU DIALED THE CORRECT NUMBER
• IF THE NUMBER IS CORRECT, ASK IF THE PERSON ON THE PHONE KNOWS OF ANOTHER NUMBER FOR THE BILLING SERVICE. IF THEY DO, GO TO THE CONTACT BLOCK AND EDIT THE INFORMATION FOR THE BILLING SERVICE.
• IF NO BETTER NUMBER IS AVAILABLE, SELECT “NO” BELOW.

[IF D1 = 1 GO TO D2,
IF D1 = 2 GO TO EXIT]

D2. We were referred to you by [PROVIDER] about [NUMBER FROM PATIENT LIST] of their patients who received medical service in 2013. I have [an] authorization form[s] for the release of billing and payment records and would like to speak to the person that can help me with that process.

IF THE PERSON YOU NEED TO TALK TO IS UNAVAILABLEATTEMPT TO GET THEIR CONTACT INFORMATION VIA THE CONTACT BLOCK AND SET AN APPOINTMENT IF POSSIBLE.

[IF D2= 1 GO TO E1,
IF D2=2 OR 3, GO TO EXIT SCREEN]

E1. Hello, my name is (YOUR NAME).

I am calling on behalf of the U.S. Department of Health and Human Services. We are conducting MEPS which is a study about how people in the United States use and pay for health care.
For quality assurance and training purposes, this call may be monitored.

POC: [POC NAME]

READ IF NECESSARY: I have [an] authorization form[s] for the release of billing and payment records and would like to speak to the person that can help me with that process.

• IF THIS PERSON CANNOT HELP, ASK TO BE TRANSFERRED TO SOMEONE WHO CAN.

[IF E1=1, GO TO E2,
IF E1=2, GO TO CONTACT BLOCK]

E2. We were referred to you by [PROVIDER] for information about one or more of (his/her/their) patients. At this time, NUMBER FROM PATIENT LIST] patient[s]signed an authorization form allowing us to contact you for information about the cost of the care they received from [PROVIDER] in 2013.

I would like to fax the authorization form[s] to you, along with additional information explaining the study.
I need to be sure I have the correct information for the package. Should I direct it to you?

• READ IF THE PERSON ON THE PHONE WOULD LIKE TO PROVIDE THE DATA PRIOR TO RECEIVING AUTHORIZATION FORM(S): In order to remain HIPAA compliant, I need to send you the authorization form[s] first. Once you have received the form[s], then we can arrange for the collection of the data.

[GO TO CONTACT BLOCK]

E3. Can you please provide the name and number for the person who needs to receive the courtesy packet/needs to receive the forms to approve the release of data?

[IF E3 = 1 GO TO CONTACT BLOCK,
IF E3 = 2 GO TO EXIT SCREEN]

F1. Once you have received the authorization form[s] [if # of patients is < or =25, show “we will call back to collect the data over the phone”, if # of patients is >25, show “you can send us the billing and payment records by either fax or mail, or we can call back to collect the data over the phone.”] For each date of service in 2013, we are requesting information about charges, payments, diagnoses, and services provided.

[IF F1 = 1 GO TO F2,
IF F1 = 2 GO TO F2,
IF F1 = 3 GO TO F2]

F2. Within the next 24 hours we will [fax/mail] you the authorization form[s] and include an instruction sheet. If you have any questions about what to send us, please call our toll-free number on the instruction sheet. We will call to verify that you received the authorization forms.

[We will work with you to set up a good time to collect the data over the phone. /We hope you can send the records to our office within two weeks.

We may call again if other patients identify your practice as a source of medical services.]

[GO TO EXIT]

G_Intro. May I please speak to [POC NAME]?

[IF G_Intro=1, GO TO G1,
IF G_Intro =2, GO TO APPOINTMENT SCREEN]

G1. Hello, my name is (YOUR NAME). I am calling on behalf of the U.S. Department of Health and Human Services. For quality assurance and training purposes, this call may be monitored. We previously spoke about the MEPS study.

Did you receive the authorization form[s] we [faxed/mailed] to you?

[IF G1=1 and F1 = 1 (PHONE) GO TO G2;
IF G1=1 and F1 = 2 (FAX) OR 3 (MAIL) GO TO G4;
IF G1=2 OR 3, GO TO G5]

G2. If it is convenient for you, we can just go ahead and complete the data forms together over the phone right now. I’d be happy to hold on while you get the information you need from your records.

[IF G2=1 GO TO EXIT SCREEN;
IF G2=2 GO TO G3]

G3. I understand. What would be the best day and time to call you back to complete the data forms?

• EARLY MORNING = 9AM
• LATE MORNING = 11AM
• EARLY AFTERNOON = 2PM
• LATE AFTERNOON = 4PM

[IF COMPLETE, GO TO EXIT SCREEN]

G4 Our records indicate that you will [fax/mail] the records to us. We hope you can do so within two weeks.

YOUR NEXT STEP WILL BE TO EXIT THE CONTACT GUIDE AND CODE THE CASE AS “AFS RECEIVED. WAITING FOR RECORDS TO BE SENT”.

[GO TO EXIT SCREEN]

G5. I'm sorry. Let me re-send the authorization form[s] to you.
I need to be sure I have the correct information for the package. Should I direct it to you?

[IF G5=1, GO TO CONTACT_BLOCK,
IF G5=2, GO TO CONTACT_BLOCK,]

H1. ASK (BY NAME) TO SPEAK WITH THE POC WHO DEALS WITH THE EXTERNAL BILLING SERVICE

This is (YOUR NAME) calling on behalf of the U.S. Department of Health and Human Services.
For quality assurance and training purposes, this call may be monitored.

We previously spoke about the MEPS study. Thank you for providing the contact information for [BILLING SERVICE NAME]. Unfortunately we were unable to locate [BILLING SERVICE NAME] with the contact information you provided. Could you please verify the contact information we currently have for [BILLING SERVICE NAME]?

[PRESENT BILLING SERVICE CONTACT INFO HERE]

[IF H1=1, GO TO H2,
IF H1=2, GO TO CONTACT BLOCK]

H2. That is currently the information we have on file. Do you know of any other way we can get in touch with [BILLING SERVICE NAME]?

[IF H2 = 1 GO TO CONTACT_BLOCK,
IF H2=2 GO TO EXIT]

I1. ASK (BY NAME) TO SPEAK WITH THE POC WHO DEALS WITH THE EXTERNAL BILLING SERVICE

This is (YOUR NAME) calling on behalf of the U.S. Department of Health and Human Services.
For quality assurance and training purposes, this call may be monitored.

We previously spoke about the MEPS study. Thank you for providing the contact information for [BILLING SERVICE NAME]. We were able to locate [BILLING SERVICE NAME] with the information you provided. However, they reported that they did not maintain the billing and payment records for [PROVIDER(S)] in 2013. Could you please check to see if another billing service maintained billing and payment records for [PROVIDER(S)] in 2013?

[IF I1=1, GO TO CONTACT BLOCK,
IF I1=2, GO TO EXIT SCREEN]

CONTACT FIELDS
PROVIDER NAME:
BILLING SERVICE NAME:
POC FIRST NAME:
POC LAST NAME:
PHONE:
EXT:
TIME ZONE:
FAX:
VERIFY FAX:
E-MAIL:
TITLE:
DEPARTMENT:
ADDRESS:
CITY:
STATE:
ZIP:

FOLLOW-UP QUESTIONS

CB1. WILL YOU BE CALLING THIS PERSON NEXT?

1. YES
2. NO

CB2. WHAT TYPE OF POC IS THIS PERSON?

1. PROVIDER LEVEL GATEKEEPER
2. HANDLES RELEASE OF IN-HOUSE RECORDS
3. DEALS WITH EXTERNAL BILLING SERVICE
4. EXTERNAL BILLING SERVICE GATEKEEPER
5. HANDLES RELEASE OF RECORDS FOR EXTERNAL BILLING SERVICE
6. COURTESY PACKET RECIPIENT
7. PERMISSION PACKET RECIPIENT
8. NEW/UPDATED NAME FOR PROVIDER

CB3. WHAT TYPE OF PACKAGE ARE YOU SENDING?

1. FAX
2. MAIL
3. N/A

CB3A: COMMENTS

CB4. ADD ANOTHER POC?

1. YES
2. NO

If the user indicated earlier in the contact guide that the provider has no billing service (B4=1), then the program will complete this screen and skip to Section F of contact guide to explain next steps to this provider POC. If the user indicated earlier that there is a billing service (B4=2), then the program will complete this screen and skip to Exit screen.

TYPICAL CONTACT SEQUENCE BY SECTION:

INTERNAL BILLING: A, B, Contact Block, F, end call
EXTERNAL BILLING SERVICE: Call provider: A, B, C, Contact Block, end call.
Call billing service: D, E, edit Contact Block, F, end call
VERIFY AFs WERE RECEIVED: Go to G

1. IDENTIFY A POC AT THIS PROVIDER’S OFFICE (SECTION B)
2. IDENTIFY A POC WHO WORKS WITH EXTERNAL BILLING SERVICE (SECTION C)
3. CALL THE EXTERNAL BILLING SERVICE (SECTION D)
4. VERIFY AUTHORIZATION FORMS WERE RECEIVED (SECTION G)

PROGRAMMER NOTES
IF FIRST RADIO BUTTON IS SELECTED, GO TO B1.
IF SECOND RADIO BUTTON IS SELECTED, GO TO C1.
IF THIRD RADIO BUTTON IS SELECTED, GO TO D1.
IF FOURTH RADIO BUTTON IS SELECTED, GO TO G1.

Can you please provide me with a better time to call back in order to reach him/her?

• EARLY MORNING = 9AM
• LATE MORNING = 11AM
• EARLY AFTERNOON = 2PM
• LATE AFTERNOON = 4PM

[ALL GO TO EXIT FROM HERE]

PRESS "FINISH" TO EXIT THE CONTACT GUIDE AND GO TO CASE MANAGEMENT SYSTEM.
DO NOT HANG UP UNTIL YOU REACH THE CALL DISPOSITION SCREEN.

IF POC RECEIVED AUTHORIZATIONS FORMS AND CAN REPORT DATA BY PHONE NOW, ENTER EVENT CODE 441: AFs Received-Ready for Phone Data Collection

IF YOU NEED TO SEND A COURTESY OR PERMISSION PACKET:

1. SAVE EVENT CODE FOR FAX/MAIL PACKET TO THIS POC FIRST
2. RE-ENTER CONTACT GUIDE AND CALL THE BILLING SERVICE OR PERMISSION POC.

SAVE EVENT CODE FOR FAX/MAIL PACKET FOR COURTESY OR PERMISSION PACKET

[EXIT TO CMS BY PRESSING FINISH, BREAK-OFF SHOULD BE A SEPARATE FUNCTION.]

INTRODUCTION:

May I Please speak to [POC NAME]?
Hello, my name is (YOUR NAME).

I am calling on behalf of the U.S. Department of Health and Human Services. We are conducting MEPS which is a study about how people in the United States use and pay for health care. For quality assurance and training purposes, this call may be monitored.

I recently spoke with {POC YOU ARE WORKING WITH FOR DATA COLLECTION} about the study. I explained that at this time, [NUMBER FROM PATIENT LIST] patient[s] identified [PROVIDER] as a source of health care during 2013. [The/Each]patient signed an authorization form allowing us to contact you for information about the cost of the care they received from [PROVIDER] in 2013. Much of the information we need is within the billing and payment records.

{POC YOU ARE WORKING WITH FOR DATA COLLECTION} has agreed to participate and provide us with the information we are looking for, but has requested that we first send you a copy of the authorization form[s] for patients in order to receive permission to release the data to us.

I’m calling to confirm that you are in fact the best person to receive the form[s] and information about the study by fax, and confirm your contact information so that I can address the fax to you.

[GO TO CONTACT BLOCK]

VERIFY PERMISSION PACKET RECEIPT:
May I please speak to [POC NAME]?

• IF THE PERSON ON THE PHONE DID RECEIVE THE FORMS, ASK:
  
  • Do you have any questions or concerns about the study information or the forms we sent?
  • At this point may I follow-up with {POC YOU ARE WORKING WITH FOR DATA COLLECTION} about the release of data?
    
    
    • IF YOU ARE CLEARED TO SPEAK WITH THE POC YOU ARE WORKING WITH FOR DATA COLLECTION,
      • EXIT TO THE CMS, MAKE THE POC YOU ARE WORKING WITH FOR DATA COLLECTION THE PRIMARY POC ON THE POC SCREEN
      • CALL THEM USING SECTION G: VERIFY RECEIPT OF AFs
    • IF THE PERSON ON THE PHONE DOES NOT GIVE YOU PERMISSION
      • EXIT TO THE CMS TO CODE THE CASE AS “CASE REQUIRES SUPERVISOR REVIEW” AND ENTER A PROBLEM REPORT ON THIS CASE WHEN YOU RETURN TO THE CMS
        
        
• IF THE PERSON ON THE PHONE DID NOT RECEIVE THE FORMS, SAY
  
  • I'm sorry. Let me re-send the authorization form[s] to you.
    
    
    • GO TO THE CONTACT BLOCK BY PRESSING NEXT AND VERIFY THE CONTACT INFORMATION WE HAVE ON FILE, THEN,
    • EXIT TO THE CMS AND TRIGGER A RE-SEND OF THE PERMISSION PACKET TO THIS PERSON.
      
      

[NEXT TAKES USER TO CONTACT BLOCK]