MEDICAL EXPENDITURE PANEL SURVEY
MEDICAL PROVIDER COMPONENT
MEDICAL EVENT FORM FOR HOME CARE - NON-HEALTH CARE PROVIDERS
FOR
REFERENCE YEAR 2009
INTRODUCTION: (PATIENT NAME) reported that (he/she) received home care services from someone in this
organization during the calendar year 2009.
1 CONFIRM PATIENT RECEIVED SERVICES (GO TO HOWBILL)
2 PROVIDER KNOWS PATIENT BUT NO EVENTS RECORDED FOR 2009 (GO TO NEXT PATIENT, PAIR IS FINAL)
3 PROVIDER DOES NOT KNOW PATIENT (GO TO NEXT PATIENT, REVIEW TO SEE IF DISAVOWAL IS ELIGIBLE FOR CONVERSION)
HOWBILL: How did you bill for the services provided in (PATIENT NAME)’s home during the calendar year 2009?
Was it:
1 By month; [REFERENCES TO BILLING PERIOD IN EVENT FORM WILL BE BY MONTH]
2 By 60-day episode; or [REFERENCES TO BILLING PERIOD IN EVENT FORM WILL BE BY 60-DAY EPISODE]
3 By some other period? [REFERENCES TO BILLING PERIOD IN EVENT FORM WILL BE BY WHAT’S SPECIFIED]
(IF SOME OTHER PERIOD: What was that?)
_____________________________________
D1. During calendar year 2009, what (was the (first/next) month/were the begin and end dates of the (first/next) 60-day episode/were the begin and end dates of the (first/next) OTHER PERIOD) during which your records show that services were provided in (PATIENT NAME)'s home?
MONTH: _____________ YEAR: 2009
OR
BEGIN DATE: MONTH____ DAY ____ YEAR _____
END DATE: MONTH____ DAY ____ YEAR ____
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), question above) and either the number of hours or the number of visits for each type.
SELECT ALL TYPES THAT APPLY.
EXPLAIN IF NECESSARY: By type of person I mean a housekeeper, therapist, nurse aide, yard worker, and so forth.
1. HOME CARE AID HOURS/MINUTES:_____ OR VISITS:___
2. HOMEMAKER (INCLUDE HOUSEKEEPER) HOURS/MINUTES:_____ OR VISITS:___
3. I.V./INFUSION THERAPIST HOURS/MINUTES:_____ OR VISITS:___
4. NURSE/NURSE PRACTITIONER HOURS/MINUTES:_____ OR VISITS:___
5. NURSE’S AIDE HOURS/MINUTES:_____ OR VISITS:___
6. OCCUPATIONAL THERAPIST HOURS/MINUTES:_____ OR VISITS:___
7. PERSONAL CARE ATTENDANT HOURS/MINUTES:_____ OR VISITS:___
8. PHYSICAL THERAPIST HOURS/MINUTES:_____ OR VISITS:___
9. RESPIRATORY THERAPIST HOURS/MINUTES:_____ OR VISITS:___
10. SOCIAL WORKER HOURS/MINUTES:_____ OR VISITS:___
11. SPEECH THERAPIST HOURS/MINUTES:_____ OR VISITS:___
12. OTHER (SPECIFY):_______ HOURS/MINUTES:_____ OR VISITS:___
21. YARD WORKER HOURS/MINUTES:_____ OR VISITS:___
22. DRIVER HOURS/MINUTES:_____ OR VISITS:___
23. BABYSITTER HOURS/MINUTES:_____ OR VISITS:___
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))?
TOTAL CHARGES: $________.__
VERIFY: Is this the total charge for (this/these) service(s)? IF NOT, RECORD TOTAL CHARGE.
C4a. From which of the following sources did the organization receive payment for the charges (for (MONTH)/from (BEGIN DATE) through (END DATE)) and how much was paid by each source?
SELECT ALL THAT APPLY
[DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO, PROBE: And is that Medicare, Medicaid, or private insurance?
[SYSTEM WILL ALLOW FOR A MAXIMUM OF 20 SOURCES OF PAYMENT TO BE COLLECTED]
OTHER SPECIFY: PROBE FOR SOURCE OF FUNDS AND TYPE OF PLAN.
a. Patient or Patient’s Family; $________.__
b. Medicare; $________.__
c. Medicaid; $________.__
d. Private Insurance; $________.__
e. VA/Champva; $________.__
f. Tricare; $________.__
g. Worker's Comp; or $________.__
h. Something else (What was that?_____) $________.__
C5. I show the total of all payments received (for (MONTH)/from (BEGIN DATE) through (END DATE)) as [SYSTEM WILL COMPUTE AND DISPLAY TOTAL]. Is that correct?
IF NO, CORRECT ENTRIES ABOVE AS NEEDED.
TOTAL PAYMENTS: $________.__
BOX 1
DO TOTAL PAYMENTS EQUAL TOTAL CHARGES?
YES, AND ALL PAID BY PATIENT OR PATIENT’S FAMILY 1 (GO TO D4)
YES, OTHER PAYERS 2 (GO TO C5a)
NO 3 (GO TO C6)
IF, AFTER VERIFICATION, PAYMENTS DO NOT EQUAL CHARGES COMPLETE C6 AND GO TO D4
C5a I recorded that the payment(s) you received equal the charges. 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 C4a AND C5 1 (GO TO D4)
NO 2 (GO BACK TO C4a)
C6. It appears that the total payments were (less than/more than) the total charges. What is the reason for that difference?
CODE 1 (YES) FOR ALL REASONS MENTIONED.
PAYMENTS LESS THAN CHARGES:
Adjustment or discount:
a. Medicare limit or adjustment -- YES=1/NO=2
b. Medicaid limit or adjustment -- YES=1/NO=2
c. Contractual arrangement with insurer or managed care organization -- YES=1/NO=2
d. Courtesy discount -- YES=1/NO=2
e. Insurance write-off -- YES=1/NO=2
f. Worker's Comp limit or adjustment -- YES=1/NO=2
g. Eligible veteran -- YES=1/NO=2
h. Something else (SPECIFY):_________ -- YES=1/NO=2
Expecting additional payment:
i. Patient or Patient’s Family -- YES=1/NO=2
j. Medicare -- YES=1/NO=2
k. Medicaid -- YES=1/NO=2
l. Private Insurance -- YES=1/NO=2
m. VA/Champva -- YES=1/NO=2
n. Tricare -- YES=1/NO=2
o. Worker’s Comp -- YES=1/NO=2
p. Something else (specify):_____ -- YES=1/NO=2
q. Charity care or sliding scale -- YES=1/NO=2
r. Bad debt -- YES=1/NO=2
PAYMENTS MORE THAN CHARGES:
s. Medicare adjustment -- YES=1/NO=2
t. Medicaid adjustment -- YES=1/NO=2
u. Private insurance adjustment -- YES=1/NO=2
v. Something else (SPECIFY):___ -- YES=1/NO=2
D4. Have we covered all of the (months/60-day episodes/OTHER PERIODS) your organization provided services to (PATIENT NAME) during the calendar year 2009?
YES, ALL (MONTHS/60-DAY EPISODES/OTHER PERIODS) COVERED 1 (GO TO D5)
NO, NEED TO COVER ADDITIONAL (MONTHS/60-DAY EPISODES/OTHER PERIODS) 2 (GO TO D1-NEXT EVENT FORM)
D5. IF ALL (MONTHS/60-DAY EPISODES/OTHER PERIODS) ARE COMPLETED FOR THIS PATIENT, REVIEW NUMBER OF MONTHS OF HOME CARE SERVICE REPORTED BY HOUSEHOLD. IF FEWER MONTHS OF SERVICE ARE REPORTED BY THE HOME CARE ORGANIZATION, PROBE TO EXPLAIN THE DIFFERENCE.
[SYSTEM WILL COMPUTE NUMBER OF MONTHS REPORTED BY THE HOME CARE ORGANIZATION AND COMPARE IT TO THE NUMBER OF MONTHS REPORTED BY HOUSEHOLD]
NO DIFFERENCE OR PROVIDER REPORTED MORE MONTHS OF HOME CARE SERVICE THAN HOUSEHOLD -- 1 (GO TO D6)
PROVIDER RECORDED FEWER ISITS -- 2
[DCS ONLY] PROBE: (PATIENT NAME) reported (NUMBER) months of home care service during 2009, but I have only recorded (NUMBER) months. Do you have any information in your records that would explain this discrepancy?
DON’T KNOW 1
UNACCESSIBLE ARCHIVED RECORDS 2
ACCESSIBLE ARCHIVED RECORDS 3
COLLECT CONTACT INFORMATION FOR PERSON WITH RECORDS
OTHER (SPECIFY):_____ 4
D6. GO TO NEXT PATIENT FOR THIS PROVIDER.
IF NO MORE PATIENTS, THANK THE RESPONDENT AND END THE CALL.