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 2011

(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

Did you bill for the services provided in (PATIENT NAME)’s home during the calendar year 2011 by month, by 60-day period, or by week?

(IF SOME OTHER PERIOD: What was that?)

D1. During calendar year 2011, 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 2011

MONTH:

D2. I need to know which types of home care personnel provided care to (PATIENT NAME) (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.

1. HOME HEALTH AIDE
   
   HOURS/MINUTES_____ VISITS_____
   
   
2. HOMEMAKER
   
   HOURS/MINUTES_____ VISITS_____
   
   
3. I.V./INFUSION THERAPIST
   
   HOURS/MINUTES_____ VISITS_____
   
   
4. NURSE/ NURSE PRACTIONER
   
   HOURS/MINUTES_____ VISITS_____
   
   
5. NURSE’S AIDE
   
   HOURS/MINUTES_____ VISITS_____
   
   
6. OCCUPATIONAL THERAPIST
   
   HOURS/MINUTES_____ VISITS_____
   
   
7. PERSONAL CARE ATTENDANT
   
   HOURS/MINUTES_____ VISITS_____
   
   
8. PHYSICAL THERAPIST
   
   HOURS/MINUTES_____ VISITS_____
   
   
9. RESPIRATORY THERAPIST
   
   HOURS/MINUTES_____ VISITS_____
   
   
10. SOCIAL WORKER
    
    HOURS/MINUTES_____ VISITS_____
    
    
11. SPEECH THERAPIST
    
    HOURS/MINUTES_____ VISITS_____
    
    
12. YARD WORKER
    
    HOURS/MINUTES_____ VISITS_____
    
    
13. DRIVER
    
    HOURS/MINUTES_____ VISITS_____
    
    
14. BABYYSITTER
    
    HOURS/MINUTES_____ VISITS_____
    
    
15. Any other home care personnel?
    
    YES ..... 1
    NO ...... 2

D3. I need a description of the services provided (during (MONTH)/from (BEGIN DATE) through (END DATE)).

C2. What were the charges for the services provided to (PATIENT NAME) (during (MONTH)/from (BEGIN DATE) through (END DATE))?

NOTE: WE NEVER ENTER $0 FOR A CHARGE

$________.____

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.

1. Patient or Patient’s Family ....... $__________.____
2. Medicare ............................... $__________.____
3. Medicaid ................................ $__________.____
4. Private Insurance ................... $__________.____
5. VA/Champva ......................... $__________.____
6. Tricare .................................. $__________.____
7. Worker’s Comp; ..................... $__________.____
8. 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 DK/REF/RETRIEVABLE – CONTINUE TO BOX 1.]

DO TOTAL PAYMENTS EQUAL TOTAL CHARGES?

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 C4.

PLC1. It appears that the total payments were less than the total charge. Is that because...

1. There were adjustments or discounts ..... YES=1 NO=2
2. You are expecting additional payment .... YES=1 NO=2
3. This was charity care or sliding scale ..... YES=1 NO=2
4. This was bad debt ................................ YES=1 NO=2

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 (VISIT DATE) and now for (this visit/these visits). Was it a:

C6_adjustments
PAYMENTS LESS THAN CHARGES:
Adjustment or discount

1. Medicare limit or adjustment? ................ YES=1 NO=2
2. Medicaid limit or adjustment? ................. YES=1 NO=2
3. Contractual arrangement with insurer or managed care organization? ............... YES=1 NO=2
4. Courtesy discount? ............................... YES=1 NO=2
5. Insurance write-off? ............................. YES=1 NO=2
6. Worker’s Comp limit or adjustment? ...... YES=1 NO=2
7. Eligible veteran? .................................. YES=1 NO=2
8. Something else? .................................. YES=1 NO=2
   (IF SOMETHING ELSE: What was that? _______________)

9. Patient or Patient’s Family? ................... YES=1 NO=2
10. Medicare? ........................................... YES=1 NO=2
11. Medicaid? ............................................ YES=1 NO=2
12. Private Insurance? ............................... YES=1 NO=2
13. VA/Champva? ..................................... YES=1 NO=2
14. Tricare? .............................................. YES=1 NO=2
15. Worker’s Comp? ................................. YES=1 NO=2
16. Something else ................................... YES=1 NO=2
    (IF SOMETHING ELSE: What was that? _______________)

17. Charity care or sliding scale?.............. YES=1 NO=2
18. Bad debt?......................................... YES=1 NO=2

19. Medicare adjustment?...................... YES=1 NO=2
20. Medicaid adjustment?...................... YES=1 NO=2
21. Private insurance adjustment?.......... YES=1 NO=2
22. Something else?.............................. YES=1 NO=2
    (IF SOMETHING ELSE: What was that? _______________)

LSPCHECK WAS ANY LUMP SUM ASSOCIATED WITH THE SOURCES OF PAYMENT?

YES ..... 1
NO ...... 2

[GO TO FINISH.]

FINISH SCREEN

PRESS VALIDATE TO COMPLETE THIS EVENT FORM.