MEDICAL PROVIDER COMPONENT
FOR REFERENCE YEAR 2009
CONTACT GUIDE FOR SEPARATELY BILLING DOCTORS
A1. [1] (ASK IF NOT OBVIOUS) Have I reached (PROVIDER)?
YES -- CONTINUE WITH A2
NO -- VERIFY TELEPHONE NUMBER, ADDRESS, AND NAME OF PROVIDER. IF PROVIDER IS DIFFERENT, RECORD PROBLEM AND TERMINATE CALL. CONTACT DIRECTORY ASSISTANCE. IF NO BETTER TELEPHONE NUMBER CAN BE FOUND, MARK FOR SUPERVISOR REVIEW.
A2. [2] May I please have the name and telephone number of the office manager or the person who can help me with billing records from 2009?
___ SPEAKING TO PERSON WHO DID THE BILLING IN 2009 --> RECORD NAME AND VERIFY TELEPHONE NUMBER
(May I please have your name?) (IF ONLY FIRST NAME GIVEN PROBE FOR FULL NAME)
NAME: ____________________
The telephone number that I dialed is (FILL TELEPHONE NUMBER). Is that the best number at which to reach you?
TELEPHONE NUMBER: (____) ____________________ EXT: ________
YES -- CONTINUE WITH "INTRODUCTION"
NO -- MAKE CORRECTIONS AS NECESSARY, THEN CONTINUE WITH "INTRODUCTION"
___ OFFICE MANAGER -- RECORD NAME AND TELEPHONE NUMBER
NAME: _______________
TELEPHONE NUMBER: (____) ____________________ EXT: ________
Will you please transfer me to them?
YES -- CONTINUE WITH "INTRODUCTION"
NO -- TERMINATE CALL, CONTACT OFFICE MANAGER, CONTINUE WITH "INTRODUCTION"
___ INTERNAL BILLING DEPARTMENT -- RECORD NAME AND TELEPHONE NUMBER
NAME: ___________________
TELEPHONE NUMBER: (_____)____________________ EXT: ________
Will you please transfer me to them?
YES -- CONTINUE WITH "INTRODUCTION"
NO -- TERMINATE INITIAL CALL, CONTACT BILLING DEPARTMENT, CONTINUE WITH "INTRODUCTION"
___ BILLING IS PERFORMED BY AN OUTSIDE BILLING SERVICE --
ASK TO SPEAK TO SOMEONE AT THE PROVIDER OFFICE WHO DEALS WITH THE OUTSIDE BILLING SERVICE -- RECORD NAME AND TELEPHONE NUMBER
NAME: ________________
TELEPHONE NUMBER: (_____)____________________ EXT: ________
Will you please transfer me to them?
YES -- CONTINUE WITH "INTRODUCTION"
NO -- TERMINATE CALL, CONTACT PERSON WHO DEALS WITH BILLING SERVICE, CONTINUE WITH "INTRODUCTION"
___ NO BILLING DEPARTMENT; NOT CLEAR WHO TO SPEAK TO --> RECORD PROBLEM;
TERMINATE CALL AND MARK FOR SUPERVISOR REVIEW
[INTRODUCTION]
(Hello,) my name is (YOUR NAME) and 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.
A3. [A2] CONTROL SYSTEM WILL FLAG IF PROVIDER IS PART OF CONTACT GROUP:
IF CONTACT GROUP 1 (GO TO A3a)
IF NOT CONTACT GROUP 2 (GO TO A4)
A3a. [A2a] I need to determine if the following providers were associated with this practice during 2009.
REVIEW EACH PROVIDER WITH THE POC AND VERIFY WHETHER THE PROVIDER IS IN THE CONTACT GROUP
[CONTINUE WITH A4 FOR PROVIDERS IN THE CONTACT GROUP. PROVIDERS WHO ARE NOT IN THE CONTACT GROUP WILL BE REMOVED FROM THIS GROUP AND TREATED SEPARATELY WITHIN THE SYSTEM]
[ALL GO TO A4 EXCEPT OUTSIDE BILLING; IF A2 = OUTSIDE BILLING GO TO A7]
A4. [A3] We were referred to you by (HOSPITAL/INSTITUTIONAL PROVIDER(S)) for information about [NUMBER FROM PATIENT LIST] of their patient(s) who received care from (SBD PROVIDER) in 2009. (The/Each) patient signed an authorization form allowing us to contact you for information about the cost of the care they received from (SBD PROVIDER) in 2009. Much of the information we need is within the billing records. I would like to fax the authorization form(s) to you, along with additional information explaining the study.
IF ASKED READ PATIENT NAMES AND OTHER IDENTIFYING INFORMATION FROM THE PATIENT DATA FORM
READ IF THE RESPONDENT 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.
OFFICE MAINTAINS THE INFORMATION:
FAX AUTHORIZATION FORM(S) 1 (GO TO A4)
MAIL AUTHORIZATION FORM(S) 2 (GO TO A5)
OFFICE DOES NOT MAINTAIN THE INFORMATION:
NEED TO CONTACT BILLING SERVICE 3 (GO TO A8)
THIS TYPE OF INFORMATION IS NOT AVAILABLE
(RECORD REASON:) 4 (TERMINATE AND MARK FOR SUPERVISOR REVIEW)
A4. [A4] I need to be sure I have the correct information for the fax cover page.
Should I address this fax to you?
YES -- What is the fax number I can use to send you these authorization form(s)?
FAX NUMBER: (_____)
Can I also have your title and department?
TITLE: ________________
DEPARTMENT: ______________
GO TO A6
NO -- Please tell me to whom I should fax this information.
NAME: ______________
TITLE: _____________
DEPARTMENT: ___________
FAX NUMBER: (_____)
TELEPHONE: (_____) ______________ EXT: ________
GO TO A6
A5. [A5] I need to make sure that I have the correct mailing information.
Should I address the package to you?
YES -- What is the mailing address that I can use to send you the authorization form(s)?
TITLE: _________________
DEPARTMENT: _____________
ADDRESS: ________________
CITY: _______ STATE: ________ ZIP: ________
NO -- Can I have that person's information to mail the authorization form(s)?
NAME: __________________
TITLE: ____________
DEPARTMENT: _______________
ADDRESS: ______________
CITY: _______ STATE: ________ ZIP: ______
TELEPHONE NUMBER: (____) _____________________
A6. [A6] Once you have received the authorization form(s), we will call back to collect the data over the phone.
For specific dates of service in 2009, we are requesting information about charges, payments, diagnoses, and services provided.
What would be the best day and time to call back to collect this information by phone?
DAY:___________ DATE:_________ R's TIME: ______ AM/PM _____
IF PROVIDER DOESN'T WANT TO PROVIDE DATA OVER THE PHONE, OFFER FAX OR MAIL
You can send us the medical records by either fax or mail.
PROVIDER WILL RESPOND:
BY PHONE 1
BY FAX 2
BY MAIL 3
IF POINT OF CONTACT (POC) WILL RESPOND BY PHONE READ:
Thank you very much. We will allow time for you to receive and review the authorization form(s), and then we will call you back to collect the data.
IF POC WILL RESPOND BY FAX OR MAIL READ:
We hope you can send the records to our office within two weeks. We will include an instruction sheet when we (fax/mail) the authorization form(s). If you have any questions about what to send us, please call our toll-free number on the instruction sheet. We may call again if other patients identify this practice as a source of medical services. Thank you very much for your help.
A7. [A3/A7] [NUMBER FROM PATIENT LIST] patient(s) identified (SBD PROVIDER) as a source of health care during 2009. (The/Each) patient signed an authorization form allowing us to contact you for information about the cost of the care they received from (SBD PROVIDER) in 2009. 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.
A8. [A7] Can you please provide the name of the billing service, the name of a contact person, their telephone number and title?
NAME OF BILLING SERVICE: _________________
CONTACT NAME: _________________
TELEPHONE:(______) ____________________ EXT: ________
TITLE: ________________________________________
Thank you for that information.
A9. [A8] We would like to fax you a copy of the authorization form(s) for your files.
FAX AUTHORIZATION FORM(S) 1 (GO TO A9a)
MAIL AUTHORIZATION FORM(S) 2 (GO TO A9b)
A9a. [A8] I need to be sure I have the correct information for the fax cover page.
Should I address this fax to you?
YES -- What is the fax number I can use to send you the authorization form(s)?
FAX NUMBER: (____) ____________________
Can I also have your title and department?
TITLE: ____________________________
DEPARTMENT: _____________________
NO -- Please tell me to whom I should fax this information.
NAME: _________________
TITLE: _________________
DEPARTMENT: _______________
FAX NUMBER: ________________________
TELEPHONE: (_____) ________________________
Thank you very much for your help. We may call again if other patients identify this practice as a source of medical services. END CONTACT AND CALL BILLING SERVICE NAMED IN A8.
[CONTINUE WITH A10]
A9b. [A8] I need to make sure that I have the correct mailing information.
Should I address the package to you?
YES -- What is the mailing address that I can use to send you the authorization form(s)?
TITLE: _________________
DEPARTMENT: _______________
ADDRESS: ____________
CITY: _______ STATE: ________ ZIP: ________
NO -- Can I have that person's information to mail the authorization form(s)?
NAME: _________________
TITLE: __________________
DEPARTMENT: ____________
ADDRESS:__________________
CITY: _______ STATE: ________ ZIP: ______
TELEPHONE NUMBER: (____) __________________ EXT: ________
Thank you very much for your help. We may call again if other patients identify this practice as a source of medical services. END CONTACT AND CALL BILLING SERVICE NAMED IN A8.
[CONTINUE WITH A10]
BILLING SERVICE
A10. [N/A] (ASK IF NOT OBVIOUS) Have I reached (BILLING SERVICE)?
YES -- CONTINUE WITH A11
NO -- VERIFY TELEPHONE NUMBER, ADDRESS, AND NAME OF BILLING SERVICE. IF BILLING SERVICE IS DIFFERENT, RECORD PROBLEM AND TERMINATE CALL. CONTACT DIRECTORY ASSISTANCE. IF NO BETTER TELEPHONE NUMBER CAN BE FOUND, GO TO "RECONTACT PROVIDER OFFICE"
A11. [N/A] May I please speak to the person who did the billing for (PROVIDER(S)) in 2009?
___ SPEAKING TO PERSON WHO DID THE BILLING IN 2009 -- RECORD NAME AND VERIFY TELEPHONE NUMBER
(May I please have your name?) (IF ONLY FIRST NAME GIVEN PROBE FOR FULL NAME)
NAME: ______________
The telephone number that I dialed is (FILL TELEPHONE NUMBER). Is that the best number at which to reach you?
TELEPHONE NUMBER: (____) __________________ EXT: ________
YES -- CONTINUE WITH A12
NO -- MAKE CORRECTIONS AS NECESSARY, THEN CONTINUE WITH A12
___ POC PROVIDED
May I please have the (name and) telephone number of the person who did the billing for (PROVIDER(S)) in 2009? --
RECORD NAME AND TELEPHONE NUMBER
NAME: _______________
TELEPHONE NUMBER: (____)___________________ EXT: ________
Will you please transfer me to them?
YES -- CONTINUE WITH A12
NO -- TERMINATE CALL, CONTACT PERSON WHO DEALS WITH BILLING FOR PROVIDER(S), AND CONTINUE WITH A12
___ BILLING SERVICE DID NOT MAINTAIN RECORDS FOR (PROVIDER(S)) IN 2009 -- TERMINATE CALL; GO TO "RECONTACT PROVIDER OFFICE"
A12. [A9] (Hello,) my name is (YOUR NAME) and 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. We were referred to you by HOSPITAL/INSTITUTIONAL PROVIDER(S)) for information about [NUMBER FROM PATIENT LIST] of their patient(s) who received care from (SBD PROVIDER) in 2009. (The/Each) patient signed an authorization form allowing us to contact you for information about the cost of the care they received from (SBD PROVIDER) in 2009. I would like to fax the authorization form(s) to you along with additional information explaining the study.
IF ASKED READ PATIENT NAMES AND OTHER IDENTIFYING INFORMATION FROM THE PATIENT DATA FORM
[READ IF THE RESPONDENT 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.
FAX AUTHORIZATION FORM(S) ...1 (GO TO A13)
MAIL AUTHORIZATION FORM(S) ... 2 (GO TO A14)
OFFICE DOES NOT MAINTAIN THE INFORMATION ...3 (TERMINATE AND MARK FOR SUPERVISOR REVIEW)
A13. [A10] I need to be sure I have the correct information for the fax cover page.
Should I address this fax to you?
YES -- What is the fax number I can use to send you the authorization form(s)?
FAX NUMBER: (____)_____________________
Can I also have your title and department?
TITLE: ______________
DEPARTMENT: ________________
GO TO A15
NO -- Please tell me to whom I should fax this information:
NAME: _____________
TITLE: _______________
DEPARTMENT: ______________
FAX NUMBER: (____)______________________
TELEPHONE NUMBER: ( ____)___________________ EXT: ________
GO TO A15
A14. [A11] I need to make sure that I have the correct mailing information.
Should I address the package to you?
YES -- What is the mailing address that I can use to send you the authorization form(s)?
TITLE: _________________
DEPARTMENT: _______________
ADDRESS: _________________
CITY: _______ STATE: ________ ZIP: ________
NO -- Can I have that person's information to mail the authorization form(s)?
NAME: _______________
TITLE: ____________
DEPARTMENT: ______________
ADDRESS: __________________
CITY: _______ STATE: ________ ZIP: ______
TELEPHONE NUMBER: (____) ______________ EXT: ________
A15. [A12] Once you have received the authorization form(s), we will call back to collect the data over the phone. For specific dates of service in 2009, we are requesting information about charges, payments, diagnoses, and services provided.
What would be the best day and time to call back to collect this information by phone?
DAY:___________ DATE:_________ R's TIME: AM/PM
IF BILLING SERVICE DOESN'T WANT TO PROVIDE DATA OVER THE PHONE, OFFER FAX OR MAIL
You can send us the medical records by either fax or mail.
BILLING SERVICE WILL RESPOND:
BY PHONE 1
BY FAX 2
BY MAIL 3
IF POC WILL RESPOND BY PHONE READ:
Thank you very much. We will allow time for you to receive and review the authorization form(s), and then we will call you back to collect the data.
IF POC WILL RESPOND BY FAX OR MAIL READ:
We hope you can send the records to our office within two weeks. We will include an instruction sheet when we (fax/mail) the authorization form(s). If you have any questions about what to send us, please call our toll-free number on the instruction sheet. We may call again if other patients identify a practice associated with this billing service as a source of medical services. Thank you very much for your help.
CALL BACK TO CONFIRM AUTHORIZATION FORM(S)
A16. [A13] May I please speak to (POC)?
Hello, my name is (YOUR NAME) and I am calling on behalf of the U.S. Department of Health and Human Services. We previously spoke about the MEPS study. Did you receive the authorization form(s) we (faxed/sent)?
YES (GO TO A17 IF MODE = PHONE; GO TO A19 IF MODE = FAX OR MAIL)
NO(GO TO A20)
IF MODE = PHONE, ASK A17
A17. [A18] If it is convenient for you, we can just go ahead and complete the data form(s) together over the phone right now. I’d be happy to hold on while you get the information you need from your records.
WILL COMPLETE BY PHONE NOW 1 (GO TO EVENT FORM)
WILL COMPLETE BY PHONE IN THE FUTURE 2 (GO TO A18)
A18. [A17] What would be the best day and time to call you back?
DAY:___________ DATE:_________ R's TIME:____ AM/PM ____
Thank you very much for your help.
IF MODE = FAX OR MAIL, ASK A19
A19. [N/A] Our records indicate that you will (fax/mail) the records to us. We hope you can do so within two weeks.
Thank you very much for your help.
A20. [A14] I'm sorry. Let me (re-fax/re-send) the authorization form(s) to you.
FAX AUTHORIZATION FORM(S) 1 (GO TO A21)
MAIL AUTHORIZATION FORM(S) 2 (GO TO A22)
IF ASKED READ PATIENT NAMES AND OTHER IDENTIFYING INFORMATION FROM THE PATIENT DATA FORM
[READ IF THE RESPONDENT 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.
A21. [A15] IF FAXED PREVIOUSLY: Before I send the authorization form(s) again, I would like to verify the information to include on the fax cover page.
CONFIRM PRELOAD INFORMATION
FAX NUMBER: (____) _____________
NAME: ______________
TITLE: ________________
DEPARTMENT: _________________
We will call again to ensure that you received the authorization form(s). Thank you for your help.
IF MAILED PREVIOUSLY: I need to be sure I have the correct information for the fax cover page.
Should I address this fax to you?
YES -- What is the fax number I can use to send you the authorization form(s)?
FAX NUMBER: (_____)______________________
Can I also have your title and department?
TITLE: ________________________________
DEPARTMENT: ________________
NO -- Please tell me to whom I should fax this information.
NAME: ______________
TITLE: _______________
DEPARTMENT: ___________________
FAX NUMBER: (_____)______________________
TELEPHONE NUMBER: (______)_______________ EXT: ________
We will call again to ensure that you received the authorization form(s). Thank you for your help.
A22. [A16] IF MAILED PREVIOUSLY: Before I send the authorization form(s) again, I would like to verify the information on the mailing label.
CONFIRM PRELOAD INFORMATION
NAME: __________________
TITLE: ______________
DEPARTMENT: _______________
ADDRESS: ________________
CITY: __________ STATE: ______ ZIP:
TELEPHONE NUMBER: (______)_______________ EXT: ________
We will call again to ensure that you received the authorization form(s). Thank you for your help.
IF FAXED PREVIOUSLY: I need to make sure that I have the correct mailing information.
Should I address the package to you?
YES -- What is the mailing address that I can use to send you the authorization form(s)?
TITLE: _____________
DEPARTMENT: __________
ADDRESS: ________________
CITY: _______ STATE: ________ ZIP: ________
NO -- Can I have that person's information to mail the authorization form(s)?
NAME: ____________
TITLE: ______________
DEPARTMENT: ______________
ADDRESS: _________________
CITY: _______ STATE: ________ ZIP: ______
TELEPHONE NUMBER: (______)_______________ EXT: ________
We will call again to ensure that you received the authorization form(s). Thank you for your help.
RECONTACT PROVIDER OFFICE [N/A]
INCORRECT BILLING SERVICE
Hello may I speak to (POC)? This is (YOUR NAME) calling on behalf of the U.S. Department of Health and Human Services. We previously spoke about the MEPS study. Thank you for providing the contact information for (BILLING SERVICE). Unfortunately we were unable to locate (BILLING SERVICE) with the information you provided. Could you please verify the contact information we currently have for (BILLING SERVICE)?
NAME OF BILLING SERVICE: __________________
CONTACT NAME: __________________
TELEPHONE NUMBER: (______)_______________ EXT: ________
TITLE: ___________________________________________
SAME INFORMATION CONFIRMED – That is currently the information we have on file. Do you know of any other way we can get in touch with (BILLING SERVICE)?
YES -- COLLECT OTHER CONTACT INFORMATION
NAME OF BILLING SERVICE: ______________
CONTACT NAME: ___________________
TELEPHONE NUMBER: (______)_______________ EXT: ________
TITLE: __________________________________________
NO -- END CONTACT AND MARK FOR SUPERVISOR REVIEW
Thank you very much for your help.
DID NOT MAINTAIN RECORDS
Hello may I speak to (POC)? This is (YOUR NAME) calling on behalf of the U.S. Department of Health and Human Services. We previously spoke about the MEPS study. Thank you for providing the contact information for (BILLING SERVICE). We were able to locate (BILLING SERVICE) with the information you provided. However, they reported that they did not maintain the billing records for (PROVIDER(S)) in 2009. Could you please check to see if another billing service provided billing records for (PROVIDER(S)) in 2009?
OTHER BILLING SERVICE PROVIDED --
What is the name of the billing service, the name of a contact person, their telephone number and title?
NAME OF BILLING SERVICE: _____________
CONTACT NAME: _______________
TELEPHONE NUMBER: (______)_______________ EXT: ________
TITLE: __________________________________________
Thank you very much for your help.
NO OTHER BILLING SERVICE PROVIDED -- END CONTACT AND MARK FOR SUPERVISOR REVIEW