Form Approved
OMB Number 0935-0118
Expiration Date 12/31/2015
OMB STATEMENT
(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.)
[A] CALL PROVIDER
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 A2b= 1 GO TO B1,
IF A2b=2, GO TO CONTACT BLOCK
IF A2=3 GO TO EXIT SCREEN]
[B] IDENTIFY DC POC
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 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]
B4. At this time, [NUMBER FROM PATIENT LIST] patient[s] identified [PROVIDER] as a source of health care during 2014. [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 2014. {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?
[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.]
[C] IDENTIFY BILLING SERVICE
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 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 2014. [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 2014.)
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?
[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 C3 = 1 GO TO CONTACT BLOCK,
IF C2 = 2 GO TO EXIT SCREEN.]
[D] CALL BILLING SERVICE
D1. Have I reached [BILLING SERVICE]?
PHONE NUMBER: [BILLING SERVICE TELEPHONE NUMBER]
[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 2014. 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 UNAVAILABLE ATTEMPT 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]
[E] BILLING SERVICE: IDENTIFY POC
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 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 2014.
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?
[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]
[F] DC: EXPLAIN NEXT STEPS
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 2014, 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.
[If F1=1; We will work with you to set up a good time to collect the data over the phone.
We may call again if other patients identify your practice as a source of medical services.]
[Instrument logic will be implemented so text only appears on screen when provider verification has not been completed]: Before we send you the form(s) I’ll need to determine that all of the providers I have listed were in fact associated with this home care agency in 2014. I’m going to read you a list of providers; please tell me if each one was associated with this home care agency in 2014.]
[GO TO EXIT]
[G] VERIFY RECEIPT OF AFs
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?
[IF COMPLETE, GO TO EXIT SCREEN]
G4 Our records indicate that you will [fax/mail] the records to us.
Please send in the complete billing and payment records for all [FILL_YR\ dates of service for each client listed. The information we are attempting to collect from these records includes services, charges, payments, and adjustments for each date of service. [IF THE POC MENTIONS UB04 OR CMS 1500, SAY:] We can use UB04/CMS1500 forms, but also need a final itemized statement that includes payments and adjustments so that we do not have to call back to obtain this information.
When will you send us these records?
DATE:_______
IF DATE IS SELECTED REPEAT THE DATE AND THE DAY OF THE WEEK
OR
________ (NUMBER)G4_1: Thank you. We will call you back if we do not receive the records by [FILL DATE FROM G4 (CALCULATE DATE IF DAYS/WEEKS ENTERED)].
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
G4_2:
INTERVIEWER: USE THIS SCREEN WHEN PROMPTING FOR RECORDS
We were anticipating receiving billing and payment records from you by [DATE/CALCULATED DATE FROM G4], but my records show we have not received them. Have you sent the records to us?
FILL DATE/CALCULATED DATE FROM G4.
IF G4_2 = 2 GO G4_5
G4_3: How did you send the records? Did you fax, mail hardcopies via express or regular mail, mail CDs via express or regular mail, or use healthport?
FAX..............................................................1
MAIL HARDCOPIES VIA EXPRESS MAIL...2
MAIL HARDCOPIES VIA REGULAR MAIL...3
MAIL CDs VIA EXPRESS MAIL...................4
MAIL CDs VIA REGULAR MAIL...................5
HEALTHPORT.............................................6
OTHER (Specify:__________________)…….7
IF POC IS SENDING CD: Was the password provided or did you send it separately?
G4_4: What date did you send them?
DATE:_______
Thank you for sending them. The records are received in a separate department and it can take a few days to upload the documents into our system. We will investigate and call you back if we have further questions. We apologize for any inconvenience.
INTERVIEWER:
DATE SHOULD BE CALENDAR DROP DOWN
NEXT WILL ROUTE TO EXIT SCREEN
G4_5
We need to obtain these records for the study as soon as possible. Is there something that can be done to speed up (or expedite) the process?
INTERVIEWER: LISTEN TO POC TO DETERMINE IF THERE IS ANYTHING WE CAN DO TO HELP FACILITATE THEM SENDING IN RECORDS. OFFER:
When will you send us these records?
DATE:______________
IF DATE IS SELECTED REPEAT THE DATE AND DAY OF THE WEEK
OR
____________(NUMBER)
Please send in the complete billing and payment records for all [FILL_YR] dates of service for each client listed. The information we are attempting to collect from these records includes, services, charges, payments, and adjustments for each date of service. [IF THE POC MENTIONS UB04 OR CMS 1500, SAY:] We can use UB04/CMS1500 forms, but also need a final itemized statement that includes payments and adjustments so that we do not have to call back to obtain this information.
G4_6: Thank you. We will call you back if we do not receive the records by [FILL DATE FROM G4_5 (CALCULATE DATE IF DAYS/WEEKS ENTERED)].
INTERVIEWER: SET A CALL BACK AFTER THE RECORDS ARE EXPECTED SO WE CAN PROMPT AGAIN IF THEY STILLHAVE NOT BEEN RECEIVED.
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,]
[H] BAD BILLING SERVICE INFO.
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]
[I] ANY OTHER BILLING SERVICE?
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 2014. Could you please check to see if another billing service maintained billing and payment records for [PROVIDER(S)] in 2014?
[IF I1=1, GO TO CONTACT BLOCK,
IF I1=2, GO TO EXIT SCREEN]
CONTACT BLOCK
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?
CB2. WHAT TYPE OF POC IS THIS PERSON?
UndefinedCB3. WHAT TYPE OF PACKAGE ARE YOU SENDING?
CB3A: COMMENTS
CB4. ADD ANOTHER POC?
SET CALLBACK/APPOINTMENT
Can you please provide me with a better time to call back in order to reach him/her?
[ALL GO TO EXIT FROM HERE]
[J] Gaining Permission
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 2014. [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 2014. 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]?