MEDICAL EXPENDITURE PANEL SURVEY
MEDICAL PROVIDER COMPONENT
EVENT FORM
FOR
HOME CARE - NON-HEALTH CARE PROVIDERS
FOR
REFERENCE YEAR 2017

OMB

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DCS: READ THIS ALOUD ONLY IF REQUESTED BY RESPONDENT.

PRESS NEXT TO CONTINUE IN THIS EVENT FORM

PRESS BREAKOFF TO DISCONTINUE

BILLING

Did you bill for the services provided in (PATIENT NAME)’s home during the calendar year 2017 by month, by 60-day period, or by week?

BY MONTH = 1
BY 60-DAY PERIOD = 2
BY SOME OTHER PERIOD?
(USE THIS RESPONSE ONLY IF PROVIDER ABSOLUTELY CANNOT CALCULATE COSTS BY MONTH) = 3
BY WEEK = 4

(IF SOME OTHER PERIOD: What was that?)

DK/REF/RETRIEVABLE – CONTINUE TO D1

VISIT DATE

D1. During calendar year 2017, 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 2017

MONTH:

Month:_____
Year:_______

OR

BEGIN DATE:

Month:_____
Day:________
Year:_______

END DATE:

Month:_____
Day:________
Year:_______

SERVICES/CHARGES

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)) 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.

HOME HEALTH AIDE

HOURS/MINUTES_____ OR VISITS_____
HOMEMAKER

HOURS/MINUTES_____ OR VISITS_____
I.V./INFUSION THERAPIST

HOURS/MINUTES_____ OR VISITS_____
NURSE/ NURSE PRACTITIONER

HOURS/MINUTES_____ OR VISITS_____
NURSE’S AIDE

HOURS/MINUTES_____ OR VISITS_____
OCCUPATIONAL THERAPIST

HOURS/MINUTES_____ OR VISITS_____
PERSONAL CARE ATTENDANT

HOURS/MINUTES_____ OR VISITS_____
PHYSICAL THERAPIST

HOURS/MINUTES_____ OR VISITS_____
RESPIRATORY THERAPIST

HOURS/MINUTES_____ OR VISITS_____
SOCIAL WORKER

HOURS/MINUTES_____ OR VISITS_____
SPEECH THERAPIST

HOURS/MINUTES_____ OR VISITS_____
YARD WORKER

HOURS/MINUTES_____ OR VISITS_____
DRIVER

HOURS/MINUTES_____ OR VISITS_____
BABYSITTER

HOURS/MINUTES_____ OR VISITS_____
Other (Specify):

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
(IF OTHER WHAT WAS THAT?)

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

IF NO CHARGE: Some facilities that don't charge for each individual service do associate dollar amounts with services for purposes of budgeting or cost analysis. This is sometimes called a "charge equivalent". Could you give me the charge equivalents for these services?

VERIFY: IS THIS THE TOTAL CHARGE FOR (THIS/THESE) SERVICE(S)?
IF NOT, RECORD TOTAL CHARGE.

NOTE: WE NEVER ENTER $0 FOR A CHARGE

TOTAL CHARGES: $________.____

C2 - DK/REF/RETRIEVABLE – CONTINUE TO C4a

SOURCES OF PAYMENT

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.

Patient or Patient’s Family ....... $__________.____
Medicare ............................... $__________.____
Medicaid ................................ $__________.____
Private Insurance ................... $__________.____
VA/Champva ......................... $__________.____
Tricare .................................. $__________.____
Worker’s Comp; ..................... $__________.____
Or something else? ................. $__________.____
(IF SOMETHING ELSE: What was that? __________)
C4a(h) – “Other Specify” menu
Auto or Accident Insurance
Indian Health Service
State Public Mental Plan
State/County Local program
Other

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

VERIFICATION OF PAYMENT

C5a. 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 C4a.

YES, FINAL PAYMENTS RECORDED IN C4 AND C5 = 1 (GO TO LUMP SUM PAYMENT QUESTION)
NO = 2 (GO BACK TO C4a)

PAYMENTS LESS THAN CHARGES (UNDERPAYMENT)

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

There were adjustments or discounts ..... YES=1 NO=2
You are expecting additional payment .... YES=1 NO=2
This was charity care or sliding scale ..... YES=1 NO=2
This was bad debt ................................ YES=1 NO=2
Person is an eligible veteran................... YES=1 NO=2

DIFFERENCE BETWEEN PAYMENTS AND CHARGES

Are you expecting additional payment from:
IF THE ONLY PAYMENT FOR THIS EVENT WAS A LUMP SUM, ANSWER “NO” TO ALL OPTIONS

Expecting additional payment

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

ADJEXTRA

It appears that the total payments were more than the total charges. Is that correct?

YES = 1
NO = 2

DCS: IF THE ANSWER IS "NO" PLEASE GO BACK TO C5 (VERIFY TOTAL PAYMENTS) TO RECONFIRM CHARGES AND PAYMENTS AS NEEDED.

LUMP SUM PAYMENTS

LSPCHECK WAS THIS EVENT COVERED BY A LUMP SUM?

YES = 1
NO = 2

DK/REF/RET ALLOWABLE and SKIP TO END OF EVENT FORM

FINISH SCREEN

PRESS VALIDATE TO COMPLETE THIS EVENT FORM.

MEDICAL EXPENDITURE PANEL SURVEYMEDICAL PROVIDER COMPONENT EVENT FORMFORHOME CARE - NON-HEALTH CARE PROVIDERS FORREFERENCE YEAR 2017

OMB