MEPS-HC Survey Instrument

OMB#: 0935-0108

PATIENT LABEL

FORM ___ OF ___

MEDICAL EXPENDITURE SURVEY
MEDICAL PROVIDER COMPONENT
HOME CARE EVENT BOOKLET
FOR HEALTH CARE PROVIDERS
FOR
REFERENCE YEAR 2005

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M:\7690\7690.19.04\MPC 2005\Forms\HH\HH HC Prov Event Form.DOC - 4/26/2006 - 2:24 PM - cg

INTRODUCTION: [PATIENT NAME] reported that (he/she) received home care services from someone in this
organization during the calendar year 2005.
E1. During calendar year 2005, what was the
(first/next) month during which your records
show that home care services were provided to
(PATIENT NAME)?

E2. I need to know the diagnosis for [PATIENT
NAME] during [MONTH]. I would prefer the
ICD-9 codes (or DSM-IV codes), if they are
available.

MONTH: _____________ YEAR: 2005

CODE

DESCRIPTION

|__| ______________

_______________________

|__| ______________

_______________________

[IF CODES ARE NOT USED, RECORD
DESCRIPTIONS.]

|__| ______________

_______________________

[IF THERE ARE MORE THAN 4 DIAGNOSES,
USE A CONTINUATION SHEET.]

|__| ______________

_______________________

IF ONLY ONE DIAGNOSIS, GO TO E3. IF MORE THAN
ONE DIAGNOSIS:
E2a. Which of these was the principal diagnosis?

„ CHECK BOX FOR PRINCIPAL

DIAGNOSIS
„ CIRCLE '-8' IF PRINCIPAL

DIAGNOSIS NOT KNOWN ........................ -8

E3. I need to know which types of home care
personnel provided care to (PATIENT NAME)
during (MONTH) and either the number of
hours or the number of visits for each type.

HOURS/MINUTES: VISITS:
1. HOME HEALTH AIDE

_____ /

OR _____

2. HOMEMAKER

_____ /

OR _____

3. I.V./INFUSION THERAPIST _____ /

OR _____

4. NURSE/NURSE
PRACTITIONER

_____ /

OR _____

5. NURSE’S AIDE

_____ /

OR _____

6. OCCUPATIONAL
THERAPIST

_____ /

OR _____

7. PERSONAL CARE
ATTENDANT

_____ /

OR _____

8. PHYSICAL THERAPIST

_____ /

OR _____

9. RESPIRATORY
THERAPIST

_____ /

OR _____

10. SOCIAL WORKER

_____ /

OR _____

11. SPEECH THERAPIST

_____ /

OR _____

_____ /

OR _____

12. OTHER (SPECIFY):
___________________

|__| DURABLE MEDICAL
EQUIPMENT ONLY

2

|__|__|
OFFICE
USE
ONLY

E4.

I need the services provided during (MONTH). I would
prefer either the CPT-4 codes or the revenue codes, if
they are available.
[IF CODES ARE USED, CIRCLE WHICH TYPE OF
CODE IS USED. IF CODES ARE NOT USED,
RECORD DESCRIPTION OF SERVICES AND
PROCEDURES PROVIDED.]
[IF THERE ARE MORE THAN 8 SERVICES,
USE A CONTINUATION SHEET.]

C1a. Could you tell me the full established charges -before any adjustments or discounts -- for all services
provided by home care personnel during (MONTH).

CPT-4
CODE

REVENUE
CENTER
CODE

DESCRIPTION

__________

_________________

_______

__________

_________________

_______

__________

_________________

_______

__________

_________________

_______

__________

_________________

_______

__________

_________________

_______

__________

_________________

_______

__________

_________________

_______

FULL ESTABLISHED CHARGES FOR:

[EXPLAIN IF NECESSARY: This would be the
charges for the (READ TYPES OF PERSONNEL
FROM E3 ABOVE) who provided services during
(MONTH).]
C1b. And could you tell me the full established charges for
everything other than personnel during (MONTH),
including durable medical equipment, drugs, supplies,
and so forth?

PERSONNEL SERVICES:

$__________.____

ALL OTHER CHARGES:

$__________.____

(NON-PERSONNEL CHARGES)

[EXPLAIN IF NECESSARY: This would include
charges for anything OTHER than the services of the
home care personnel you just told me about.]
[EXPLAIN IF NECESSARY: The “full” established
charge is the charge maintained in the organization’s
billing system for billing insurance carriers and
Medicare or Medicaid. It is the “list price” for the
service, before consideration of any discounts or
adjustments resulting from contractual arrangements
or agreements with insurance plans. ]
[IF NO CHARGE: Some organizations that don't
charge on the basis of services provided 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 procedures? ]
C2. IF NOT VOLUNTEERED, ASK: And what was the
total of all of the full, established charges for
(PATIENT NAME) during (MONTH) ? [IF NOT
AVAILABLE, COMPUTE.]

TOTAL CHARGES:

3

$__________.____

|__|__|
OFFICE
USE
ONLY

C3. Was your organization reimbursed for the charges
during (MONTH) on a fee-for-service basis or a
capitated basis?
FEE-FOR-SERVICE BASIS...... 1

[EXPLAIN IF NECESSARY]
Fee-for-service means that the organization was
reimbursed on the basis of the services provided.

CAPITATED BASIS ................. 2 (C7a)

Capitated basis means that the patient was
enrolled in a prepaid managed care plan where
reimbursement is not tied to specific visits.
[INTERVIEWER: IF IN DOUBT, CODE FEE-FORSERVICE.]
C4. From what sources did the organization receive
payment for the charges for (MONTH) and how much
was paid by each source?
[INTERVIEWER NOTE: IF PAYMENT WAS A SET
DOLLAR AMOUNT FOR ALL CHARGES FOR THE
MONTH, GO BACK TO C3 AND CHANGE CODE
TO 2 (CAPITATED BASIS).]
IF NAME OF INSURER OR HMO, PROBE: And is
that Medicare, Medicaid, or private insurance?

C5. (IF NOT VOLUNTEERED, ASK:) And what was the
total of all payments received for (MONTH)?
(IF NOT AVAILABLE, COMPUTE.)

a. Patient or patient’s family

$__________.____

b. Medicare

$__________.____

c. Medicaid

$__________.____

d. Private Insurance

$__________.____

e. VA

$__________.____

f. TRICARE/CHAMPVA/
CHAMPUS

$__________.____

g. WORKER'S COMP

$__________.____

h. OTHER (SPECIFY):
_____________________

$__________.____

TOTAL PAYMENTS:

$__________.____

BOX 1
DO TOTAL PAYMENTS (C5) EQUAL TOTAL CHARGES (C2)?
YES ............................... 1 (E5)
NO ................................. 2 (C6)

4

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:
YES NO
Adjustment or discount
a. Medicare limit or adjustment..................... 1
2
b. Medicaid limit or adjustment ..................... 1
2
c. Contractual arrangement with insurer
or managed care organization................ 1
2
d. Courtesy discount ..................................... 1
2
e. Insurance write-off .................................... 1
2
f. Worker's Comp limit or adjustment........... 1
2
g. Eligible veteran ......................................... 1
2
h. Other (Specify:) ____________________ 1
2
Expecting additional payment
i. Patient or Patient’s Family ...........................
j. Medicare ........................................................
k. Medicaid .........................................................
l. Private Insurance ..........................................
m. VA....................................................................
n. TRICARE/CHAMPVA/CHAMPUS..............
o. WORKER'S COMP ..................................
p. Other (Specify:) ____________________

1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2

q. Charity care or sliding scale .................... 1
r. Bad debt ........................................................ 1

2
2

PAYMENTS MORE THAN CHARGES:
s. Medicare adjustment ....................................
t. Medicaid adjustment ....................................
u. Private insurance adjustment......................
v. Other (Specify:).........................................
________________________________

2
2
2
2

GO TO E5

5

1
1
1
1

CAPITATED BASIS
C7a. What kind of insurance plan covered the patient
during (MONTH)? Was it:
IF NAME OF INSURER OR HMO, PROBE: And is
that Medicare, Medicaid, or private insurance?

a.
b.
c.
d.
e.
f.
g.

YES NO
Medicare;.................................................. 1
2
Medicaid; .................................................. 1
2
Private Insurance; .................................... 1
2
VA;............................................................ 1
2
TRICARE/CHAMPVA/CHAMPUS;........... 1
2
Worker's Comp; or ................................... 1
2
Something else? (SPECIFY:).................. 1
2
________________________________

C7b. Was there a co-payment for any of the services
provided during (MONTH)?

YES ...........................................................
NO .............................................................

C7c. What was the total of all co-payments for
(MONTH)?

$___________.__

C7d. Who paid these co-payments?
IF NAME OF INSURER OR HMO, PROBE: And is
that Medicare, Medicaid, or private insurance?

a.
b.
c.
d.
e.

YES NO
PATIENT OR PATIENT’S FAMILY .......... 1
2
MEDICARE .............................................. 1
2
MEDICAID ................................................ 1
2
PRIVATE INSURANCE............................ 1
2
OTHER
(SPECIFY:) _______________________ 1
2

C7e. Do your records show any other payments for any
of the services provided during (MONTH)?

YES ..........................................................
NO ............................................................

C7f. From what other sources has the organization
received payment and how much was paid by
each source?

a. Patient or patient’s family
b. Medicare
c. Medicaid
d. Private Insurance
e. VA
f. TRICARE/CHAMPVA/
CHAMPUS
g. WORKER'S COMP
h. OTHER (SPECIFY):
_____________________

IF NAME OF INSURER OR HMO, PROBE: And
is that Medicare, Medicaid, or private insurance?

6

1
2 (C7e)

1
2 (E5)

$__________.____
$__________.____
$__________.____
$__________.____
$__________.____
$__________.____
$__________.____
$__________.____

E5. Have we covered all of the months (PATIENT NAME)
received home care services during the calendar year
2005?

YES, ALL MONTHS COVERED............. 1 (E6)

E6. IF ALL MONTHS 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.

NO DIFFERENCE OR PROVIDER
REPORTED MORE MONTHS OF
HOME CARE SERVICE THAN
HOUSEHOLD ....................................... 1 (E7)

NO, NEED TO COVER ADDITIONAL
MONTHS .............................................. 2 (E1 NEXT
EVENT
FORM)

PROVIDER RECORDED FEWER
VISITS................................................... 2
PROBE: (PATIENT NAME) reported
(NUMBER) months of home care service.
Do you have any information in your records
that would explain this discrepancy?
_____________________________
_____________________________
_____________________________

E7.

GO TO NEXT PATIENT FOR THIS PROVIDER.
IF NO MORE PATIENTS, THANK THE RESPONDENT AND END THE CALL.

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