MEPS-MPC-Home Health

OMB#: 0935-0108

PROVIDER LABEL

MEDICAL PROVIDER COMPONENT
FOR REFERENCE YEAR 2005
CONTACT GUIDE FOR OFFICE-BASED PROVIDERS

A1.

ASK IF NOT OBVIOUS: Have I reached (PROVIDER)?
CORRECT PROVIDER Æ CONTINUE WITH A2
PROBLEM WITH PROVIDER Æ RECORD INFORMATION BELOW, TERMINATE CALL,
AND CONSULT WITH TASK COORDINATOR
__________________________________________________________________
__________________________________________________________________

A2.

May I please speak to the office manager or the person who does the billing?
HAS BILLING DEPARTMENT Æ CONTINUE WITH A3
BILLING IS PERFORMED BY AN OUTSIDE BILLING SERVICE
Æ ASK TO SPEAK TO SOMEONE WHO DEALS WITH THE BILLING SERVICE
NO BILLING DEPARTMENT AND IT IS NOT CLEAR WHO TO SPEAK TO
Æ RECORD INFORMATION BELOW, TERMINATE CALL, AND CONSULT WITH
TASK COORDINATOR ____________________________________________
________________________________________________________________

A3.

Hello, my name is (YOUR NAME) and I am calling on behalf of the U.S. Public Health Service.
First, let me verify that this is a doctor's office and not a hospital.
PHYSICIAN'S OFFICE, PUBLICLY-FUNDED CLINIC,
URGI-CENTER ......................................................................
HEALTH MAINTENANCE ORGANIZATION (HMO) ...................
HOSPITAL, HOSPITAL SATELLITE CLINIC, HOSPITAL
OUTPATIENT DEPARTMENT, SURGI-CENTER ................

(TERMINATE CALL AND
CONSULT A TASK
COORDINATOR)
(HOSPITAL CONTACT
GUIDE)

HOME HEALTH PROVIDER ........................................................

(HOME HEALTH
CONTACT GUIDE)

LONG-TERM CARE FACILITY SUCH AS A NURSING HOME...

(INSTITUTION CONTACT
GUIDE)

SOMETHING ELSE (SPECIFY:__________________________
________________________________________________ ...

(TERMINATE AND
CONSULT A TASK
COORDINATOR)

1
M:\7690\7690.19.04\2005 Deliveries\DEL #165 Data Collection Forms\OB Contact Guide.doc - 12/9/2005 - 12:07 PM - SH

A4.

And is there at least one physician in the practice who is a Medical Doctor or a Doctor of Osteopathy?
YES ...............................................................................................
NO ...............................................................................................

1
2 Æ For this study, we are
only asking about care
provided by or supervised by
Medical Doctors and Doctors
of Osteopathy. Thank you
very much for your time.
[END CONTACT.
PRACTICE NOT ELIGIBLE.]

A5.

INTERVIEWER: IS THIS A RUBBERBAND CASE?
YES................................................................................................
NO .................................................................................................
A5a.

A6.

1 (A5a)
2 (A6)

I need to determine if the following providers were associated with this practice during 2005.
[REVIEW EACH PROVIDER WITH THE CONTACT PERSON AND COMPLETE SAMPLE
PROBLEM FORM AS APPROPRIATE]

[NUMBER] of your patients identified (PROVIDER) as a source of health care during 2005. We would
like to send you a copy of the authorization form(s) they signed allowing us to contact you for information
about their care. We will then call back to collect information about the services provided, charges, and
payments.
May I FAX the forms to you? (IF NOT: May I mail the forms to you?)
OFFICE CAN PROVIDE INFORMATION:
CAN PROVIDE INFORMATION BEFORE RECEIVING
AUTHORIZATION FORM(S) .............................................
FAX AUTHORIZATION FORM(S) BEFORE COLLECTING
INFORMATION..................................................................
MAIL AUTHORIZATION FORM(S) BEFORE COLLECTING
INFORMATION..................................................................
PREFERS MAILING RECORDS ...........................................

1 (A7)
2 (A8)
3 (A9)
4 (A9)

OFFICE CANNOT PROVIDE INFORMATION:
NEED TO CONTACT BILLING SERVICE............................. 5 (A14)
THIS TYPE OF INFORMATION IS NOT AVAILABLE
(RECORD VERBATIM:) _________________________ 6 (TERMINATE AND
CONSULT TASK
COORDINATOR)

A7.

[COMPLETE EVENT FORMS NOW. WHEN ALL FORMS HAVE BEEN COMPLETED, SAY:] Thank you
very much for your time and help with this study. We will FAX you a copy of the authorization form(s) for
your files.
HAS FAX .......................................................................................
DOES NOT HAVE FAX OR PREFERS MAIL ...............................

2

1 (A8)
2 (A9)

A8.

What is your FAX number?
FAX NUMBER: (_______) _____________________________

A8a.

RESPONDENT NAME:
SAME AS NAME ON FAX COVER PAGE ....................................
DIFFERENT FROM NAME ON FAX COVER PAGE
(RECORD:)______________________________________ ....

A8b.

1
2

And what name and title should I put on the FAX cover page?
NAME:
TITLE:
DEPARTMENT:
PROVIDER:

_____________________________________
_____________________________________
_____________________________________
_____________________________________
GO TO A10

A9.

Would you be the best person to receive the authorization form(s)?
YES ...............................................................................................

1 (VERIFY NAME, TITLE,

NO ...............................................................................................

2 (OBTAIN NAME, TITLE,

AND DEPARTMENT)
AND DEPARTMENT)

A9a.

RESPONDENT NAME:
SAME AS NAME WHO WILL RECEIVE FORMS .........................
DIFFERENT FROM NAME WHO WILL RECEIVE
FORMS (RECORD:) ___________________________ ...........

A9b.

Let me also verify that I have the correct mailing address:
NAME:

___________________________________

TITLE:

___________________________________

DEPARTMENT:

___________________________________

PROVIDER NAME: ___________________________________
ADDRESS:

___________________________________
___________________________________

CITY:

__________ STATE: ______ ZIP: _______

TELEPHONE:

(______)_______________ EXT:________

3

1
2

A10.

CODE ONE:
MEDICAL EVENT FORM(S) COMPLETE, NEED TO SEND
AUTHORIZATION FORM(S)......................................................
FAX AUTHORIZATION FORM(S) BEFORE COLLECTING
DATA ..........................................................................................
MAIL AUTHORIZATION FORM(S) BEFORE COLLECTING
DATA ..........................................................................................
RESPONDENT WILL MAIL RECORDS, NEED TO SEND
AUTHORIZATION FORM(S)......................................................

1 (A10a)
2 (A11)
3 (A11)
4 (A13)

A10a. We will be sending you the authorization form(s) today. Thanks again. [END CONTACT]
A11.

We will call you back shortly to collect the information.
What would be the best day and time to call?
DAY:___________ DATE:_________ R's TIME: ___________ AM/PM
Thank you very much for your help. [END CONTACT AND RECORD FAX/MAIL DATE AND
APPOINTMENT ON CALL RECORD.]

A12.

OMITTED

A13.

After you receive the authorization form(s), we hope you can mail the records to our office within 2 weeks.
Thank you very much for your time and your help with this study. [END CONTACT.]

A14.

We will need to get in touch with the billing service to obtain some of the information we need. What is
the name of the billing service, their telephone number, and the name of a contact person?
PERSON'S NAME:

_________________________________

TITLE:

_________________________________

NAME OF SERVICE: _________________________________
TELEPHONE:
A15.

(______)_______________ EXT: ______

I think we can probably get all the additional information we need from (BILLING SERVICE). We will
send you a copy of the authorization form(s) for your files. Let me verify that I have your correct mailing
address.
NAME:

___________________________________

TITLE:

___________________________________

DEPARTMENT:

___________________________________

PROVIDER NAME: ___________________________________
ADDRESS:

___________________________________
___________________________________

CITY:

__________ STATE: ______ ZIP: _______

Thank you very much for your help. [END CONTACT AND CALL BILLING SERVICE NAMED IN
A14.]
4

BILLING SERVICE
A16.

Hello, my name is (YOUR NAME). We are conducting the Medical Expenditure Panel Survey for the U.S.
Public Health Service. The survey is about how people in the United States use and pay for health care.
We were referred to you by (PROVIDER) for information about (NUMBER) of their patients. [READ IF
NECESSARY: We are collecting information about the care this/these patient(s) received from
(PROVIDER) during 2005. We would like to send you copies of the authorization form(s) we have from
this/these patient(s) and then call back to collect the information we need. May I FAX the form(s) to you?
(IF NOT: May I mail the form(s) to you?)]
IF ASKED FOR WHAT TYPE OF INFORMATION WE NEED: For each date of service, we need
information about diagnoses, services provided, charges, and payments.
CAN PROVIDE INFORMATION BEFORE RECEIVING
AUTHORIZATION FORM(S).....................................................
FAX AUTHORIZATION FORM(S) BEFORE COLLECTING
INFORMATION..........................................................................
MAIL AUTHORIZATION FORM(S) BEFORE COLLECTING
INFORMATION..........................................................................
PREFERS MAILING RECORDS...................................................

A17.

1 (A17)
2 (A18)
3 (A19)
4 (A19)

COMPLETE EVENT FORMS NOW.
WHEN ALL FORMS HAVE BEEN COMPLETED, SAY: Thank you very much for your time and help with
this study. We will send you a copy of the authorization form(s) for your files.

CODE ONE:

A18.

FAX AUTHORIZATION FORM(S).................................................

1

MAIL AUTHORIZATION FORM(S) ...............................................

2 (A19)

What is your FAX number?
FAX NUMBER:

(_______) _________________________

A18a. RESPONDENT NAME:
SAME AS NAME ON FAX COVER PAGE ....................................
DIFFERENT FROM NAME ON FAX COVER PAGE
(RECORD:)_____________________________________ .....

A18b. And what name and title should I put on the fax cover page?
NAME:
TITLE:
DEPARTMENT:
NAME OF SERVICE:

_________________________________
_________________________________
_________________________________
_________________________________
GO TO A20

5

1
2

A19.

Would you be the best person to receive the authorization form(s)?
YES ...............................................................................................

1 (VERIFY NAME, TITLE,

NO ...............................................................................................

2 (OBTAIN NAME, TITLE,

AND DEPARTMENT)
AND DEPARTMENT)

A19a. RESPONDENT NAME:
SAME AS NAME WHO WILL RECEIVE FORM(S).......................
DIFFERENT FROM NAME WHO WILL RECEIVE
FORM(S) (RECORD:)___________________________.........

1
2

A19b. Let me also verify that I have the correct mailing address.
NAME:

___________________________________

TITLE:

___________________________________

DEPARTMENT:

___________________________________

PROVIDER NAME: ___________________________________

A20.

ADDRESS:

___________________________________
___________________________________

CITY:

__________ STATE: ______ ZIP: _______

TELEPHONE:

(______)_______________ EXT:________

CODE ONE:
MEDICAL EVENT FORM(S) COMPLETE, NEED TO SEND
AUTHORIZATION FORM(S)......................................................
FAX AUTHORIZATION FORM(S) BEFORE COLLECTING
DATA ..........................................................................................
MAIL AUTHORIZATION FORM(S) BEFORE COLLECTING
DATA ..........................................................................................
RESPONDENT WILL MAIL RECORDS, NEED TO SEND
AUTHORIZATION FORM(S)......................................................

1 (A20a)
2 (A21)
3 (A21)
4 (A23)

A20a. We will be sending you the authorization form(s) today. Thanks again. [END CONTACT]
A21.

We will call you back shortly to collect the information. (IF MAILING, ALLOW ONE WEEK FOR RECEIPT
OF MAIL.)
What would be the best day and time to call?
DAY:___________ DATE:_________ R's TIME: ___________ AM/PM
Thank you very much for your help.
APPOINTMENT ON CALL RECORD.]

[END CONTACT AND RECORD FAX/MAIL DATE AND

A22.

OMITTED

A23.

After you receive the authorization form(s), we hope you can mail the records to our office within 2 weeks.
Thank you very much for your time and your help with this study. [END CONTACT.]

6

FOLLOWUP INTRODUCTION
A24.

May I please speak to (RESPONDENT)?
Hello, my name is (YOUR NAME) and I am calling about the Medical Expenditure Panel Survey, which
we are conducting for the U.S. Public Health Service. Did you receive the authorization form(s) we
(FAXed/sent)?
YES ...............................................................................................
NO AND WAS FAXED ..................................................................
NO AND WAS MAILED .................................................................

A25.

Let me (FAX/send) the authorization form(s) to you (again).
HAS FAX .......................................................................................
DOES NOT HAVE FAX OR PREFERS MAIL ...............................

A26.

1 (A29)
2 (A25)
3 (A25)

1 (A26)
2 (A27)

I would like to verify your name and FAX number. I have (NAME AND FAX NUMBER FROM A8a). Is
that correct?
FAX NUMBER:
NAME:
TITLE:
DEPARTMENT:
PROVIDER:

(_______) _____________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________

We will FAX the materials to you and call back shortly to collect the information. 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. [END CONTACT AND RECORD FAX DATE AND APPOINTMENT
ON CALL RECORD.]

A27.

I would like to verify your name and address. I have (NAME AND ADDRESS FROM A9a). Is that
correct? [MAKE CORRECTIONS AS NECESSARY]
NAME:

___________________________________

TITLE:

___________________________________

DEPARTMENT:

___________________________________

PROVIDER NAME: ___________________________________
ADDRESS:

___________________________________
___________________________________

CITY:

__________ STATE: ______ ZIP: _______

TELEPHONE:

(______)_______________ EXT:________

7

A28.

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. [END CONTACT AND RECORD MAIL DATE AND APPOINTMENT
ON CALL RECORD.]

A29.

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.
WILL COMPLETE BY PHONE NOW ............................................
WILL COMPLETE BY PHONE IN THE FUTURE .........................
PREFERS MAILING RECORDS...................................................

A30.

1 (A30)
2 (A31)
3 (A33)

COMPLETE EVENT FORMS NOW.
WHEN ALL FORMS HAVE BEEN COMPLETED, SAY: Thank you very much for your time and your help
with this study. [END CONTACT]

A31.

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.
RECORD.]

[END CONTACT AND RECORD APPOINTMENT ON CALL

A32.

OMITTED

A33.

After you receive the authorization form(s), we hope you can mail the records to our office within 2 weeks.
Thank you very much for your time and your help with this study. [END CONTACT.]

8