MEPS-MPC-Office Based

Global Fee Continue OB.pdf

Medical Expenditure Panel Survey Household Component and Medical Provider Component (MEPS-HC and MEPS-MPC through 2009)

MEPS-MPC-Office Based

OMB: 0935-0118

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0935-0118 can be found here:

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OMB#: 0935-0108

PROVIDER LABEL

MEDICAL PROVIDER COMPONENT FOR REFERENCE YEAR 2005
CONTACT GUIDE FOR SEPARATELY BILLING DOCTORS
1.

ASK IF NOT OBVIOUS: Have I reached (PROVIDER)?
CORRECT PROVIDER
VERIFY ADDRESS AND THEN CONTINUE WITH 2
PROBLEM WITH PROVIDER
RECORD INFORMATION BELOW, TERMINATE CALL,
AND CONSULT WITH A TASK COORDINATOR
__________________________________________________________________
__________________________________________________________________

May I please speak to someone in the patient billing department?
HAS BILLING DEPARTMENT
Æ CONTINUE WITH INTRODUCTION
BILLING IS PERFORMED BY AN OUTSIDE BILLING SERVICE
Æ ASK TO SPEAK TO SOMEONE WHO DEALS WITH THE BILLING SERVICE
ALL SERVICES PROVIDED ON PREPAID OR CAPITATED BASIS
Æ ASK TO SPEAK TO SOMEONE WHO DEALS WITH MEDICAL RECORDS
NO BILLING DEPARTMENT AND IT IS NOT CLEAR WHO TO SPEAK TO
Æ RECORD INFORMATION BELOW, TERMINATE CALL, AND CONSULT WITH
A TASK COORDINATOR ___________________________________________
________________________________________________________________
NOTE: IF ON SECOND CALL PERSON IS UNAVAILABLE, ASK TO SPEAK TO SOMEONE
ELSE IN THAT DEPARTMENT

INTRODUCTION
Hello, my name is (YOUR NAME) and I am calling about the Medical Expenditure Panel Survey which is being
conducted for the U.S. Public Health Service. This is a nationwide study about how people in the United States
use and pay for health care.

A1.

ASK IF NOT OBVIOUS: Have I reached (PROVIDER)?
CORRECT PROVIDER Æ CONTINUE WITH A4
PROBLEM WITH PROVIDER Æ RECORD INFORMATION BELOW, TERMINATE CALL,
AND CONSULT WITH A TASK COORDINATOR
__________________________________________________________________
__________________________________________________________________

M:\7690\7690.19.04\2005 Deliveries\DEL #165 Data Collection Forms\SBD Contact Guide.doc - 12/9/2005 - 12:09 PM - SH

A2 THROUGH A3 NOT ASKED THIS VERSION
A4.

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

1
2 (A5)

A4a.

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

A5.

This practice was identified as a source of health care for (NUMBER) patient(s) who received care at
(HOSPITAL). The patient(s) (has/have) signed authorization form(s) allowing us to contact you for
information about their care. For each date of service, we need information about diagnoses, services
provided, charges, and payments. Would you or someone in your office be able to provide this
information?
YES, OFFICE CAN PROVIDE INFORMATION ............................
NO, NEED TO CONTACT BILLING SERVICE .............................
NO, THIS TYPE OF INFORMATION IS NOT AVAILABLE
(RECORD RESPONSE BELOW VERBATIM) ......................

A6.

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

[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 ...............................

A8.

3 (TERMINATE AND
CONSULT A TASK
COORDINATOR)

We would like to send you a copy of the authorization form(s) and then call back to collect the
information. May I FAX the form(s) to you? (IF NOT: May I mail the form(s) to you?)
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...................................................

A7.

1
2 (A14)

What is your FAX number?
FAX NUMBER: (_______) _____________________________
A8a.

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

_____________________________________
_____________________________________
_____________________________________
_____________________________________
2

1
2 (A9)

A8b.

RESPONDENT NAME:
SAME AS NAME RECORDED IN A8a.......................................... 1
DIFFERENT FROM NAME RECORDED IN A8a
(RECORD):______________________________________ 2

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.

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

________________________________________________________

TITLE:

________________________________________________________

DEPARTMENT:

________________________________________________________

PROVIDER NAME: ________________________________________________________
ADDRESS:

________________________________________________________
________________________________________________________

A9b.

CITY:

__________________________ STATE: ___________ ZIP: _______

TELEPHONE:

(______)______________________ EXT: ______________________

RESPONDENT NAME:
SAME AS NAME RECORDED IN A9a.......................................... 1
DIFFERENT FROM NAME RECORDED IN A9a
(RECORD):______________________________________ 2

A10.

CODE ONE:
MEDICAL EVENT FORM(S) COMPLETE ....................................
FAX AUTHORIZATION FORM(S) BEFORE COLLECTING
DATA ..........................................................................................
MAIL AUTHORIZATION FORM(S) BEFORE COLLECTING
DATA ..........................................................................................
RESPONDENT MAILING RECORDS...........................................

1
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 CPCR.]

A12.

OMITTED

A13.

After you receive the authorization form(s), we hope you will mail the records to our office within two
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.]

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.

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 fax you a copy of the authorization form(s) for
your files.
HAS FAX .......................................................................................
DOES NOT HAVE FAX OR PREFERS MAIL ...............................

A18.

1
2 (A19)

What is your FAX number?

FAX NUMBER:

(_______) ________________________

A18a. And what name and title should I put on the FAX cover page?
NAME:
TITLE:
DEPARTMENT:
NAME OF SERVICE:

_________________________________
_________________________________
_________________________________
_________________________________

A18b. RESPONDENT NAME:
SAME AS NAME RECORDED IN A18a........................................ 1
DIFFERENT FROM NAME RECORDED IN A18a
(RECORD):______________________________________ 2
GO TO A20

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

________________________________________________________

TITLE:

________________________________________________________

DEPARTMENT:

________________________________________________________

BILLING SERVICE NAME:___________________________________________________
ADDRESS:

________________________________________________________
________________________________________________________

CITY:

____________________________ STATE: ________ ZIP: ________

TELEPHONE:

(______)_____________________ EXT: _______________________

A19b. RESPONDENT NAME:
SAME AS NAME RECORDED IN A19a........................................ 1
DIFFERENT FROM NAME RECORDED IN A19a
(RECORD):______________________________________ 2

A20.

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

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

A21.

A22.

OMITTED

A23.

After you receive the authorization form(s), we hope you will mail the records to our office within two
weeks. Thank you very much for your time and your help with this study.
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
3

1
2 (A27)

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

(_______) _____________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________

We will FAX the materials to you, then call you 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 CPCR.]

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: ___________

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 CPCR.]

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
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. [END CONTACT AND RECORD APPOINTMENT ON CPCR.]

A32.

OMITTED

A33.

After you receive the authorization form(s), we hope you will mail the records to our office within two
weeks. Thank you very much for your time and your help with this study.

File Type	application/pdf
File Title	715111: Contact Guide for Separately Billing Doctors
Author	MARKOVICH_L
File Modified	2005-12-09
File Created	2005-12-09