MCPSS Survey - Redlined for OMB

ATTACHMENT 3
MCPSS NATIONAL IMPLEMENTATION
SURVEY INSTRUMENT
REDLINE VERSION

Instructions to Complete the Survey Instrument
The attached MCPSS survey instrument includes the following seven key areas of the interface between you and
your contractor, [CONTRACTOR NAME]:
Section A: Provider Inquiries
Section B: Provider Outreach & Education
Section C: Claims Processing
Section D: Appeals
Section E: Provider Enrollment
Section F: Medical Review
Section G: Provider Audit and Reimbursement
Most of the key areas pertain to your facility’s interaction with your Medicare Contractor.
For each main section of the survey, you have a choice:
•
Complete the section yourself , or
•
Forward the section to the person at your facility who interacts on a regular basis with your Medicare
Contractor
Once complete, please mail the survey directly to:
Joshua Rubin
Westat
1650 Research Boulevard
Rm # RA 1153
Rockville, MD 20850
OR
Fax the completed survey instrument to Westat at 1-888-748-5820
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information collection is 0938-0915. The time required to complete
this information collection is estimated to average 16-21 minutes per response, including the time to review instructions, search existing
data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy
of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Baltimore, Maryland 21244-1850.

If you have any questions or concerns, please call the MCPSS Provider Helpline at 1-888-863-3561 or send an
email to [email protected]
2

Deleted: Provider Communications

MEDICARE CONTRACTOR PROVIDER SATISFACTION SURVEY
Introduction
Medicare is listening! CMS has selected your facility to participate in a satisfaction survey. We know that your time is
valuable and greatly appreciate your willingness to participate in this very important study to assess your satisfaction with
your Contractor.
Your Office Manager or staff in the Billing Department might be the appropriate staff to complete the survey. Please
note that your participation is voluntary. The reports prepared for this study will summarize findings across the sample and
will not associate responses with a specific individual. We will not provide information that identifies you to anyone outside
the study team, except as required by law.
Thank you in advance for taking the time to complete the Medicare Contractor Provider Satisfaction Survey. If you
have any questions or concerns, please call the MCPSS Provider Helpline at 1-888-863-3561 or send an email to
[email protected]

If you have any questions or concerns, please call the MCPSS Provider Helpline at 1-888-863-3561 or send an
email to [email protected]
3

MEDICARE CONTRACTOR PROVIDER SATISFACTION SURVEY

About Your Facility and Overall Satisfaction with Your Contractor
Q0. Approximately how long have you been a Medicare Provider?






Less than 6 months
6 to 12 months
1-2 years
2-5 years
5 years or more

Q1. {CONTRACTOR}, your Contractor, provides a number of services on behalf of Medicare to Medicare
Providers in your area. Thinking about ALL your interactions with your Contractor, {CONTRACTOR},
{in the last twelve months/ since {DATE}, how satisfied have you been with your Contractor’s performance
overall.
Please rate your level of satisfaction on a scale of 1 to 6, where 1 is “Not at all Satisfied” and 6 is
“Completely Satisfied.”








1
NOT AT ALL SATISFIED
2
3
4
5
6
COMPLETELY SATISFIED
Don’t Know
Please Continue to Section A

If you have any questions or concerns, please call the MCPSS Provider Helpline at 1-888-863-3561 or send
an email to [email protected]
A-1

MEDICARE CONTRACTOR PROVIDER SATISFACTION SURVEY

Section A: Provider Inquiries
[CONTRACTOR] has Provider Inquiry staff to answer questions from Providers via telephone, written
correspondence or e-mail. You might use a toll-free number to call the Contractor’s Provider Inquiries staff or use a “Call
Center” or “Provider Hotline/ Help Line.” Please note that Provider Inquiry activities related to this section of the survey
instrument are NOT related to your “Provider Rep” or “Ombudsman” if you have one. For the purposes of this survey
instrument, your “Contractor’s Provider Inquiries performance” includes the activities and interactions that you have with
[Contractor] related to asking questions and receiving answers from their Inquiries staff.

INSTRUCTIONS FOR SECTION A
It should take you approximately two (2) minutes to complete this section.

You have a choice for Section A: Provider Inquiries:
•

Complete Section A yourself ---PROCEED TO QUESTION A1 on PAGE A-3
OR

•

Forward Section A to the person at your facility who interacts on a regular basis with
[CONTRACTOR NAME]---PROCEED TO SECTION B on PAGE B-5

If you have any questions or concerns, please call the MCPSS Provider Helpline at 1-888-863-3561 or send
an email to [email protected]
A-2

Your Ratings of [CONTRACTOR]’S
Performance of PROVIDER INQUIRIES
While answering the following questions, please think about your facility’s experiences in the last twelve (12) months/since [DATE]
involving Provider Inquiries you and any other persons in your facility make to your Contractor, [Contractor] ONLY (called “your
Contractor” in the survey instrument).

In the last twelve months/since [DATE],
how satisfied have you been with…..
A1.

How quickly you can reach a
representative to make a Provider
Inquiry by telephone

A2.

Receiving the correct information

For each of the following items, please rate your level of satisfaction on a scale of
1 to 6, where 1 is “Not at all Satisfied” and 6 is “Completely Satisfied.” Please
circle the relevant number.
Completely
Not at all
Satisfied
Satisfied
Don’t
Not
2
3
4
5
6
Know
Applicable
1

1
A3.

A4.

A5.

A6.

The consistency of responses that you
get from different Provider Inquiries
representatives

Not at all
Satisfied

The effort your Contractor makes to
make the Provider Inquiries process as
easy as possible for you

Not at all
Satisfied

The modes of communication that are
offered by your Contractor to exchange
information with them about Inquiries

Not at all
Satisfied

The professionalism and courtesy of
your Contractor’s representatives
throughout Provider Inquiries activities

Not at all
Satisfied

A7. Your Contractor’s ability to fully resolve
problems without you having to make
multiple inquiries

Completely
Satisfied

Not at all
Satisfied

1

1

1

1

2

3

4

5

Completely
Satisfied
2

3

4

5

6
Completely
Satisfied

2

3

4

5

6
Completely
Satisfied

2

3

4

5

6
Completely
Satisfied

2

3

4

5

Not at all
Satisfied
1

6

6
Completely
Satisfied

2

3

4

5

6

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

If you have any questions or concerns, please call the MCPSS Provider Helpline at 1-888-863-3561 or send
an email to [email protected]
A-3

The next few questions are about methods you use to communicate with your Contractor.

A8.

In the last twelve months/Since {DATE} which
method(s) have you used to communicate with your
Contractor?

(Please check all that apply)

A10. In the last twelve months/ Since {DATE} how many
inquires have you and any other persons in your
facility made?
 1-2

 Telephone call with a Contractor representative

 3-5

 Automated telephone system

 6-10

 Web

 11-20

 E-mail

 21-50

 Mail

 51-100

 Fax

 101 or more

 Other (specify).

A9. In the last twelve months/ Since {DATE} which
method have you used most often to communicate with
your Contractor?
 Telephone call with a Contractor representative
 Automated telephone system
 Web

A11. Do you use the internet to get any of the following?
(Mark all that apply)
 CMS Program updates
 Contractor updates
 Training
 Billing and coverage regulations

 E-mail

 Other (Please specify)
_________________________________

 Mail
 Fax
 Other (specify).
A12.

We are interested in any general comments you have about [CONTRACTOR NAME]'s handling of Provider Inquiry
activities. Do you have any comments you would like to share with CMS and with your Contractor about this topic?

Thank you for completing this section of the survey instrument.

If you have any questions or concerns, please call the MCPSS Provider Helpline at 1-888-863-3561 or send
an email to [email protected]
A-4

MEDICARE CONTRACTOR PROVIDER SATISFACTION SURVEY

Section B: Provider Outreach & Education

Deleted: Provider Communication
(Education and Training)

[CONTRACTOR] offers Providers Education and Training in a variety of ways including Web-based training,
newsletters, bulletins, workshops/seminars, videos, on-site training, demonstrations, reference materials, CDs, contractor Web
site, email/listserv, etc.. Your organization might also have a “Provider Rep” that acts as a liaison for education issues or as an
actual trainer. For the purposes of this survey instrument, your “Contractor’s Education and Training performance” includes
all of these ways that [CONTRACTOR] provides training and education to your organization. Please do not include resources
that are provided directly by CMS, e.g., MedLearn.

INSTRUCTIONS FOR SECTION B
It should take you approximately two (2) minutes to complete this section.

You have a choice for Section B: Provider Outreach & Education:
•

Complete Section B yourself ---PROCEED TO QUESTION B1 on PAGE B-6
OR

•

Forward Section B to the person at your facility who interacts on a regular basis with your
[CONTRACTOR NAME]---PROCEED TO SECTION C on PAGE C-8

If you have any questions or concerns, please call the MCPSS Provider Helpline at 1-888-863-3561 or send
an email to [email protected]
B-5

Deleted: Provider Communication
(Education and Training)

Your Ratings of [CONTRACTOR]’S
Deleted: PROVIDER
COMMUNICATION

Performance of Provider Outreach & Education

Deleted: (Formerly EDUCATION
AND TRAINING)

While answering the following questions, please think about your experiences in the last twelve (12) months/since {DATE}
involving the types of training resources provided by your Contractor, [Contractor] ONLY (called “your Contractor” in the
survey instrument). These resources include Web-based training, newsletters, bulletins, workshops/seminars, videos, on-site
training, demonstrations, reference materials, CDs, contractor Web site, email/listserv, etc. Please do not include resources that
are provided directly by CMS, e.g., MedLearn.

B1. In the last twelve months/ Since {DATE} what education and training resources of (CONTRACTOR) have you used?
 Web-based Training
 Contractor Web site
 In-person training / Workshops
 Teleconference
 Hard copy materials
 Other (specify)
___________________________________________
 None used
The next few questions are about your satisfaction with the Contractors Communication (Education and Training)
In the last twelve months/Since {DATE},
how satisfied have you been with…
B2.

The amount of training and educational
resources available from your
Contractor

B3.

The detail in which topics are covered

For each of the following items, please rate your level of satisfaction on a scale of 1
to 6, where 1 is “Not at all Satisfied” and 6 is “Completely Satisfied.” Please circle
the relevant number.
Not at all
Completely
Satisfied
Satisfied
Don’t
Not
2
4
5
Know
1
3
6
Applicable
Not at all
Satisfied
1

B4.

The tailoring of training or education at
a level you can understand

The topics of the training and education
materials are up-to-date

The relevance of the training and
education material topics to your
organizations needs.

3

4

5

2

3

4

5

Not
Applicable

Don’t
Know

Not
Applicable

6

Don’t
Know

Not
Applicable

Completely
Satisfied

Don’t
Know

Not
Applicable

6
Completely
Satisfied

2

3

4

5

Not at all
Satisfied
1

Don’t
Know

6
Completely
Satisfied

Not at all
Satisfied
1

B6.

2

Not at all
Satisfied
1

B5.

Completely
Satisfied

2

3

4

5

6

If you have any questions or concerns, please call the MCPSS Provider Helpline at 1-888-863-3561 or send
an email to [email protected]
B-6

In the last twelve months/Since {DATE},
how satisfied have you been with…
B7.

The accessibility of education and
training resources from your Contractor

B8.

The expertise of your Contractor’s
provider education and training staff

For each of the following items, please rate your level of satisfaction on a scale of 1
to 6, where 1 is “Not at all Satisfied” and 6 is “Completely Satisfied.” Please circle
the relevant number.
Not at all
Completely
Satisfied
Satisfied
Don’t
Not
2
4
5
Know
1
3
6
Applicable
Not at all
Satisfied
1

B9.

Your contractor’s communication with
you about changes that have been or are
being made to Medicare policies and
regulations

B10. The professionalism and courtesy of
your Contractor’s training and
education representatives
B11. If you are an eligible professional,
CMS’ outreach and educational
efforts on the "Physician Quality
Reporting Initiative or PQRI”?

Completely
Satisfied
2

3

4

5

Not at all
Satisfied
1

Completely
Satisfied
2

3

4

5

2

3

4

5

6
Completely
Satisfied

Not at all
Satisfied
1

6
Completely
Satisfied

Not at all
Satisfied
1

6

2

3

4

5

6

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

B12. For which of the following topics would you like to see more training and education material (mark all that apply)?


Claims processing



Payment policy



Local coverage determination



NPI



Enrollment



Appeals



Audit and reimbursement



Other (specify)

Deleted: B11

__________________________________
B13. Do you find CMS listserv messages {@ ADDRESS} an effective method of communication to notify you about new
Medicare Fee-for-Service information?
 Yes
 No
B14.

We are interested in any general comments you have about [CONTRACTOR NAME]'s handling of Provider Outreach &
Education activities. Do you have any comments you would like to share with CMS and with your Contractor about this topic?

Thank you for completing this section of the survey instrument.

If you have any questions or concerns, please call the MCPSS Provider Helpline at 1-888-863-3561 or send
an email to [email protected]
B-7

Deleted: Provider Communication
(Education and Training)

MEDICARE CONTRACTOR PROVIDER SATISFACTION SURVEY

Section C: Claims Processing
[CONTRACTOR] has procedures and regulations and statutes associated with how they receive, process
and pay claims that Providers submit. For the purposes of this survey instrument, your “Contractor’s Claims
Processing performance” includes the activities and interactions that you have with [CONTRACTOR]
throughout the lifecycle of a claim submission to payment or denial.

INSTRUCTIONS FOR SECTION C
It should take you approximately three (3) minutes to complete this section.

You have a choice for Section C: Claims Processing:
•

Complete Section C yourself ---PROCEED TO QUESTION C1 on PAGE C-9
OR

•

Forward Section C to the person at your facility who interacts on a regular basis with your
[CONTRACTOR NAME]---PROCEED TO SECTION D on PAGE D-10

If you have any questions or concerns, please call the MCPSS Provider Helpline at 1-888-863-3561 or send
an email to [email protected]
C-8

Your Ratings of [CONTRACTOR]’S
Performance of CLAIMS PROCESSING
While answering the following questions, please think about your experiences in the last twelve (12) months/since {DATE} involving
Claims Processing activities with your Contractor, [Contractor] ONLY (called “your Contractor” in the survey instrument).
In the last twelve months, how satisfied
have you been with…
C1.

The accuracy of your Contractor’s
claims editing

For each of the following items, please rate your level of satisfaction on a scale of 1
to 6, where 1 is “Not at all Satisfied” and 6 is “Completely Satisfied.” Please circle
the relevant number.
Not at all
Satisfied
1

C2.

C3.

The timeliness of notification from your
Contractor that a claim will not be
paid, including denied, returned or
unprocessed claims
The accuracy of remittance advices
received from your Contractor

The ease of submitting electronic
claims

1

C6.

C7.

4

5

Not at all
Satisfied

The clarity of remittance advices you
receive from your Contractor

Not at all
Satisfied

1

6
Completely
Satisfied

2

3

4

5

6
Completely
Satisfied

2

3

4

5

Not at all
Satisfied

The availability of your Contractor’s
representatives to address claimsrelated issues

The ease of correcting claims, such as
correcting claims online or asking for a
change over the phone

3

Not at all
Satisfied

1
C5.

2

Not at all
Satisfied

1
C4.

Completely
Satisfied

6
Completely
Satisfied

2

3

4

5

6
Completely
Satisfied

2

3

4

5

6
Completely
Satisfied

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

1

2

3

4

5

6

Don’t
Know

Not
Applicable

Not at all
Satisfied

2

3

4

5

Completely
Satisfied

Don’t
Know

Not
Applicable

1

6

C8. In the last twelve months/ Since {DATE} how have you submitted claims?



C9.

Paper
Electronic
Both

We are interested in any general comments you have about [CONTRACTOR NAME]'s handling of Claims
Processing activities. Do you have any comments you would like to share with CMS and with your Contractor about
this topic?

Thank you for completing this section of the survey instrument
If you have any questions or concerns, please call the MCPSS Provider Helpline at 1-888-863-3561 or send
an email to [email protected]
C-9

MEDICARE CONTRACTOR PROVIDER SATISFACTION SURVEY

Section D: Appeals
[CONTRACTOR] has procedures and regulations associated with how and when it addresses Appeals,

makes determinations about Appeals and communicates with Providers about Appeals decisions. For the
purposes of this survey instrument, your “Contractor’s Appeals performance” includes the activities and
interactions that you have with [CONTRACTOR] throughout the lifecycle of a first-level Appeal—from when
you first receive a denial of a claim to when [CONTRACTOR] states its decision to reverse or uphold its
decision about paying the claim.

.

INSTRUCTIONS FOR SECTION D
It should take you approximately two (2) minutes to complete this section
You have a choice for Section D: Appeals:
•

Complete Section D yourself ---PROCEED TO QUESTION D_1A BELOW
OR

•

Forward Section D to the person at your facility who interacts on a regular basis with your
[CONTRACTOR NAME]---PROCEED TO SECTION E on PAGE E-1

D_1A. In the last twelve months/ Since {DATE} has your facility had a first level appeal?


Yes--- PROCEED TO QUESTION D 1 on PAGE D-11



No---PROCEED TO SECTION E on PAGE E-12

If you have any questions or concerns, please call the MCPSS Provider Helpline at 1-888-863-3561 or send
an email to [email protected]
D-10

Your Ratings of [CONTRACTOR]’S
Performance of APPEALS
While answering the following questions, please think about your experiences in the last twelve (12) months/since {DATE} involving first
level Appeals activities with your Contractor, [Contractor] ONLY (called “your Contractor” in the survey instrument).
In the last twelve months/Since {DATE},
how satisfied have you been with…

For each of the following items, please rate your level of satisfaction on a scale of 1
to 6, where 1 is “Not at all Satisfied” and 6 is “Completely Satisfied.” Please circle
the relevant number.
Not at all
Completely
Satisfied
Satisfied
Don’t
Not
1
2
4
5
6
Know
Applicable
3

D1.

The consistency of your Contractor’s
first-level appeals decisions for claims
that have been denied

D2.

The mechanisms that your Contractor
offers for exchanging information with
them about first-level appeals

Not at all
Satisfied

Your Contractor’s responsiveness,
attentiveness, and availability during
the process of first-level appeals

Not at all
Satisfied

The professionalism and courtesy of
your Contractor’s representatives
during the appeals process

Not at all
Satisfied

The clarity of explanations of appeal
decisions made by your Contractor

Not at all
Satisfied

D3.

D4.

D5.

1

1

1

1

D6.

Completely
Satisfied
2

3

4

5

6
Completely
Satisfied

2

3

4

5

6
Completely
Satisfied

2

3

4

5

6
Completely
Satisfied

2

3

4

5

6

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

We are interested in any general comments you have about [CONTRACTOR NAME]'s handling of Appeals
activities. Do you have any comments you would like to share with CMS and with your Contractor about this topic?

Thank you for completing this section of the survey instrument.

If you have any questions or concerns, please call the MCPSS Provider Helpline at 1-888-863-3561 or send
an email to [email protected]
D-11

MEDICARE CONTRACTOR PROVIDER SATISFACTION SURVEY

Section E: Provider Enrollment
[CONTRACTOR] has procedures and regulations associated with how and when they require and make
determinations about applications for Provider Enrollment in the Medicare program. Providers new to Medicare
since 1997, as well as established Providers with new changes in their qualifications or in payment assignments
since 1997 (as in mergers or acquisitions), are required to submit the appropriate CMS 855 Enrollment
Application to their Medicare contractor.
For the purposes of this survey instrument, your “Contractor’s Provider Enrollment performance”
includes the activities and interactions that you have with [CONTRACTOR] regarding enrolling your
organization or members in your facility as a Provider with the Medicare program. This includes all of your
interaction with the Medicare contractor including initial enrollment and updates to enrollment information —
from the first contact you made with [Contractor] since 1997 through your assignment of a Provider number.

INSTRUCTIONS FOR SECTION E
It should take you approximately two (2) minute to complete this section.
You have a choice for Section E: Provider Enrollment:
•

Complete Section E yourself ---PROCEED TO QUESTION E_1A BELOW
OR

•

Forward Section E to the person at your facility who interacts on a regular basis with your
[CONTRACTOR NAME]---PROCEED TO SECTION F on PAGE F-1

E_1A. In the last twelve months/ Since {DATE}, have you gone through the Medicare enrollment
process?


Yes--- PROCEED TO QUESTION E1 on PAGE E-13



No--- PROCEED TO QUESTION E9 on PAGE E-14

If you have any questions or concerns, please call the MCPSS Provider Helpline at 1-888-863-3561 or send
an email to [email protected]
E-12

Your Ratings of [CONTRACTOR]’S
Performance of PROVIDER ENROLLMENT
While answering the following questions, please think about your experiences in the last twelve (12) months/since {DATE} involving
Provider Enrollment activities with your Contractor, [Contractor] ONLY (called “your Contractor” in the survey instrument).
In the last twelve months/Since {DATE},
how satisfied have you been with…

E1.

E2.

The ability of your Contractor
representative to respond to your
questions about the Medicare enrollment
application, CMS Form 855
The consistency of your Contractor’s
responses or decisions

For each of the following items, please rate your level of satisfaction on a scale of 1
to 6, where 1 is “Not at all Satisfied” and 6 is “Completely Satisfied.” Please circle
the relevant number.

Not at all
Satisfied
1

E4.

E5.

2

3

4

The professionalism and courtesy of your
Contractor’s representatives during the
Provider Enrollment process

Not at all
Satisfied

Your Contractor’s responsiveness,
attentiveness, and availability during the
process of enrollment

Not at all
Satisfied

Your Contractor’s ability to answer
questions specific to your situation or
specialty.

Not at all
Satisfied

1

1

1

3

4

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

6

Don’t
Know

Not
Applicable

Completely
Satisfied

Don’t
Know

Not
Applicable

6

5

6
Completely
Satisfied

2

3

4

5

6
Completely
Satisfied

2

2

3

3

4

4

Deleted: s

Not
Applicable

Completely
Satisfied
2

Deleted: ’s

Don’t
Know

5

Not at all
Satisfied
1

E3.

Completely
Satisfied

5

5

6

E6. {In the last twelve (12) months/since {DATE}} have you completed the enrollment process?
 Yes
 No
If No Please Go to Question E 8

Deleted: answer
Deleted: application

Deleted: E6. Once your enrollment
was approved, the quality and
thoroughness of the information provided
by your Contractor to enable you to start
billing for services.

Deleted: The next two questions are
about the Revised 855 Form¶
¶
¶
E7. The 855 Form was recently revised
in May of 2006. Were you aware of this
revision?¶
 Yes¶
 No
If No Please Go to Question
E 9¶
¶
¶
E8. Compared to the old 855 form,
would you say the revised 855 form is…¶
 Easier to fill out,¶
 Harder to fill out, or¶
 About the same?¶
 I have not filled out the old or new
form

If you have any questions or concerns, please call the MCPSS Provider Helpline at 1-888-863-3561 or send
an email to [email protected]
E-13

Deleted: The next two Questions are
about efforts made by CMS to make
you aware of the need to get the National
Provider Identifier (NPI)

In the last twelve months/Since {DATE},
how satisfied have you been with…
E7.

E8.

The information provided by your
Contractor to enable you to start billing
for services.

For each of the following items, please rate your level of satisfaction on a scale of 1
to 6, where 1 is “Not at all Satisfied” and 6 is “Completely Satisfied.” Please circle
the relevant number.
Not at all
Completely
Don’t
Not
Satisfied
Satisfied
Know
Applicable
1

2

3

4

5

Deleted: E9. CMS efforts to make you
aware of the need to obtain the NPI before
May 23, 2007
Deleted: E10. The education and
training provided by CMS to prepare you
to obtain the NPI.

6

We are interested in any general comments you have about [CONTRACTOR NAME]'s handling of Provider
Enrollment activities. Do you have any comments you would like to share with CMS and with your Contractor about
this topic?

Thank you for completing this section of the survey instrument.

If you have any questions or concerns, please call the MCPSS Provider Helpline at 1-888-863-3561 or send
an email to [email protected]
E-14

Deleted: 11

MEDICARE CONTRACTOR PROVIDER SATISFACTION SURVEY

Section F: Medical Review
[CONTRACTOR] has procedures and regulations that require them to sometimes perform Medical
Review of Providers’ records. For the purposes of this survey instrument, your “Contractor’s Medical Review
performance” includes the activities and interactions that you have with [CONTRACTOR] during Pre-Pay
and/or Post-Pay Medical Review. Please note that Medical Review activities in this section of the survey
instrument are NOT related to fraud investigations, overpayments, or appeals.

INSTRUCTIONS FOR SECTION F
It should take you approximately two (2) minutes to complete this section.
You have a choice for Section F: Medical Review:
•

Complete Section F yourself ---PROCEED TO QUESTION F_1A BELOW
OR

•

Forward Section F to the person at your facility who interacts on a regular basis with your
[CONTRACTOR NAME]---PROCEED TO SECTION G on PAGE G-17

F_1A {In the last twelve (12) months/ Since {New contractor} has been your contractor} have you
had a medical review ?


Yes---PROCEED TO QUESTION F1 on PAGE F-2



No---PROCEED TO SECTION G on PAGE G-17

If you have any questions or concerns, please call the MCPSS Provider Helpline at 1-888-863-3561 or send an
email to [email protected]
F-15

Your Ratings of [CONTRACTOR]’S
Performance of MEDICAL REVIEW
While answering the following questions, think about your experiences in the last twelve (12) months involving Medical Review activities
with your Contractor, [Contractor] ONLY (called “your Contractor” in the survey instrument).
In the last twelve (12) months, how
satisfied have you been with
F1.

F2.

F3.

F4.

F5.

The clarity of the notification (letter,
phone call, etc.) from your Contractor
that your claims were selected for
Medical Review

For each of the following items, please rate your level of satisfaction on a scale of
1 to 6, where 1 is “Not at all Satisfied” and 6 is “Completely Satisfied.” Please
circle the relevant number.

1

The clarity of the explanations of your
Contractor’s Medical Review
decisions

Not at all
Satisfied

Receiving timely local Medical Review
policy changes and updates that affect
your organization from your Contractor

Not at all
Satisfied

The follow through that your
Contractor provided after Medical
Review decisions

Not at all
Satisfied

The knowledge of your Contractor’s
Medical Reviewers

Not at all
Satisfied

1

1

1

1
F6.

F7.

F8.

F9.

Completely
Satisfied

Not at all
Satisfied

How well your Contractor makes an
effort to make things as easy and as fair
as possible for you

Not at all
Satisfied

The consistency of your Contractor’s
Medical Review decisions and answers
to your questions

Not at all
Satisfied

The professionalism and courtesy of
your Contractor representatives
throughout the medical review process

Not at all
Satisfied

1

1

1

2

3

4

5

6
Completely
Satisfied

2

3

4

5

6
Completely
Satisfied

2

3

4

5

6
Completely
Satisfied

2

3

4

5

6
Completely
Satisfied

2

3

4

5

6
Completely
Satisfied

2

3

4

5

6
Completely
Satisfied

2

3

4

5

6
Completely
Satisfied

2

3

4

5

6

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

We are interested in any general comments you have about [CONTRACTOR]'s handling of Medical Review
activities. Do you have any comments you would like to share with CMS and with your Contractor about this topic?

Thank you for completing this section of the survey instrument.

If you have any questions or concerns, please call the MCPSS Provider Helpline at 1-888-863-3561 or send an
email to [email protected]
F-16

MEDICARE CONTRACTOR PROVIDER SATISFACTION SURVEY

Section G: Provider Audit and Reimbursement
[CONTRACTOR] has procedures and regulations that require them to work with Providers who are paid
on either a cost reimbursement or prospective payment basis for treating Medicare patients. For the purposes of
this survey instrument, your “Contractor’s Provider Audit and Reimbursement activities” includes all
interactions with [CONTRACTOR] related to how they decide and make adjustments to what Medicare has paid
or is supposed to pay your organization, cost report audit activities you may participate in each year, and interim
payments you receive. Please note that Audit and Provider Reimbursement activities in this section of the survey
instrument are NOT related to the direct payment or denial of claims or to appeals activities related to claims.

INSTRUCTIONS FOR SECTION G
It should take you approximately three (3) minutes to complete this section.
You have a choice for Section G: Provider Audit and Reimbursement:
•

Complete Section G yourself ---PROCEED TO QUESTION G_1A BELOW
OR

•

Forward Section G to the person at your facility who interacts on a regular basis with your
[CONTRACTOR]

G_1A. In the last twelve (12) months/Since {DATE}, have you submitted a cost report to
{CONTRACTOR}?


Yes--- PROCEED TO QUESTION G1 on PAGE G-18



No---. PROCEED TO PAGE G-20

If you have any questions or concerns, please call the MCPSS Provider Helpline at 1-888-863-3561 or send
an email to [email protected]
G-17

Your Ratings of [CONTRACTOR]’S
Performance of PROVIDER AUDIT AND REIMBURSEMENT
While answering the following questions, think about your experiences in the last twelve (12) months/since {DATE} involving Audit and
Reimbursement activities with your Contractor, [Contractor] ONLY (called “your Contractor” in the survey instrument).
In the last twelve months/Since {DATE}, how
satisfied have you been with…
G1.

G2.

G3.

G4.

Availability of timely updates from
your Contractor on Medicare policy
(regulations, manuals and other
instructions) that affect Provider Audit
and Reimbursement

For each of the following items, please rate your level of satisfaction on a
scale of 1 to 6, where 1 is “Not at all Satisfied” and 6 is “Completely
Satisfied.” Please circle the relevant number.

1

The professionalism and courtesy of
your Contractor representatives
throughout all Provider Audit and
Reimbursement activities

Not at all
Satisfied

How well your Contractor makes an
effort to make things as easy and as
fair as possible for you during Cost
Report settlement activities

Not at all
Satisfied

Your Contractor’s interpretations of
CMS’ rules for Cost Report and
payment policies.

Not at all
Satisfied

1

1

1
G5.

G6.

G7.

The knowledge of your Contractor’s
Cost Report Auditors

The timeliness of your Contractor’s
audit of your Cost Report, if one is
conducted, and the final settlement
The overall communication between
you and your Contractor about
adjustments and Cost Reports/ Cost
Report Audits

Completely
Satisfied

Not at all
Satisfied
2

3

4

5

6

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

Completely
Satisfied
2

3

4

5

6
Completely
Satisfied

2

3

4

5

6
Completely
Satisfied

2

3

4

5

6
Completely
Satisfied

Not at all
Satisfied
1

2

3

4

5

6

Don’t
Know

Not
Applicable

Not at all
Satisfied

2

3

4

5

Completely
Satisfied

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

1

6

Not at all
Satisfied

Completely
Satisfied

1

2

3

4

5

6

The next few questions are about Interim Payments you receive from Your Contractor
G8.

G9.

The clarity of your Contractor’s
instructions for the process of
requesting a review and adjustment to
your Interim Payments
The reasonableness of your
Contractor’s requests during their
consideration of an adjustment to your
Interim Payments, including the time
you are given to submit documentation
and the methods you are given for
submitting those documents

Completely
Satisfied

Not at all
Satisfied
1

2

3

4

5

Completely
Satisfied

Not at all
Satisfied
1

6

2

3

4

5

6

If you have any questions or concerns, please call the MCPSS Provider Helpline at 1-888-863-3561 or send
an email to [email protected]
G-18

In the last twelve months/Since {DATE}, how
satisfied have you been with…

G10. The clarity of your Contractor’s
explanations for decisions about
adjustments to your Interim Payments
G11. The timeliness of your Contractor’s
decisions about adjustments to your
Interim Payments

G12.

For each of the following items, please rate your level of satisfaction on a
scale of 1 to 6, where 1 is “Not at all Satisfied” and 6 is “Completely
Satisfied.” Please circle the relevant number.
Completely
Satisfied

Not at all
Satisfied
1

2

3

4

5

Don’t
Know

Not
Applicable

Don’t
Know

Not
Applicable

Completely
Satisfied

Not at all
Satisfied
1

6

2

3

4

5

6

We are interested in any general comments you have about [CONTRACTOR NAME]'s handling of Provider Audit
and Reimbursement activities. Do you have any comments you would like to share with CMS and with your Contractor
about this topic?

Thank you for completing this section of the survey instrument.

If you have any questions or concerns, please call the MCPSS Provider Helpline at 1-888-863-3561 or send
an email to [email protected]
G-19

MEDICARE CONTRACTOR PROVIDER SATISFACTION SURVEY

Instructions for Submitting Your Completed MCPSS Instrument

Please mail your completed survey directly to:
Joshua Rubin
Westat
1650 Research Boulevard
Rm # RA 1153
Rockville, MD 20850
OR

Fax the completed survey instrument to Westat at 1-888-748-5820

THANK YOU

If you have any questions or concerns, please call the MCPSS Provider Helpline at 1-888-863-3561 or send an
email to [email protected]
G-20