Form CMS-10097 MCPSS National Implementation 2009 Survey Instrument

ATTACHMENT 2

MCPSS NATIONAL IMPLEMENTATION
2009 SURVEY INSTRUMENT

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

A

ccording 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.

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. I

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

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

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

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…..	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.
A1. How quickly you can reach a representative to make a Provider Inquiry by telephone	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
A2. Receiving the correct information	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
A3. The consistency of responses that you get from different Provider Inquiries representatives	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
A4. The effort your Contractor makes to make the Provider Inquiries process as easy as possible for you	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
A5. The modes of communication that are offered by your Contractor to exchange information with them about Inquiries	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
A6. The professionalism and courtesy of your Contractor’s representatives throughout Provider Inquiries activities	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
A7. Your Contractor’s ability to fully resolve problems without you having to make multiple inquiries	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable

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)  Telephone call with a Contractor representative  Automated telephone system  Web  E-mail  Mail  Fax  Other (specify).		A10. In the last twelve months/ Since {DATE} how many inquires have you and any other persons in your facility made?  1-2  3-5  6-10  11-20  21-50  51-100  101 or more
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  E-mail  Mail  Fax  Other (specify).		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  Other (Please specify) _________________________________

A12. We are interested in any general comments you have about [CONTRACTOR NAME]'s handling of Provider Inquiry activities. In what ways (if any) do you think this service could be improved?

Thank you for completing this section of the survey instrument.

MEDICARE CONTRACTOR PROVIDER SATISFACTION SURVEY

Section B: Provider Outreach & Education

[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

Your Ratings of [CONTRACTOR]’S

Performance of Provider Outreach & Education

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…	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.
B2. The amount of training and educational resources available from your Contractor	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
B3. The detail in which topics are covered	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
B4. The tailoring of training or education at a level you can understand	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
B5. The topics of the training and education materials are up-to-date	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
B6. The relevance of the training and education material topics to your organizations needs.	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
B7. The accessibility of education and training resources from your Contractor	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
B8. The expertise of your Contractor’s provider education and training staff	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
B9. Your contractor’s communication with you about changes that have been or are being made to Medicare policies and regulations	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
B10. The professionalism and courtesy of your Contractor’s training and education representatives	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
B11. If you are an eligible professional, CMS’ outreach and educational efforts on the “Physician Quality Reporting Initiative or PQRI”?	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable

B11a. CMS products to educate you on how to bill for preventive services.

Not at all Satisfied 1

2

3

4

5

Completely Satisfied 6

Don’t Know

Not Familiar With products

B11b. CMS outreach and education on how Durable Medical Equipment Prosthetics, Orthotics and Supplies (Competitive Bidding Program) affects you and your Medicare patients.

Not at all Satisfied 1

2

3

4

5

Completely Satisfied 6

Don’t Know

Not Familiar With products

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)

__________________________________

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. In what ways (if any) do you think this service could be improved?

Thank you for completing this section of the survey instrument.

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

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…	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.
C1. The accuracy of your Contractor’s claims editing	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
C2. The timeliness of notification from your Contractor that a claim will not be paid, including denied, returned or unprocessed claims	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
C3. The accuracy of remittance advices received from your Contractor	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
C4. The ease of submitting electronic claims	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
C5. The availability of your Contractor’s representatives to address claims-related issues	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
C6. The clarity of remittance advices you receive from your Contractor	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
C7. The ease of correcting claims, such as correcting claims online or asking for a change over the phone	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable

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

• Paper

• Electronic

• Both

C9. We are interested in any general comments you have about [CONTRACTOR NAME]'s handling of Claims Processing activities. In what ways (if any) do you think this service could be improved?

Thank you for completing this section of the survey instrument

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

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.
D1. The consistency of your Contractor’s first-level appeals decisions for claims that have been denied	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
D2. The mechanisms that your Contractor offers for exchanging information with them about first-level appeals	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
D3. Your Contractor’s responsiveness, attentiveness, and availability during the process of first-level appeals	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
D4. The professionalism and courtesy of your Contractor’s representatives during the appeals process	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
D5. The clarity of explanations of appeal decisions made by your Contractor	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable

D6. We are interested in any general comments you have about [CONTRACTOR NAME]'s handling of Appeals activities. In what ways (if any) do you think this service could be improved?

Thank you for completing this section of the survey instrument.

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

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…	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.
E1. The ability of your Contractor representative to respond to your questions about the Medicare enrollment application, CMS Form 855	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
E2. The consistency of your Contractor’s responses or decisions	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
E3. The professionalism and courtesy of your Contractor’s representatives during the Provider Enrollment process	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
E4. Your Contractor’s responsiveness, attentiveness, and availability during the process of enrollment	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
E5. Your Contractor’s ability to answer questions specific to your situation or specialty.	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable

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

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.
E7. The information provided by your Contractor to enable you to start billing for services.	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable

E8. We are interested in any general comments you have about [CONTRACTOR NAME]'s handling of Provider Enrollment activities. In what ways (if any) do you think this service could be improved?

Thank you for completing this section of the survey instrument.

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

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		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.
F1. The clarity of the notification (letter, phone call, etc.) from your Contractor that your claims were selected for Medical Review		Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
F2. The clarity of the explanations of your Contractor’s Medical Review decisions		Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
F3. Receiving timely local Medical Review policy changes and updates that affect your organization from your Contractor		Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
F4. The follow through that your Contractor provided after Medical Review decisions		Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
F5. The knowledge of your Contractor’s Medical Reviewers		Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
F6. How well your Contractor makes an effort to make things as easy and as fair as possible for you		Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
F7. The consistency of your Contractor’s Medical Review decisions and answers to your questions	Not at all Satisfied 1		2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
F8. The professionalism and courtesy of your Contractor representatives throughout the medical review process	Not at all Satisfied 1		2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable

F9. We are interested in any general comments you have about [CONTRACTOR]'s handling of Medical Review activities. In what ways (if any) do you think this service could be improved?

Thank you for completing this section of the survey instrument.

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

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…	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.
G1. Availability of timely updates from your Contractor on Medicare policy (regulations, manuals and other instructions) that affect Provider Audit and Reimbursement	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
G2. The professionalism and courtesy of your Contractor representatives throughout all Provider Audit and Reimbursement activities	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
G3. 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 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
G4. Your Contractor’s interpretations of CMS’ rules for Cost Report and payment policies.	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
G5. The knowledge of your Contractor’s Cost Report Auditors	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
G6. The timeliness of your Contractor’s audit of your Cost Report, if one is conducted, and the final settlement	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
G7. The overall communication between you and your Contractor about adjustments and Cost Reports/ Cost Report Audits	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
The next few questions are about Interim Payments you receive from Your Contractor
G8. The clarity of your Contractor’s instructions for the process of requesting a review and adjustment to your Interim Payments	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
G9. 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	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
G10. The clarity of your Contractor’s explanations for decisions about adjustments to your Interim Payments	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable
G11. The timeliness of your Contractor’s decisions about adjustments to your Interim Payments	Not at all Satisfied 1	2	3	4	5	Completely Satisfied 6	Don’t Know	Not Applicable

G12. We are interested in any general comments you have about [CONTRACTOR NAME]'s handling of Provider Audit and Reimbursement activities. In what ways (if any) do you think this service could be improved?

Thank you for completing this section of the survey instrument.

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

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