Form CMS-10633 Web Based Surveys

Supporting Statement for the

Paperwork Reduction Act of 1995

Attachment A: Web-Based Survey Instrument and Recruitment Materials

QIC Demonstration Evaluation Contractor (QDEC): Analyze Medicare Appeals to Conduct Formal Discussions and Reopenings with Suppliers

December 8, 2016

Centers for Medicare & Medicaid Services

Center for Medicare (CM)

Medicare Enrollment and Appeals Group (MEAG)

Division of Appeals Operations (DAO)

7500 Security Boulevard

Baltimore, MD 21244

Table of Contents

Initial Electronic Mail Invitation 3

First Reminder Electronic Mail Invitation 3

Second Reminder Electronic Mail Invitation 4

Web-Based Supplier Survey Instrument 6

Initial Electronic Mail Invitation

Dear [CONTACTNAME]

You were randomly selected from a list of suppliers who recently participated in the Centers for Medicare & Medicaid Services (CMS) Formal Telephone Discussion Demonstration. We need your help to refine and improve the Demonstration by responding to a brief survey.

Our records show that you participated in a formal telephone discussion related to a Medicare durable medical equipment (DME) claim on [DISCUSSIONDATE]. CMS is interested in your experience with the Demonstration, the DME Qualified Independent Contractor, C2C Innovative Solutions, Inc. (“the QIC”), and your suggestions on how the Demonstration could be improved.

CMS has contracted with IMPAQ International to conduct a DME supplier satisfaction and experience survey. We invite you to take this short web-based survey, which will ask you about your experience with the formal telephone discussion, satisfaction with timeliness and quality of the formal telephone discussion, and aspects of the formal telephone discussion that could be improved. The survey is voluntary, and CMS and C2C will not know your identity, whether you respond, or your specific responses.

The survey should take between 5 to 10 minutes of your time, and can be taken using a mobile device or desktop computer.

Please follow the link to access the survey.

[SURVEYLINK]

If you have any questions please contact the Evaluation Team at [email protected]. We appreciate your time and feedback.

Thank you, 

Guido Cataife, Ph.D.

Project Director

IMPAQ International

PRA Disclosure Statement

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-XXXX, Expiration Date: March 31, 2020.

First Reminder Electronic Mail Invitation

Dear [CONTACTNAME]

You were randomly selected from a list of suppliers who recently participated in the Centers for Medicare & Medicaid Services (CMS) Formal Telephone Discussion Demonstration. This is a reminder about your invitation to participate in a satisfaction survey. Your input is very important to CMS, and will be used to improve the formal telephone discussion process.

Our records show that you participated in a formal telephone discussion related to a Medicare durable medical equipment (DME) claim on [DISCUSSIONDATE]. CMS is interested in your experience with the Demonstration, the DME Qualified Independent Contractor, C2C Innovative Solutions, Inc. (“the QIC”), and your suggestions on how the Demonstration could be improved.

CMS has contracted with IMPAQ International to conduct a DME supplier satisfaction and experience survey. We invite you to take this short web-based survey, which will ask you about your experience with the formal telephone discussion, satisfaction with timeliness and quality of the formal telephone discussion, and aspects of the formal telephone discussion that could be improved. The survey is voluntary, and CMS and C2C will not know your identity, whether you respond, or your specific responses.

The survey should take between 5 to 10 minutes of your time, and can be taken using a mobile device or desktop computer.

Please follow the link to access the survey.

[SURVEYLINK]

If you have any questions please contact the Evaluation Team at [email protected]. We appreciate your time and feedback.

Thank you, 

Guido Cataife, Ph.D.

Project Director

IMPAQ International

PRA Disclosure Statement

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-XXXX, Expiration Date: March 31, 2020.

Second Reminder Electronic Mail Invitation

Dear [CONTACTNAME]

You were randomly selected from a list of suppliers who recently participated in the Centers for Medicare & Medicaid Services (CMS) Formal Telephone Discussion Demonstration. This is a second reminder about your invitation to participate in a satisfaction survey. Your input is very important to CMS, and will be used to improve the formal telephone discussion process.

Our records show that you participated in a formal telephone discussion related to a Medicare durable medical equipment (DME) claim on [DISCUSSIONDATE]. CMS is interested in your experience with the Demonstration, the DME Qualified Independent Contractor, C2C Innovative Solutions, Inc. (“the QIC”), and your suggestions on how the Demonstration could be improved.

CMS has contracted with IMPAQ International to conduct a DME supplier satisfaction and experience survey. We invite you to take this short web-based survey, which will ask you about your experience with the formal telephone discussion, satisfaction with timeliness and quality of the formal telephone discussion, and aspects of the formal telephone discussion that could be improved. The survey is voluntary, and CMS and C2C will not know your identity, whether you respond, or your specific responses.

The survey should take between 5 to 10 minutes of your time, and can be taken using a mobile device or desktop computer.

Please follow the link to access the survey.

[SURVEYLINK]

If you have any questions please contact the Evaluation Team at [email protected]. We appreciate your time and feedback.

Thank you, 

Guido Cataife, Ph.D.

Project Director

IMPAQ International

PRA Disclosure Statement

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-XXXX, Expiration Date: March 31, 2020.

Web-Based Supplier Survey Instrument

CMS is conducting a Formal Telephone Discussion Demonstration with Durable Medical Equipment (DME) Suppliers in Medicare Administrative Contractor (MAC) Jurisdictions {C} and {D} that submit Medicare Fee-For-Service claims.

As part of the Demonstration, CMS is assessing supplier experiences with the formal telephone discussion conducted by the DME Qualified Independent Contractor, {C2C Innovative Solutions}, Inc. (the QIC).

Our records show that you participated in a formal telephone discussion related to one or more pending DME claims on {FILL DISCUSSION DATE}. To help improve the Demonstration, please take –5-10 minutes to provide CMS feedback on your recent experience.

PRA Disclosure Statement

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-XXXX, Expiration Date: March 31, 2020.

The time required to complete this information collection is estimated to average between 5 to 10 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, Mail Stop C4-26-05,

Baltimore, Maryland 21244-1850.

1. Considering your participation in the formal telephone discussion that occurred on [DISCUSSIONDATE], please tell us whether you agree or disagree with each of the following statements.

1. The QIC clearly explained why the claim was originally denied by the Medicare Appeals Contractor (MAC).

Strongly Disagree

Disagree

Agree

Strongly Agree

2. The QIC clearly explained Medicare requirements that apply to the claims.

Strongly Disagree

Disagree

Agree

Strongly Agree

3. The QIC clearly explained Medicare policies that apply to the claims.

Strongly Disagree

Disagree

Agree

Strongly Agree

4. The QIC identified additional documentation needed for the reconsideration review or, stated that no further documentation was needed.

Strongly Disagree

Disagree

Agree

Strongly Agree

5. Following the formal telephone discussion, I had a better understanding of how the MAC reached its decision on our case.

Strongly Disagree

Disagree

Agree

Strongly Agree

2. How satisfied were you with the formal telephone discussion experience overall?

Very dissatisfied

Dissatisfied

Satisfied
Very satisfied

3. Did the QIC provide enough information before the discussion so that you could adequately prepare?

Yes (skip to Q4)

No (skip to 3a)

Not Sure (skip to Q4)

a. What information from the QIC would have been useful to help you prepare for the formal telephone discussion?

Type answer here: [open ended text box]

4. Considering your experience with the formal telephone discussion that occurred on [DISCUSSIONDATE], please tell us whether you agree or disagree with each of the following statements.

1. The formal telephone discussion provided adequate opportunity to give verbal testimony in support of the case.

Strongly Disagree

Disagree

Agree

Strongly Agree

2. Making formal telephone discussions available for additional types of claims would be helpful.

Strongly Disagree

Disagree

Agree

Strongly Agree

3. The formal telephone discussion process is better than the traditional on-the-record review process.

Strongly Disagree

Disagree

Agree

Strongly Agree

5. Please tell us how satisfied you were with each of the following aspects of the formal telephone discussion that took place on [DISCUSSIONDATE].

1. Timeliness of communication from the QIC about scheduling the formal discussion

Very satisfied

Satisfied

Dissatisfied

Very dissatisfied

2. The QIC’s knowledge of CMS regulations applicable to the claim under formal telephone discussion

Very satisfied

Satisfied

Dissatisfied

Very dissatisfied

3. The way the QIC listened to you during the formal telephone discussion

Very satisfied

Satisfied

Dissatisfied

Very dissatisfied

4. The professionalism of the QIC in handling the formal telephone discussion process

Very satisfied

Satisfied

Dissatisfied

Very dissatisfied

5. Timeliness of communication from the QIC about the outcomes of the formal telephone discussion

Very satisfied

Satisfied

Dissatisfied

Very dissatisfied

6. Thoroughness of communication from the QIC about the formal telephone discussion decision letter

Very satisfied

Satisfied

Dissatisfied

Very dissatisfied

6. Did you find the following aspects of the formal telephone discussion beneficial?

	Beneficial	Not Beneficial
Opportunity to present verbal testimony	□	□
Opportunity to learn more about Medicare policies and requirements applicable to the case	□	□
Opportunity to provide additional documentation	□	□
Speed of resolving the case compared to going through the Office of Medicare Hearings and Appeals process	□	□

7. During or after your formal telephone discussion on [DISCUSSIONDATE], did the QIC offer to reopen any cases that are currently pending at the Office of Medicare Hearings and Appeals (OMHA)?

Yes (go to Q7a)

No (skip to Q9)

Not Sure (skip to Q9)

a. Did you participate in the reopening?

Yes

No (skip to Q9)

Not Sure (skip to Q9)

8. Considering your experience with the reopenings process that accompanied your formal discussion on [DISCUSSIONDATE], please tell us whether you agree or disagree with each of the following statements.

1. The QIC clearly explained how the reopenings process works

Strongly Disagree

Disagree

Agree

Strongly Agree

2. The QIC provided a list of documents necessary to reopen the case(s)

Strongly Disagree

Disagree

Agree

Strongly Agree

3. The time provided to submit necessary documentation for the reopened case(s) (14 days) was adequate.

Strongly Disagree

Disagree

Agree

Strongly Agree

4. If you answered strongly disagree or disagree to 8c., enter the number of days you feel would be adequate.

[response box] days

5. [If supplier indicated they participated in a reopening] Please tell us what about the reopenings process could be improved.

[Text Box]

9. How likely is it that you would recommend participating in a formal discussion to other DME suppliers?
   
   

Not at all Neutral Extremely

Likely Likely

0. 1 2 3 4 5 6 7 8 9 10

10. How likely is it that you would participate in another formal discussion?
    
    

Not at all Neutral Extremely

Likely Likely

0. 1 2 3 4 5 6 7 8 9 10

11. Please tell us what about the formal discussions process could be improved.

[Text Box]

12. What changes, if any, have you made to your billing and documentation practices AFTER your participation in the formal telephone discussion?

Please type in your answer here: [Text Box]

I have not made any changes to practices

13. Do you have any other comments about the formal telephone discussion process, reopenings process, or this survey itself?

[Text Box]