Health Care Providers and Suppliers

Appendix B3.
Appellant Climate Survey-Mail

English

Instructions

Mark your response to each question by checking the related box or circling your answer choice. If you do not have an answer, you may leave it blank.

In the questions that follow, “OMHA” refers to the Office of Medicare Hearings and Appeals.

Section I. Hearings History

1. Approximately how many OMHA hearings have you participated in during the last 12 months?

1 0

2 1

3 2 to 10

4 More than 10

Please respond to the survey questions based on your most recent hearing experience with OMHA.

2. Were you the actual appellant or did you represent the appellant?

1 Actual appellant (skip to Question 4)

2 Represented the appellant (answer Question 3)

3. What is your relationship to the appellant?

1 Third party or outside counsel

2 Employee of appellant

3 Hired representative on behalf of State

4 Hired representative or an organization

5 A family member or friend

6 An estate executor or administrator

7 Other. Please specify: _____________________________________________________

Section II. Overall Experience

4. Independent of the judge’s decision, to what extent do you think you were given the opportunity to have your case fully heard and considered?

1 Very great extent

2 Great extent

3 Some extent

4 Very little extent

5 Not heard and considered at all

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 0990-0330. The time required to complete this information collection is estimated to average 15 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: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave. SW, Suite 537-H, Washington DC 20201, Attention: PRA Reports Clearance Officer.

5. Next, think about the entire process of working with OMHA, from requesting an Administrative Law Judge hearing up to receiving a final decision. Regardless of the outcome of that decision, how satisfied were you with the process of working with OMHA overall?

1 Very satisfied

2 Satisfied

3 Neither satisfied nor dissatisfied

4 Dissatisfied

5 Very dissatisfied

6. How satisfied were you with the professionalism of OMHA staff when they assisted you with the Administrative Law Judge hearing process?

1 Very satisfied

2 Satisfied

3 Neither satisfied nor dissatisfied

4 Dissatisfied

5 Very dissatisfied

Section III. Hard Copy, Internet, and Phone Information

7. The table below lists documents that you may have received during the appeals process. For each document listed, indicate its clarity on the scale provided.

Document Name	Type of Information	Very Clear	Generally Clear	Some- what Clear	Generally Unclear	Not at All Clear
Acknowledgment of a Request for a Hearing before an Administrative Law Judge (Form OMHA-110)	Confirmed that OMHA had received your request for a hearing and included a record number for your appeal.	1	2	3	4	5
Notice of Assignment to an Administrative Law Judge	Provided information about the Administrative Law Judge who was assigned to your appeal.	1	2	3	4	5
Notice of Hearing (Form OMHA-1024)	Specified the date and time that the hearing was scheduled, the type of hearing, instructions about what to do next, and other instructions.	1	2	3	4	5
Response to Notice of Hearing (Form OMHA-102)	Provided with the Notice of Hearing; this document required you to provide information about the hearing, the responding party, and your representative, if you had one.	1	2	3	4	5
Notice of Nondiscrimination (Form OMHA-001)	Included instructions in several languages on how to obtain aid/services for people with disabilities and how to obtain free language services.	1	2	3	4	5
Exhibit List (Form OMHA-156)	Part of the case record; this document may have listed medical record evidence, among other topics.	1	2	3	4	5
Rights to appeal the Administrative Law Judge’s Decision	Provided with the decision letter after participating in the Administrative Law Judge hearing; this document explains your rights to appeal the decision to the next higher level.	1	2	3	4	5

8. Have you used the online Administrative Law Judge Appeal Status Information System, or AASIS? This feature of the OMHA website allows you to look up the status of appeals you have filed with OMHA.

1 Yes (answer Question 9)

2 No (skip to Question 10)

9. How satisfied are you with the online capability to check the status of your appeal?

1 Very satisfied

2 Satisfied

3 Neither satisfied nor dissatisfied

Please explain why you were dissatisfied in the lines provided below.

4 Dissatisfied

5 Very dissatisfied

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

10. Have you accessed OMHA’s website?

1 No, I did not try

2 No, I do not have access to a computer and/or the Internet

3 No, I tried to but could not find it

4 Yes

11. What suggestions do you have for improving the OMHA website? If you have not viewed the website, what types of information would be useful for you to find on the website?

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

12. Did you ever use the toll-free helpline to contact OMHA?

1 Yes (answer Question 13)

2 No (skip to Question 14)

13. How satisfied were you with the customer service provided by OMHA through the toll-free helpline?

1 Very satisfied

2 Satisfied

3 Neither satisfied nor dissatisfied

4 Dissatisfied

5 Very dissatisfied

Section IV. Experience Scheduling Your Hearing

14. There were four different phases of the scheduling process (listed below), starting with your initial request for a hearing, up to when you actually participated in the hearing and received the Administrative Law Judge’s decision. Please rate your level of satisfaction with each phase.

Phases of the Scheduling Process	Very Satisfied	Satisfied	Neither Satisfied nor Dissatisfied	Dissatisfied	Very Dissatisfied
The timeframe between filing your request for a hearing and when you were notified that your case had been assigned to an Administrative Law Judge	1	2	3	4	5
The amount of time you waited until your hearing was scheduled	1	2	3	4	5
The timeframe between scheduling the hearing and the hearing itself	1	2	3	4	5
The timeframe between the hearing and receiving a decision	1	2	3	4	5

15. Overall, how satisfied were you with the process to schedule the Administrative Law Judge hearing?

1 Very satisfied

2 Satisfied

Please explain why you were dissatisfied in the lines provided below.

3 Neither satisfied nor dissatisfied

4 Dissatisfied

5 Very dissatisfied

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

16. After your hearing was scheduled, was it ever rescheduled?

1 Yes (answer Questions 17A and 17B)

2 No (skip to Question 19) [for non-beneficiaries, PRINT SKIP TO Question 18]

17A. Did any of the following rescheduling activities occur? (Check all that apply)

1 You requested a rescheduling of the hearing.

2 The Administrative Law Judge, or staff, changed the time and/or place of the hearing as it was originally scheduled.

17B. How satisfied were you with the rescheduling process?

1 Very satisfied

2 Satisfied

3 Neither satisfied nor dissatisfied

4 Dissatisfied

5 Very dissatisfied

[printed on the version sent to NON-BENEFICIARIES ONLY; numbering will adjust accordingly] 18. Were you made aware of the volume of appeals that OMHA was processing other than yours?

1 Yes

2 No

Section V. Interaction with OMHA Between Scheduling and Hearing

19. Did you have any interaction with OMHA staff after the hearing was scheduled, but before the hearing was conducted?

1 Yes

2 No (skip to Question 23)

20. During the period after the hearing was scheduled but before it was held, how satisfied were you with your interaction with OMHA staff overall?

1 Very satisfied

2 Satisfied

3 Neither satisfied nor dissatisfied

4 Dissatisfied

5 Very dissatisfied

21. During the period after the hearing was scheduled but before it was held, did your interaction with OMHA staff help to make your hearing more effective?

1 Very helpful in making hearing more effective

2 Generally helpful

3 Neither helpful nor unhelpful

Please explain why your interaction was unhelpful in the lines below.

4 Generally unhelpful

5 Not helpful at all

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

22. What was the purpose of the interaction between you and OMHA staff [please check all that apply]?

1 To get evidence that was not in the record on the record

2 Prepare exhibits

3 Discuss procedural matters

4 Get general questions about the hearing process answered

5 Other. Please specify: ___________________________________________________

_{Section V}I. Telephone Hearing

Next are questions about your telephone hearing.

23. [OMITTED FOR APPELLANTS USING VIDEO CONFERENCING] During the telephone hearing(s), how much of the time were you able to hear people clearly when they were speaking?

1 All of the time

2 Most of the time

3 Some of the time

4 None of the time

24. Overall, how satisfied were you with the use of the telephone [print “video conferencing” when applicable] to conduct your Administrative Law Judge hearing(s)?

1 Very satisfied

2 Satisfied

3 Neither satisfied nor dissatisfied

Please explain why you were dissatisfied in the lines below.

4 Dissatisfied

5 Very dissatisfied

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Section VII. Final Questions

25. Regardless of the judge’s decision, how satisfied were you with the interaction you had with the judge?

1 Very satisfied

2 Satisfied

3 Neither satisfied nor dissatisfied

4 Dissatisfied

5 Very dissatisfied

26. Regardless of the judge’s decision, was the decision written in language that you could clearly understand?

1 Very clear

2 Generally clear

3 Somewhat clear

4 Generally unclear

5 Not at all clear

27. Please respond to the following statements about the Administrative Law Judge(s) for your hearing(s) experience.

	Always	Often	Some- times	Never
a. The judge clearly understood the issue(s) in my case(s).	1	2	3	4
b. The judge was professional.	1	2	3	4
c. The judge was an effective listener.	1	2	3	4
d. The judge was prepared.	1	2	3	4
e. The judge conducted an orderly hearing(s).	1	2	3	4

28. Based on your experience with the OMHA appeals process, do you have any suggestions for improvement?

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Section VIII. Final Questions for Non-Beneficiaries Only

As part of a broader effort to improve the Medicare appeals process, OMHA has offered alternative methods instead of the hearing process to seek review of appeals. The next two questions describe these Special Initiatives and ask about your awareness of them.

29. OMHA’s Settlement Conference Facilitation (SCF) program is an alternative dispute resolution process at OMHA that gives certain providers and suppliers an opportunity to resolve their eligible Part A and Part B appeals through mediation with the Centers for Medicare & Medicaid Services (CMS). Are you aware of this program?

1 Yes (answer Question 30)

2 No (skip to Question 32)

30. Have you participated in the program?

1 Yes (answer Question 31)

2 No-(skip to Question 32)

31. How satisfied were you with your settlement conference experience?

1 Very satisfied

2 Satisfied

3 Neither satisfied nor dissatisfied

4 Dissatisfied

5 Very dissatisfied

32. OMHA’s Statistical Sampling program provides appellants with an option for addressing large volumes of claim disputes at the Administrative Law Judge Hearing level of the Medicare claim appeals process. Are you aware of this program?

1 Yes

2 No

Thank you for taking the time to respond to this survey. If you would like to make a comment about this survey or confirm that it meets the necessary requirements as a valid information collection tool under the Paperwork Reduction Act, please contact the OMHA Survey Team at 1-866-207-4466.

Use the postage-paid return envelope to return this survey or mail it to:

2M Research

ATTN: OMHA Survey

1521 N. Cooper St., Suite 600

Arlington, TX 76011