QDEC_Attachment A Web Based Survey_508 Compliant

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

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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,
Namratha Swamy, Ph.D.
Vice President | Health
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.

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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,
Namratha Swamy, Ph.D.
Vice President | Health
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.

4

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,
Namratha Swamy, Ph.D.
Vice President | Health
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.

5

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 1 - 2
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.
a. The QIC clearly explained why the claim was originally denied by the Medicare
Appeals Contractor (MAC).
Strongly Disagree
Disagree
Agree
Strongly Agree
b. The QIC clearly explained Medicare requirements that apply to the claims.
Strongly Disagree
Disagree
Agree
Strongly Agree
c. The QIC clearly explained Medicare policies that apply to the claims.
Strongly Disagree
Disagree
Agree
Strongly Agree

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d. The QIC identified additional documentation needed for the reconsideration review
(or, stated that no further documentation was needed).
Strongly Disagree
Disagree
Agree
Strongly Agree
e. Following the formal telephone discussion, I had a better overall understanding of
how the MAC’s decision on our case was reached.
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.

a. The formal telephone discussion provided adequate opportunity to give verbal
testimony in support of the case.
Strongly Disagree
Disagree
Agree
Strongly Agree
b. Making formal telephone discussions available for additional types of claims would
be helpful.
Strongly Disagree
Disagree
Agree
Strongly Agree

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c. 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].
a. Timeliness of communication from the QIC about scheduling the formal discussion
Very satisfied
Satisfied
Dissatisfied
Very dissatisfied
b. The QIC’s knowledge of CMS regulations applicable to the claim under formal
telephone discussion
Very satisfied
Satisfied
Dissatisfied
Very dissatisfied
c. The way the QIC listened to you during the formal telephone discussion
Very satisfied
Satisfied
Dissatisfied
Very dissatisfied
d. The professionalism of the QIC in handling the formal telephone discussion process
Very satisfied
Satisfied
Dissatisfied
Very dissatisfied
e. Timeliness of communication from the QIC about the outcomes of the formal
telephone discussion
Very satisfied
Satisfied
Dissatisfied
Very dissatisfied
f.

Thoroughness of communication from the QIC about the formal telephone
discussion decision letter
Very satisfied
Satisfied
Dissatisfied
Very dissatisfied

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6. Did you find the following aspects of the formal telephone discussion 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 OMHA process

Beneficial
□
□

Not Beneficial
□
□

□

□

□

□

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.

a.

The QIC clearly explained how the reopenings process works
Strongly Disagree
Disagree
Agree
Strongly Agree

b. The QIC provided a list of documents necessary to reopen the case(s)
Strongly Disagree
Disagree
Agree
Strongly Agree

c. The time provided to submit necessary documentation for the reopened case(s) (14
days) was adequate.
Strongly Disagree
Disagree
Agree
Strongly Agree

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d. If you answered strongly disagree or disagree to 8c., enter the number of days you
feel would be adequate.
[response box] days

e. [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

0

Likely

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

0

Likely

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]

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