Form CMS-10633 Web Based Surveys

Supporting Statement A for the QIC
Demonstration Evaluation Contractor
(QDEC): Analyze Medicare Appeals to
Conduct Formal Discussions and
Reopenings with DME Suppliers and Part A
Providers
(CMS-10633/OMB control number: 0938-1348)

Attachment A: Web-Based Survey
Instrument and Recruitment Materials
June 1, 2020
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
Attachment A: Web-Based Survey Instrument and Recruitment Materials................................ 1

Appendix A. DME Survey Invite and Reminder Text............................................................ 1
Initial Electronic Mail Invitation .......................................................................................... 1
First Reminder.................................................................................................................. 2
Final Reminder ................................................................................................................. 3

Appendix B. DME Satisfaction Survey Instruments .............................................................. 4
DME QIC Discussion Participant Satisfaction Survey ........................................................ 4

Appendix C. Part A Survey Invite and Reminder Text .......................................................... 9
Initial Electronic Mail Invitation .......................................................................................... 9
First Reminder................................................................................................................ 10
Final Reminder ............................................................................................................... 11

Appendix D. Part A Satisfaction Survey Instrument .............................................................12

i

Appendix A. DME Survey Invite and Reminder
Text
Initial Electronic Mail Invitation
Dear [CONTACTNAME]
You were randomly selected from a list of suppliers who recently Discicipated 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 telephone discussion r elated to a Medicare durable
medical equipment (DME) claim on [DISCUSSION DATE]. CMS is interested in your experience
with the Demonstration, the DME Qualified Independent Contractor, MAXIMUS, 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 telephone discussion, satisfaction with timeliness and quality of
the telephone discussion, and aspects of the telephone discussion that could be improved.
The survey is voluntary, and CMS and MAXIMUS 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]
Please complete this survey by COB on [END FIELDING DATE]. 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 | QIC Demonstration Evaluation Contractor (QDEC)
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 [NUMBER], Expiration Date: [DATE].

1

First Reminder
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 telephone discussion process.
Our records show that you participated in a 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, MAXIMUS, 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 telephone discussion, satisfaction with timeliness and quality of the telephone
discussion, and aspects of the telephone discussion that could be improved. The survey is
voluntary, and CMS and MAXIMUS 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]
Please complete this survey by COB on [END FIELDING DATE]. 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 | QIC Demonstration Evaluation Contractor (QDEC)
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 [NUMBER], Expiration Date: [DATE].

2

Final Reminder
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
final reminder about your invitation to participate in a satisfaction survey. Your input is very
important to CMS, and will be used to improve the telephone discussion process.
Our records show that you participated in a 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, MAXIMUS, 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 telephone discussion, satisfaction with timeliness and quality of
the telephone discussion, and aspects of the telephone discussion that could be improved.
The survey is voluntary, and CMS and MAXIMUS 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]
Please complete this survey by COB on [END FIELDING DATE]. 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 | QIC Demonstration Evaluation Contractor (QDEC)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.

3

Appendix B. DME Satisfaction Survey
Instruments
DME QIC Discussion Participant Satisfaction Survey
CMS is conducting a Formal Telephone Discussion Demonstration with Durable Medical
Equipment (DME) Suppliers that submit Medicare Fee-For-Service claims.
As part of the Demonstration, CMS is assessing provider experiences with the formal telephone
discussion conducted by the DME Qualified Independent Contractor, MAXIMUS, Inc. (the QIC).
Our records show that you participated in a formal telephone discussion related to one or more
pending DME claims on [DISCUSSIONDATE]. To help improve the Demonstration, please
take 10 minutes to provide CMS feedback on your recent experience.

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
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. The information given by the QIC helps me or my company to submit more
complete or accurate claims.
4

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. The formal telephone discussion process is better than the traditional onthe-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

5

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 regarding 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?

Aspects of 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

□
□

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)?
6





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
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 provider 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
Likely

0

Neutral

1

2

3

4

5

Extremely
Likely

6

7

7

8

9

10

10.

How likely is it that you would participate in another formal discussion?
Not at all
Likely

1
11.

Neutral

1

2

3

4

5

Extremely
Likely

6

7

8

9

10

Please tell us what about the formal discussions process could be improved.
[Text Box]

12.

Have you made changes to your billing and documentation practices after
participating in the formal telephone discussion?

Yes (skip to 12a)

No (skip to Q13)

Not Sure (skip to Q13)
a. Please describe the changes you made to billing and documentation practices
after participating in the formal telephone discussion.
Please type your answer in the box below.
[Text Box]
13. Do you have any other comments about the formal telephone discussion process,
reopenings process, or this survey itself?
[Text Box]

8

Appendix C. Part A Survey Invite and Reminder
Text
Initial Electronic Mail Invitation
Dear [CONTACTNAME]
You were randomly selected from a list of providers 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
Part A claim on [DISCUSSIONDATE]. CMS is interested in your experience with the
Demonstration, the Part A East Qualified Independent Contractor (“the QIC”), C2C Innovative
Solutions, Inc., and your suggestions on how the Demonstration could be improved.
CMS has contracted with IMPAQ International to conduct a provider 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]
Please complete this survey by COB on [END FIELDING DATE]. 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 | QIC Demonstration Evaluation Contractor (QDEC)
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 [OMB Number], Expiration Date: [Date].

9

First Reminder
Dear [CONTACTNAME]
You were randomly selected from a list of providers 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
Part A claim on [DISCUSSIONDATE]. CMS is interested in your experience with the
Demonstration, the Part A East Qualified Independent Contractor (“the QIC”), C2C Innovative
Solutions, Inc., and your suggestions on how the Demonstration could be improved.
CMS has contracted with IMPAQ International to conduct a Part A provider 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, a nd can be taken using a mobile
device or desktop computer.
Please follow the link to access the survey. [SURVEYLINK]
Please complete this survey by COB on [END FIELDING DATE]. 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 | QIC Demonstration Evaluation Contractor (QDEC)
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 [Number], Expiration Date: [Date].

10

Final Reminder
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
final reminder about your invitation to participate in a satisfaction survey. Your input is very
important to CMS, and will be used to improve the telephone discussion process.
Our records show that you participated in a formal telephone discussion related to a Medicare
Part A claim on [DISCUSSIONDATE]. CMS is interested in your experience with the
Demonstration, the Part A East Qualified Independent Contractor (“the QIC”), C2C Innovative
Solutions, Inc., and your suggestions on how the Demonstration could be improved.
CMS has contracted with IMPAQ International to conduct a Part A provider satisfaction and
experience survey. We invite you to take this short web-based survey, which will ask you about
your experience with the telephone discussion, satisfaction with timeliness and quality of
the telephone discussion, and aspects of the 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 usin g a mobile
device or desktop computer.
Please follow the link to access the survey. [LINK]
Please complete this survey by COB on [END FIELDING DATE]. 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 | QIC Demonstration Evaluation Contractor (QDEC)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.

11

Appendix D. Part A Satisfaction Survey
Instrument
CMS is conducting a Formal Telephone Discussion Demonstration with Part A East Suppliers
that submit Medicare Fee-For-Service claims.
As part of the Demonstration, CMS is assessing supplier experiences with the telephone
discussion conducted by the Part A East Qualified Independent Contractor, C2C Innovative
Solutions, Inc. (the QIC).
Our records show that you participated in a telephone discussion related to one or more
pending Part A claims on [DISCUSSION DATE]. To help improve the Demonstration, please
take 10 minutes to provide CMS feedback on your recent experience.
1. Considering your participation in the 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
d. The QIC identified additional documentation needed for the reconsideration
review or stated that no further documentation was needed.
12

Strongly Disagree
Disagree
Agree
Strongly Agree
e. The information given by the QIC helps me or my company to submit more
complete or accurate claims.
Strongly Disagree
Disagree
Agree
Strongly Agree
2. How satisfied were you with the 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 telephone discussion?
Type answer here: [open ended text box]

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

a. The telephone discussion provided adequate opportunity to give verbal
testimony in support of the case.
Strongly Disagree
Disagree
Agree
Strongly Agree

13

b. The telephone discussion process is be tter than the traditional on-therecord review process.
Strongly Disagree
Disagree
Agree
Strongly Agree
5. Please tell us how satisfied you were with each of the following aspects of the
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
telephone discussion
Very satisfied
Satisfied
Dissatisfied
Very dissatisfied
c. The way the QIC listened to you during the telephone discussion
Very satisfied
Satisfied
Dissatisfied
Very dissatisfied
d. The professionalism of the QIC in handling the telephone discussion
process
Very satisfied
Satisfied
Dissatisfied
Very dissatisfied
e. Timeliness of communication from the QIC about the outcomes of the
telephone discussion
Very satisfied
Satisfied
14

Dissatisfied
Very dissatisfied
f.

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

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

Aspects of 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

□
□

Not
Beneficial
□
□

□

□

□

□

7. During or after your 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
15

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
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 Part A providers?
Not at all
Likely

2

Neutral

1

2

3

4

5

Extremely
Likely

6

7

8

9

10

10. How likely is it that you would participate in another formal discussion?
Not at all
Likely

3

Neutral

1

2

3

4

5

Extremely
Likely

6

7

8

9

10

11. Please tell us what about the formal discussions process could be improved.
[Text Box]

16

12. Have you made changes to your billing and documentation practices after
participating in the formal telephone discussion?”

Yes (skip to 12a)

No (skip to Q13)

Not Sure (skip to Q13)
b. Please describe the changes you made to billing and documentation practices
after participating in the formal telephone discussion.
Please type your answer in the box below.
[Text Box]
13. Do you have any other comments about the telephone discussion process,
reopenings process, or this survey itself?
[Text Box]

17