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?

 0

 1

 2 to 10

 More than 10

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

2a. Approximately, when was your most recent hearing? Month_______ Year _______

2b. Do you recall the office that heard this case?

 Albuquerque

 Arlington

 Atlanta

 Cleveland

 Denver

 Irvine

 Kansas City

 Miami

 New Orleans

 Phoenix

 Seattle

3. Which of the following best describes your relationship to the appellant?

 The appellant

 Employee of the appellant

_{ Appellant’s authorized or appointed representative}

 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?

 Very great extent

 Great extent

 Some extent

 Very little extent

 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 11 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 a 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?

 Very satisfied

 Satisfied

 Neither satisfied nor dissatisfied

 Dissatisfied

 Very dissatisfied

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

 Very satisfied

 Satisfied

 Neither satisfied nor dissatisfied

 Dissatisfied

 Very dissatisfied

Section III. Hard Copy, Internet, and Phone Information

You may have received some documents during the appeals process.

7a. [SKIP in NON-BENEFICIARY version] First, is the Notice of Nondiscrimination (Form OMHA – 001). This document included instructions in a variety of languages on how to obtain free aid and services for people with disabilities and how to obtain free language services. Did you receive this document?

 Yes

 No

7b. The [next document] /[first document] is the Index of the Administrative Record (Form-156) or Exhibit List. How satisfied were you with how clearly it listed all the documents admitted to the administrative record and was organized?

 Very satisfied

 Satisfied

 Neither satisfied nor dissatisfied

 Dissatisfied

 Very dissatisfied

 Didn’t receive

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.

 Yes (answer Question 9)

 No (skip to Question 10)

9. How satisfied are you with AASIS’s capability to provide accurate updates of your appeal?

 Very satisfied

 Satisfied

 Neither satisfied nor dissatisfied

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

 Dissatisfied

 Very dissatisfied

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

10. Have you accessed OMHA’s website?

If “no” continue to Question 12

 No, I did not try

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

 No, I tried to but could not find it

 Yes

11. What suggestions do you have for improving the OMHA website?

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

12. Did you ever use the beneficiary or national toll-free helplines to contact OMHA?

 Yes (answer Question 13)

 No (continue to Question 14)

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

 Very satisfied

 Satisfied

 Neither satisfied nor dissatisfied

 Dissatisfied

 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 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 a Judge					
The amount of time you waited after the appeal was assigned until your hearing was scheduled					
The timeframe after the hearing was scheduled but before it was held					
The timeframe between the hearing and receiving a decision					

15. Overall, how satisfied were you with the entire process to schedule the Judge’s hearing?

 Very satisfied

 Satisfied

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

 Neither satisfied nor dissatisfied

 Dissatisfied

 Very dissatisfied

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

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

 Yes (answer Questions 17 and 18)

 No (continue to Question 19)

17.

Did you request the hearing to be rescheduled or did the Judge change the time and/or place of the hearing.

 You requested a rescheduling of the hearing.

 The Judge changed the time and/or place of the originally scheduled hearing.

 Both parties requested the hearing be rescheduled and/or change in time and/or place at least one time

18. How satisfied were you with the rescheduling process?

 Very satisfied

 Satisfied

 Neither satisfied nor dissatisfied

 Dissatisfied

 Very dissatisfied

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?

 Yes

 No (continue to Question 22)

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

a. Submit evidence or other documents

b. Request a copy of the administrative record

c. Discuss procedural matters

d. Get general questions about the hearing process answered

e. Other. Please specify:

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

 Very satisfied

 Satisfied

 Neither satisfied nor dissatisfied

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

 Dissatisfied

 Very dissatisfied

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

_{Section V}I. Telephone Hearing

Next are questions about your telephone hearing.

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

 Very satisfied

 Satisfied

 Neither satisfied nor dissatisfied

Please explain why you were dissatisfied in the lines below.

 Dissatisfied

 Very dissatisfied

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Section VII. Final Questions

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

 Very satisfied

 Satisfied

 Neither satisfied nor dissatisfied

 Dissatisfied

 Very dissatisfied

24. Regardless of the judge’s decision, how satisfied were you with how clearly the decision explained the final outcome and reasoning behind the Judge’s decision?

 Very satisfied

 Satisfied

 Neither satisfied nor dissatisfied

 Dissatisfied

 Very dissatisfied

25. Regardless of the Judge’s decisions, please respond to the following statements about the Judge during your hearing(s) experience.

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

26. 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 questions describe one of OMHA’s Special Initiatives.

27. 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?

 Yes (answer Question 28)

 No (This is your last question)

28. Have you participated in the Settlement Conference Facilitation program?

 Yes (answer Question 29)

 No (This is your last question)

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

 Very satisfied

 Satisfied

 Neither satisfied nor dissatisfied

 Dissatisfied

 Very dissatisfied

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