Attachment 88 – MPC Hospital Provider Authorization Form Package, One Point of Contact for Medical and Patient Account Records

OMB#: 0935-0118

Medical Expenditure Panel Survey – Medical Provider Component

Reference #: «GID

Attachment 88

Medical Expenditure Panel Survey

Medical Provider Component

Hospital Provider Authorization Form Packet,

One Point of Contact for Medical and Patient Account Records

«DATE»

«CONTACT_NAME»

Provider Name

MEDICAL RECORDS AND PATIENT ACCOUNTS DEPARTMENT

«FAX_NUMBER»

Total Pages (including cover sheet): «TOTAL_PAGES»

Total Number of Patients: [FILL]

«Instructions»

Thank you for speaking with me earlier. Per our conversation, this fax packet includes the study information and the signed patient authorization forms. These forms were signed by your patients who are actively participating in this research study. These signed forms allow us to contact you to obtain data from the complete medical and billing records (including Emergency Room, Anesthesiology, Pathology, Radiology, and Cardiology reports, when applicable), for 2014, for the patients listed on the enclosed confidential patient checklist.

«SPECIAL_COMMENT»

Enclosures:

• Letter from the CDC and AHRQ

• Confidential Patient Check List

• Fax Coversheet and Mail Return Form

• Frequently Asked Questions (FAQ)

• «TOTAL_AFS» – Signed Authorization Forms

	DEPARTMENT OF HEALTH & HUMAN SERVICES Agency for Healthcare Research and Quality

«DATE»

Dear «POC_NAME»:

We understand that one of our data collection specialists has talked to you about the Medical Provider Component of the Medical Expenditure Panel Survey. We are appreciative of the contributions you and your hospital are providing to this important study that is being conducted for the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Disease Control and Prevention (CDC), both part of the U.S. Department of Health and Human Services. We wanted to take this opportunity to tell you more about the study.

The objective of the study is to provide accurate information to government policymakers and private researchers about the rapidly changing health care situation in this country. To accomplish this goal, we have collected data from a cross-section of American households on how they used and paid for health care during 2014. With the written permission of members of these households, we are now contacting their medical providers to determine the actual dates of service, the diagnoses/conditions, the services provided, the amount that was charged, the amount that was paid, and the sources of payment. One or more of your patients have given us written authorization to request this information from your medical and billing records.

The study materials enclosed with this letter include a list of your patients who have agreed to participate in the survey and an authorization form for each patient.

This survey is authorized by section 902(a) of the Public Health Service Act [42 U.S.C. 299a]. Participation is voluntary, but we are depending on you to help us toward a more complete understanding of the nation’s health care. The client information we obtain will be used for research purposes only and will be released publicly only in summary form in which establishments or individuals cannot be identified. The confidentiality of client information is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 242m(d)]. Information that could identify a client or establishment will not be disclosed unless that client or establishment has consented to such a disclosure.

A Data Collection Specialist from our contractors, RTI International (RTI) and Social and Scientific Systems, Inc. (SSS), will call shortly after you have received these materials to see if you have any questions and to arrange for the collection of these data. If you have questions about the forms or procedures, call RTI-SSS, toll-free at «TOLL_PHONE_NUMBER».

Sincerely,

Richard Kronick, Ph.D. Director Agency for Healthcare Research and Quality	Charles J. Rothwell, M.B.A, M.S.  Director National Center for Health Statistics Centers for Disease Control and Prevention

Confidential Patient Checklist – PLEASE RETURN

Thank you for taking the time to provide this medical and billing information.




Step 1: Please check the appropriate box next to the patient name on the list below to indicate which of the following applies to each patient: you were able to locate the patient’s records for 2014, you were able to locate the patient but there were no 2014 records, or the individual is not a patient.

Step 2: Please Provide the Complete 2014 Medical, Billing and Payment Records for Each Patient for whom you were able to locate 2014 records. For each patient listed below, we are requesting information for all 2014 services each patient received between January 1, 2014 and December 31, 2014.


FOR EACH PATIENT EVENT WE NEED THE FOLLOWING:

• Date(s) of Service in 2014

• Services Provided in 2014 (CPT-4, DRG, revenue code, HCPCS, or descriptions)

• Diagnoses or Conditions (ICD-9 Codes or descriptions)

• All Names, Roles, Specialties, and Contacting Information for All Doctors Who May Have Billed
  Separately for Each Date of Service

• Charges for Each Service Provided

• Payments and Who the Payment was Made by (if insurance, please specify Medicare, Medicaid, Private, etc.)

• Adjustment Activity

• Emergency Room, Anesthesiology, Pathology, Radiology, and Cardiology reports (when applicable)

Step 3: Please Return Copies of the Medical, Billing and Payment Records by Fax or Mail: When returning copies, please use the Fax Cover Sheet or Mail Return Form included on page 4 of this fax. Please include this completed Confidential Patient Check List, along with any records for those patients that received services in 2014.





The patient(s) listed below have given us written authorization to contact you and request information from your records. Copies of the signed authorization forms are included in this fax.

					CHECK ONE FOR EACH PATIENT
	Provider Name	Patient Name	Date of Birth	Gender	2014 Patient Records Located	Patient Located - No 2014 Records	Is Not A Patient

Fax Cover Sheet and Mail Return Form

When returning the Confidential Patient Checklist and copies of the medical, billing, and payment records, please use this page as either a Fax Cover Sheet or Mail Return Form.

To	Data Collection Specialist
Fax	«TOLL_FAX_NUMBER»
Phone	«TOLL_PHONE_NUMBER»
From
Reference Number	«GID»
Date
Total Pages (including cover sheet)

Please send mail to:

M



EPS-Medical Provider Component

«MEPS_MAIL_ADDRESS»

REFERENCE#: «GID»

This fax includes confidential information, and may be used only by the person or entity to which it is addressed. If the receiver of this fax is not the intended recipient or his or her authorized agent, the receiver is hereby notified that dissemination, distribution or copying of this fax is prohibited. If you have received this fax in error, please notify the sender by calling «TOLL_PHONE_NUMBER» and destroy the contents of this fax immediately. Thank you.

Frequently Asked Questions

What is the Medical Expenditure Panel Survey (MEPS)?

MEPS is a nationwide research study conducted to learn more about the health care services people use, the charges for those services and the sources that pay for them. MEPS is conducted annually by the U.S. Department of Health and Human Services through the Agency for Healthcare Research and Quality and the Centers for Disease Control and Prevention. Major components of MEPS include surveys of:

• A nationally representative sample of households;

• Hospitals, physicians, home care providers, and pharmacies reported by the household participants; and

• Providers of health insurance.

MEPS is the most complete source of data available on health care use and expenses in the United States and is used by government policymakers and private researchers.

How are hospitals chosen?

Hospitals and/or facilities associated with a hospital were named by respondents in the household data collection as sources of care during 2014. The patients we are asking about signed HIPAA-compliant forms authorizing and requesting you to release the information sought by the study.

How do I know the information will be kept confidential?

The confidentiality of data collected for MEPS is protected by Federal law under Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 242m(d)]. No information that could identify an individual or establishment will be disclosed unless that individual or establishment has consented to such a disclosure.

Personal identifying information such as names or addresses are removed before information from the study is made available to researchers. Findings are published in statistical summaries and tables and micro-data is released on “public use” data files.

Why should this hospital participate?

Hospital expenditures are a major component of health care costs. The information that you supply will supplement that given by your patient and help us build a more complete picture of health care expenditures for respondents in our study. Your patients have asked specifically for your help by signing the authorization form.

Who is collecting this data?

The U.S. Department of Health and Human Services has chosen RTI International (RTI) and Social and Scientific Systems, Inc. (SSS) to administer the study. A professionally trained data collection specialist from RTI-SSS will contact each hospital.

What information is needed?
For each of the patients on the enclosed list, we need information about their hospital events. For each date of service in 2014, we need:

• Date(s) of Service in 2014

• Services Provided in 2014 (CPT-4, DRG, revenue code, HCPCS, or descriptions)

• Diagnoses or Conditions (ICD-9 Codes or descriptions)

• All Names, Roles, Specialties, and Contacting Information for All Doctors Who May Have Billed Separately for Each Date of Service

• Charges for Each Service Provided

• Payments and Who the Payment was Made By (if insurance, please specify Medicare, Medicaid, Private, etc.)

• Adjustment Activity

• Emergency Room, Anesthesiology, Pathology, Radiology, and Cardiology reports (when applicable)

What questions will the data collected answer?

MEPS data provide answers to many important questions. For example:

• How much of hospital costs are covered by insurance?

• How much do people pay out of pocket for their hospital care?

• What conditions are being treated in hospitals?

• What types of health care services are people
  receiving from hospitals?

This fax includes confidential information, and may be used only by the person or entity to which it is addressed. If the receiver of this fax is not the intended recipient or his or her authorized agent, the receiver is hereby notified that dissemination, distribution or copying of this fax is prohibited. If you have received this fax in error, please notify the sender by calling «TOLL_PHONE_NUMBER» and destroy the contents of this fax immediately. Thank you.

Notice - Public reporting burden for this collection of information is estimated to average 5 minutes per patient. Any comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden should be sent to: AHRQ/MEPS Reports Clearance Officer, John M. Eisenberg Building, Room 5036, 540 Gaither Road, Rockville, MD 20850, Attention: PRA Paperwork Reduction Project (0935-0118). (Please do not send patient data to this address as it will delay data processing.)