Form CMS-10097 Medicare Contractor Provider Satisfaction Survey 2010

Medicare Contractor Provider Satisfaction Survey

2010

I nstructions to Complete the Survey

INTRODUCTION

Medicare is listening! The Centers for Medicare & Medicaid Services (CMS) has selected your practice or facility to participate in a satisfaction survey. We know that your time is valuable and greatly appreciate your willingness to participate in this very important study to assess your satisfaction with your Medicare Contractor (called “your Contractor” in the survey).

Your Office Manager or personnel in the Billing Department might be the appropriate staff to complete the survey. Please note that your participation is voluntary. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific individual, practice, or facility. We will not provide information that identifies you or your practice or facility to anyone outside the study team, except as required by law.

The attached Medicare Contractor Provider* Satisfaction Survey (MCPSS) includes the following seven key areas of the interface between you and your Contractor, [CONTRACTOR]:

• Section A: Provider Inquiries

• Section B: Provider Outreach and Education

• Section C: Claims Processing

• Section D: Appeals

• Section E: Provider Enrollment

• Section F: Medical Review

• Section G: Provider Audit and Reimbursement

Most of the key areas pertain to your practice or facility’s interaction with your Medicare Contractor.

For each section of the survey, you have a choice -– complete the section yourself or forward the section to the person at your practice or facility who interacts on a regular basis with your Medicare Contractor. Once complete, please mail the survey directly to:

Westat

1650 Research Boulevard

Rm # RA 1153

Rockville, MD 20850

OR

Fax the completed survey to Westat at 1-888-748-5820.

Thank you in advance for taking the time to complete the Medicare Contractor Provider Satisfaction Survey. If you have any questions or concerns, please call the MCPSS Provider Helpline at 1-888-863-3561 or send an e-mail to MCPSS@westat.com.

*Throughout this survey, the term “provider” applies to all Medicare provider and supplier types, unless otherwise noted.

A bout Your Practice or Facility and Overall Satisfaction with Your Contractor

Q0. Approximately how long have you been a Medicare provider?

Less than 6 months

6 to 12 months

1-2 years

2-5 years

5 years or more

Q1. [CONTRACTOR], your Contractor, provides a number of services on behalf of Medicare to Medicare providers in your area. Thinking about ALL your interactions with your Contractor, [CONTRACTOR], [in the last 12 months/ since {DATE}], how satisfied have you been with your Contractor’s performance overall?

1 Very dissatisfied 2 Dissatisfied 3 Neither satisfied nor dissatisfied 4 Satisfied 5 Very satisfied   Don’t know

Q2. Thinking about the size of your provider’s practice/facility, please answer the following: (answer only those questions that apply to your practice/facility)

	No
	Yes
a. If you are a provider, do you have fewer than 25 full-time employees in your practice/facility?
b. If you are a supplier of medical equipment, does your organization have fewer than 10 full-time employees?
c. Do you consider yourself to be a small provider?			 GO TO SECTION A

c1. Please check the group below which best applies to you:

Physician

Non-physician practitioner

DMEPOS supplier

Other (i.e., rural health clinic, federally qualified health center, etc.) _________________________________

Don’t know

Please continue with Section A on the next page.

S ection A: Provider Inquiries

[CONTRACTOR] has provider inquiry staff to answer questions from providers via telephone, written correspondence, or e-mail. Please note that provider inquiry activities related to this section of the survey are NOT related to your “Provider Rep” or “Ombudsman” if you have one. For purposes of this survey, your “Contractor’s Performance of Provider Inquiries” includes the activities and interactions that you have with [CONTRACTOR] related to asking questions and receiving answers from its general provider inquiries staff. This section excludes activities and interactions that you have with other Contractor staff answering toll free lines for specific functions like provider enrollment, electronic data interchange, first-level appeals, etc.

INSTRUCTIONS FOR SECTION A

It should take you approximately two (2) minutes to complete this section.

You have a choice for Section A: Provider Inquiries:

• Complete Section A yourself  PROCEED TO QUESTION A1 BELOW, or

• Forward Section A to the person at your practice or facility who interacts on a regular basis with [CONTRACTOR]  PROCEED TO SECTION B: Provider Outreach and Education.

Y our Ratings of [CONTRACTOR]’s Performance of Provider Inquiries

While answering the following questions, please think about your practice or facility’s experiences [in the last 12 months/since {DATE}] involving provider inquiries you and any other persons in your practice or facility make to your Contractor, [CONTRACTOR], ONLY.

For each of the following items, please rate your level of satisfaction ON A SCALE OF 1 TO 5, where 1 is “VERY DISSATISFIED” AND 5 IS “VERY SATISFIED.” Please circle the relevant number or mark the appropriate box.

A1. [In the last 12 months/since {DATE}], how satisfied have you been with…

					Very satisfied
				satisfied
			neither satisfied nor dissatisfied
		dissatisfied												DON’T KNOW	N/A
	Very dissatisfied
a. How quickly you can reach a representative to make a provider inquiry by telephone?						1	2	3		4		5
b. Receiving the correct information over the phone from a representative?						1	2	3		4		5
c. The consistency of written responses?						1	2	3		4		5
d. The modes of communication that are offered by your Contractor to exchange information with it about inquiries?						1	2	3		4		5
e. Your Contractor’s ability to fully resolve problems without you having to make multiple inquiries?						1	2	3		4		5
f. The information made available through your Contractor’s automated telephone system (IVR) meeting your needs, if accessed?						1	2	3		4		5
g. The ease of obtaining information through your Contractor’s automated telephone system (IVR), if accessed?						1	2	3		4		5

The next few questions are about methods you use to communicate with your Contractor.

A2. [In the last 12 months/since {DATE}], which method(s) have you used to communicate with your Contractor? (check all that apply).

Telephone call with your Contractor’s representative Automated telephone system (IVR) Web E-mail

Mail Fax Other specify:

A3. [In the last 12 months/ since {DATE}], which method have you used most often to communicate with your Contractor?

Telephone call with your Contractor’s representative Automated telephone system (IVR) Web E-mail

Mail Fax Other specify:

A4. [In the last 12 months/since {DATE}], what is your overall satisfaction with your Contractor’s provider inquiry activities?

1 Very dissatisfied 2 Dissatisfied 3 Neither satisfied nor dissatisfied 4 Satisfied 5 Very satisfied

Don’t know N/A

A5. We are interested in any general comments you have about [CONTRACTOR]'s handling of provider inquiry activities. In what ways (if any) do you think this service could be improved?

Thank you for completing this section of the survey.

S ection B: Provider Outreach and Education

[CONTRACTOR] offers providers outreach and education in a variety of ways, including web-based training, newsletters, bulletins, workshops/seminars, videos, on-site training, demonstrations, reference materials, CDs, Contractor website, e-mail/listserv, etc. Your practice or facility might also have a “Provider Rep” that acts as a liaison for education issues or as an actual trainer. For purposes of this survey, your “Contractor’s Performance of Provider Outreach and Education” includes all of the ways that [CONTRACTOR] provides outreach and education to your practice or facility.

INSTRUCTIONS FOR SECTION B

It should take you approximately two (2) minutes to complete this section.

You have a choice for Section B: Provider Outreach and Education:

• Complete Section B yourself  PROCEED TO QUESTION B1 BELOW, or

• Forward Section B to the person at your practice or facility who interacts on a regular basis with [CONTRACTOR]  PROCEED TO SECTION C: claims processing.

Y our Ratings of [CONTRACTOR]’s Performance of Provider Outreach and Education

While answering the following questions, please think about your experiences [in the last 12 months/since {DATE}] involving the types of training resources provided by your Contractor, [CONTRACTOR], ONLY. These resources include web-based training, newsletters, bulletins, workshops/seminars, videos, on-site training, demonstrations, reference materials, CDs, Contractor website, e-mail/listserv, etc.

B1. [In the last 12 months/since {DATE}], what education and training resources of [CONTRACTOR] have you used? (CHECK ALL THAT APPLY)

Web-based training Contractor website In-person training/workshops Teleconferences Hard copy materials

Electronic mail (e-mail) materials Listserv information Other specify: None used

The next few questions are about your satisfaction with the Contractor’s communication (Outreach and Education).

For each of the following items, please rate your level of satisfaction ON A SCALE OF 1 TO 5, where 1 is “VERY DISSATISFIED” AND 5 IS “VERY SATISFIED.” Please circle the relevant number or mark the appropriate box.

B2. [In the last 12 months/Since {DATE}], how satisfied have you been with…

					Very satisfied
				satisfied
			neither satisfied nor dissatisfied
		dissatisfied												DON’T KNOW	N/A
	Very dissatisfied
a. The expertise of your Contractor’s provider education and training staff?						1	2	3		4		5
b. Your Contractor’s communication with you about changes that have been or are being made to Medicare policies and regulations?						1	2	3		4		5
c. The professionalism and courtesy of your Contractor’s training and education representatives?						1	2	3		4		5

B3. For which of the following topics would you like to see more training and education materials?
(Check all that apply)

Claims processing Payment policy Local coverage determination

Enrollment Appeals Audit and reimbursement Other specify:

The next few questions are about your satisfaction with the Contractor’s communication (Outreach and Education) in the following categories: (a) face-to-face training, (b) non face-to-face training (i.e., webinars, “Ask the Contractor“ Teleconferences) and (c) educational materials/information resource availability.

Face-to-Face Training

For each of the following items, please rate your level of satisfaction ON A SCALE OF 1 TO 5, where 1 is “VERY DISSATISFIED” AND 5 IS “VERY SATISFIED.” Please circle the relevant number or mark the appropriate box.

B4. If you have received in-person training…

					Very satisfied
				satisfied
			neither satisfied nor dissatisfied
		dissatisfied												DON’T KNOW	N/A
	Very dissatisfied
a. Availability of training						1	2	3		4		5
b. Clarity of information presented						1	2	3		4		5
c. Detail of topics covered						1	2	3		4		5
d. The relevance of the training to meet your specific needs						1	2	3		4		5

Non Face-To- Face Training

For each of the following items, please rate your level of satisfaction ON A SCALE OF 1 TO 5, where 1 is “VERY DISSATISFIED” AND 5 IS “VERY SATISFIED.” Please circle the relevant number or mark the appropriate box.

B5. If you have participated in non face-to-face training (i.e., webinars, “Ask the Contractor” Teleconferences)…

					Very satisfied
				satisfied
			neither satisfied nor dissatisfied
		dissatisfied												DON’T KNOW	N/A
	Very dissatisfied
a. Availability of training						1	2	3		4		5
b. Clarity of information presented						1	2	3		4		5
c. Detail of topics covered						1	2	3		4		5
d. The relevance of the training to meet your specific needs						1	2	3		4		5

Educational Materials/Information Resource Availability

For each of the following items, please rate your level of satisfaction ON A SCALE OF 1 TO 5, where 1 is “VERY DISSATISFIED” AND 5 IS “VERY SATISFIED.” Please circle the relevant number or mark the appropriate box.

B6. If you have received educational materials/information resources from your Contractor…

					Very satisfied
				satisfied
			neither satisfied nor dissatisfied
		dissatisfied												DON’T KNOW	N/A
	Very dissatisfied
a. Amount of educational materials/information resources						1	2	3		4		5
b. Accessibility of educational materials/information resources						1	2	3		4		5
c. Clarity of information						1	2	3		4		5
d. The relevance of the educational materials and information resources to meet your specific needs						1	2	3		4		5
e. The usefulness of your Contractor’s listserv (e-mail) messages in notifying you about new Medicare program information						1	2	3		4		5
f. The usefulness of your Contractor’s frequently asked questions (FAQs)						1	2	3		4		5

B7. How often do you use the Medicare Learning Network (MLN) products and services?

Am familiar with, but have never used Not familiar with these products/services

Once a week or more Once every two weeks Once per month Less than once per month Don’t know

B8. What is your overall satisfaction with your Contractor’s outreach and educational activities?

1 Very dissatisfied 2 Dissatisfied 3 Neither satisfied nor dissatisfied 4 Satisfied 5 Very satisfied

Don’t know

B9. We are interested in any general comments you have about [CONTRACTOR]'s handling of provider outreach and education activities. In what ways (if any) do you think this service could be improved?

Thank you for completing this section of the survey.

S ection C: Claims Processing

[CONTRACTOR] follows procedures, regulations, and statutes associated with how it receives, processes, and pays claims that providers submit. For purposes of this survey, your “Contractor’s Performance of Claims Processing” includes the activities and interactions that you have with [CONTRACTOR] throughout the lifecycle of a claim submission to payment or denial.

INSTRUCTIONS FOR SECTION C

It should take you approximately three (3) minutes to complete this section.

You have a choice for Section C: Claims Processing:

• Complete Section C yourself  PROCEED TO QUESTION C1 BELOW, or

• Forward Section C to the person at your practice or facility who interacts on a regular basis with [CONTRACTOR]  PROCEED TO SECTION D: Appeals.

Y our Ratings of [CONTRACTOR]’s Performance of Claims Processing

While answering the following questions, please think about your experiences [in the last 12 months/since {DATE}] involving claims processing activities with your Contractor, [CONTRACTOR], ONLY.

For each of the following items, please rate your level of satisfaction ON A SCALE OF 1 TO 5, where 1 is “VERY DISSATISFIED” AND 5 IS “VERY SATISFIED.” Please circle the relevant number or mark the appropriate box.

C1. In the last 12 months/since {DATE}, how satisfied have you been with…

					Very satisfied
				satisfied
			neither satisfied nor dissatisfied
		dissatisfied												DON’T KNOW	N/A
	Very dissatisfied
a. The ease of submitting electronic claims?						1	2	3		4		5
b. The accuracy of your Contractor’s claims editing?						1	2	3		4		5
c. The timeliness of notification from your Contractor that a claim will not be paid, including denied, returned, or unprocessed claims?						1	2	3		4		5
d. The clarity of remittance advices you receive from your Contractor?						1	2	3		4		5
e. The promptness of your Contractor in resolving claims–related issues brought to its attention?						1	2	3		4		5
f. The ease of correcting claims, such as correcting claims online or requesting a change over the phone?						1	2	3		4		5
g. The correctness of the information provided to you by your Contractor in response to claims-related issues raised by you? h. The overall performance of your Contractor’s claims processing activities?						1 1	2 2	3 3		4 4		5 5

C2. We are interested in any general comments you have about [CONTRACTOR]'s handling of claims processing activities. In what ways (if any) do you think this service could be improved?

Thank you for completing this section of the survey.

S ection D: Appeals

[CONTRACTOR] follows procedures and regulations associated with how and when it addresses first-level appeals, makes determinations about first-level appeals, and communicates with providers about first-level appeals decisions. For purposes of this survey, your “Contractor’s Performance of Appeals” includes the activities and interactions that you have with [CONTRACTOR] throughout the lifecycle of a first-level appeal—from when you first receive a denial of a claim to when [CONTRACTOR] states its decision to reverse or uphold its decision about paying the claim.

INSTRUCTIONS FOR SECTION D

It should take you approximately two (2) minutes to complete this section.

You have a choice for Section D: Appeals:

• Complete Section D yourself  PROCEED TO QUESTION D1 BELOW, or

• Forward Section D to the person at your practice or facility who interacts on a regular basis with [CONTRACTOR]  PROCEED TO SECTION E: provider enrollment.

D1. In the last 12 months/ since {DATE} has your practice or facility had a first -level appeal?

Yes

No  PROCEED TO SECTION E: Provider Enrollment

Y our Ratings of [CONTRACTOR]’s Performance of Appeals

While answering the following questions, please think about your experiences [in the last 12 months/since {DATE} involving first-level appeals activities with your Contractor, [CONTRACTOR], ONLY.

For each of the following items, please rate your level of satisfaction ON A SCALE OF 1 TO 5, where 1 is “VERY DISSATISFIED” AND 5 IS “VERY SATISFIED.” Please circle the relevant number or mark the appropriate box.

D2. [In the last 12 months/since {DATE}], how satisfied have you been with…

					Very satisfied
				satisfied
			neither satisfied nor dissatisfied
		dissatisfied												DON’T KNOW	N/A
	Very dissatisfied
a. The consistency of your Contractor’s first-level appeals decisions for claims that have been denied?						1	2	3		4		5
b. The mechanisms that your Contractor offers for exchanging information with it about first-level appeals?						1	2	3		4		5
c. Your Contractor’s responsiveness, attentiveness, and availability during the process of first-level appeals?						1	2	3		4		5
d. Your average telephone hold time before talking to a live person?						1	2	3		4		5
e. If leaving a message, the average time before receiving a return call?						1	2	3		4		5
f. The professionalism and courtesy of your Contractor’s representatives during the first-level appeals process?						1	2	3		4		5
g. The clarity of explanations of first-level appeal decisions made by your Contractor?						1	2	3		4		5
h. The overall performance of your Contractor’s first-level appeals activities?						1	2	3		4		5

D3. We are interested in any general comments you have about [CONTRACTOR]'s handling of first-level appeals activities. In what ways (if any) do you think this service could be improved?

Thank you for completing this section of the survey.

S ection E: Provider Enrollment

[CONTRACTOR] follows procedures and regulations associated with how and when it requires and makes determinations about applications for provider enrollment in the Medicare program. Providers new to Medicare since 1997, as well as established providers with new changes in their qualifications or in payment assignments since 1997 (as in mergers or acquisitions), are required to submit the appropriate CMS Form 855 Enrollment Application to their Medicare Contractor.

For purposes of this survey, your “Contractor’s Performance of Provider Enrollment” includes the activities and interactions that you have with [CONTRACTOR] regarding enrolling your organization or members in your practice or facility as a provider with the Medicare program. This includes all of your interactions with the Medicare Contractor including, initial enrollment and updates to enrollment information from the time of the first contact you made with [CONTRACTOR].

INSTRUCTIONS FOR SECTION E

It should take you approximately two (2) minutes to complete this section.

You have a choice for Section E: Provider Enrollment:

• Complete Section E yourself  PROCEED TO QUESTION E1 BELOW, or

• Forward Section E to the person at your practice or facility who interacts on a regular basis with [CONTRACTOR] – PROCEED TO SECTION F: medical review.

E1. [In the last 12 months/since {DATE}], have you gone through the Medicare enrollment process including updates to enrollment information?

Yes  PROCEED TO QUESTION E2 bElow

No   PROCEED TO QUESTION E5 on THE NEXT PAGE

Y our Ratings of [CONTRACTOR]’s Performance of Provider Enrollment

While answering the following questions, please think about your experiences [in the last 12 months/since {DATE}] involving provider enrollment activities with your Contractor, [CONTRACTOR], ONLY.

For each of the following items, please rate your level of satisfaction ON A SCALE OF 1 TO 5, where 1 is “VERY DISSATISFIED” AND 5 IS “VERY SATISFIED.” Please circle the relevant number or mark the appropriate box.

E2. [In the last 12 months/since {DATE}], how satisfied have you been with…

					Very satisfied
				satisfied
			neither satisfied nor dissatisfied
		dissatisfied												DON’T KNOW	N/A
	Very dissatisfied
a. The ability of your Contractor’s representative to respond to your questions about the Medicare enrollment application, CMS Form 855?						1	2	3		4		5
b. The consistency of your Contractor’s responses or decisions?						1	2	3		4		5
c. The professionalism and courtesy of your Contractor’s representatives during the provider enrollment process?						1	2	3		4		5
d. Your Contractor’s responsiveness, attentiveness, and availability during the process of enrollment?						1	2	3		4		5
e. Your Contractor’s ability to answer questions specific to your situation or specialty?						1	2	3		4		5

E3. [In the last 12 months/since {DATE}], how satisfied have you been with the information provided by your Contractor to enable you to start billing for services?

1 Very dissatisfied 2 Dissatisfied 3 Neither satisfied nor dissatisfied 4 Satisfied 5 Very satisfied

Don’t know N/A

E4. What is your overall satisfaction with your Contractor’s provider enrollment activities?

1 Very dissatisfied 2 Dissatisfied 3 Neither satisfied nor dissatisfied 4 Satisfied 5 Very satisfied

Don’t know N/A

E5. We are interested in any general comments you have about [CONTRACTOR]'s handling of provider enrollment activities. In what ways (if any) do you think this service could be improved?

Thank you for completing this section of the survey.

S ection F: Medical Review

[CONTRACTOR] follows procedures and regulations that require it to sometimes perform medical review of providers’ records. For purposes of this survey, your “Contractor’s Performance of Medical Review” includes the activities and interactions that you have with [CONTRACTOR] during prepay and/or postpay medical review. Please note that medical review activities in this section of the survey are NOT related to fraud investigations, overpayments, or appeals.

INSTRUCTIONS FOR SECTION F

It should take you approximately two (2) minutes to complete this section.

You have a choice for Section F: Medical Review:

• Complete Section F yourself  PROCEED TO QUESTION F1 BELOW, or

• Forward Section F to the person at your practice or facility who interacts on a regular basis with [CONTRACTOR]  PROCEED TO SECTION G: provider audit and reimbursement.

F1. [In the last twelve (12) months/since {DATE}], have you had a medical review ?

Yes PROCEED TO question f2 below

No PROCEED TO SECTION G provider audit and Reimbursement

Y our Ratings of [CONTRACTOR]’s Performance of Medical Review

While answering the following questions, think about your experiences [in the last 12 months/since {DATE}] involving medical review activities with your Contractor, [CONTRACTOR], ONLY.

For each of the following items, please rate your level of satisfaction ON A SCALE OF 1 TO 5, where 1 is “VERY DISSATISFIED” AND 5 IS “VERY SATISFIED.” Please circle the relevant number or mark the appropriate box.

F2. [In the last twelve (12) months/since {DATE}], how satisfied have you been with…

					Very satisfied
				satisfied
			neither satisfied nor dissatisfied
		dissatisfied												DON’T KNOW	N/A
	Very dissatisfied
a. The clarity of the notification (letter, phone call, etc.) from your Contractor that your claims were selected for medical review?						1	2	3		4		5
b. The clarity of the explanations of your Contractor’s medical review decisions?						1	2	3		4		5
c. Receiving timely local medical review policy changes and updates that affect your practice or facility from your Contractor?						1	2	3		4		5
d. The follow through that your Contractor provided after medical review decisions?						1	2	3		4		5
e. The knowledge of your Contractor’s medical reviewers?						1	2	3		4		5
f. How well your Contractor makes an effort to make things as easy as possible for your medical review?						1	2	3		4		5
g. The consistency of your Contractor’s medical review decisions and answers to your questions?						1	2	3		4		5
h. The professionalism and courtesy of your Contractor’s representatives throughout the medical review process?						1	2	3		4		5

F3. What is your overall satisfaction with your Contractor’s medical review activities?

1 Very dissatisfied 2 Dissatisfied 3 Neither satisfied nor dissatisfied 4 Satisfied 5 Very satisfied

Don’t know N/A

F4. We are interested in any general comments you have about [CONTRACTOR]'s handling of medical review activities. In what ways (if any) do you think this service could be improved?

Thank you for completing this section of the survey.

S ection G: Provider Audit and Reimbursement

[CONTRACTOR] follows procedures and regulations that require it to work with providers who are paid on either a cost reimbursement or prospective payment basis for treating Medicare patients. For purposes of this survey, your “Contractor’s Performance of Provider Audit and Reimbursement” activities includes all interactions with [CONTRACTOR] related to how it decides and makes adjustments to what Medicare has paid or is supposed to pay your practice or facility, cost report audit activities you may participate in each year, and interim payments you receive. Please note that provider audit and reimbursement activities in this section of the survey are NOT related to the direct payment or denial of claims or to appeals activities related to claims.

INSTRUCTIONS FOR SECTION G

It should take you approximately two (2) minutes to complete this section.

You have a choice for Section G: Audit and Reimbursement:

• Complete Section G yourself  PROCEED TO QUESTION G1 BELOW, or

• Forward Section G to the person at your facility who interacts on a regular basis with

[CONTRACTOR].

G1. [In the last twelve (12) months/since {DATE}], have you submitted a cost report to [CONTRACTOR]?

Yes  PROCEED TO question g2 below

No  PROCEED TO QUESTION g3 on the next page.

Y our Ratings of [CONTRACTOR]’s Performance of Provider Audit and Reimbursement

While answering the following questions, think about your experiences [in the last 12 months/since {DATE}] involving provider audit and reimbursement activities with your Contractor, [CONTRACTOR], ONLY.

For each of the following items, please rate your level of satisfaction ON A SCALE OF 1 TO 5, where 1 is “VERY DISSATISFIED” AND 5 IS “VERY SATISFIED.” Please circle the relevant number or mark the appropriate box.

G2. [In the last 12 months/since {DATE}], how satisfied have you been with…

					Very satisfied
				satisfied
			neither satisfied nor dissatisfied
		dissatisfied												DON’T KNOW	N/A
	Very dissatisfied
a. The availability of timely updates from your Contractor on Medicare policy (regulations, manuals and other instructions) that affect provider audit and reimbursement?						1	2	3		4		5
b. The professionalism and courtesy of your Contractor’s representatives throughout all provider audit and reimbursement activities?						1	2	3		4		5
c. How well your Contractor makes an effort to make things as easy as possible for you during cost report settlement activities?						1	2	3		4		5
d. Your Contractor’s interpretations of CMS’ rules for cost report and payment policies?						1	2	3		4		5
e. The knowledge of your Contractor’s cost report auditors?						1	2	3		4		5
f. The timeliness of your Contractor’s audit of your cost report?						1	2	3		4		5
g. The timeliness of your Contractor’s settlement of your cost report?						1	2	3		4		5

G2. (Continued)

[In the last 12 months/since {DATE}], how satisfied have you been with…

					Very satisfied
				satisfied
			neither satisfied nor dissatisfied
		dissatisfied												DON’T KNOW	N/A
	Very dissatisfied
h. The overall communication between you and your Contractor about adjustments and cost reports/cost report audits?						1	2	3		4		5
i. The clarity of your Contractor’s instructions for the process of requesting a review and adjustment to your interim payments?						1	2	3		4		5
j. The reasonableness of your Contractor’s requests during its consideration of an adjustment to your interim payments, including the time you are given to submit documentation and the methods you are given for submitting those documents?						1	2	3		4		5
k. The clarity of your Contractor’s explanations for decisions about adjustments to your interim payments?						1	2	3		4		5
l. The timeliness of your Contractor’s decisions about adjustments to your interim payments?						1	2	3		4		5
m. The overall performance of your Contractor’s provider audit and reimbursement activities?						1	2	3		4		5

G3. We are interested in any general comments you have about [CONTRACTOR]'s handling of provider audit and reimbursement activities. In what ways (if any) do you think this service could be improved?

Thank you for completing this survey.

Please mail your completed survey directly to:

Westat

1650 Research Boulevard

Rm # RA 1153

Rockville, MD 20850

OR

Fax the completed survey to Westat at
1-888-748-5820

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 0938-0915. The time required to complete this information collection is estimated to average 16-21 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, Baltimore, Maryland 21244-1850.