TRICARE: Standard Survey of Civilian Providers

OMB Number XXXX-XXXX Expiration Date: XX/XX/XXXX

Continuing Viability Survey 2015 for Behavioral Health Providers

TELEPHONE SCRIPT DRAFT

[FOR REVIEWERS: BH CATI follow-up]

INTRO Hi, my name is ____ and I’m calling on behalf of the Department of Defense TRICARE health benefits Program. May I speak with the person who is most familiar with billing and insurance for [Insert Provider Name]?

(INTERVIEWER NOTE: I'm calling from Ipsos, a healthcare survey firm and would like to speak with the billing manager or the person most familiar with billing and insurance for [Insert Provider Name]? We have a few questions regarding how your office works with the TRICARE program. REINTRODUCE AS NECESSARY.)

(IF UNAVAILABLE: Do you know when the (billing manager or the person most familiar with billing and insurance) will be available?" ARRANGE CALLBACK IF POSSIBLE.)

Respondent on phone

Not available

Go to SMS

[Insert Provider] no longer works at this office

Already returned survey

Alternate phone number

Respondent refuses

Refused – already returned survey

Medical school

Only receives messages

Billing contact unavailable permanently

Moved practice

No Billing – accepts walk-ins

Outsource billing

Military (unspecified)

Not at this address

ER (Emergency Room) doctor

Out of area address change

Left practice

Retired

Not practicing

Military leave

Resident/Doctor in training

Radiologist

Anesthesiologist

Fellow

Military – only sees TRICARE patients

Pathologist

Hospitalist

Pediatrician

Interservist

Hospital accreditation surveyor

Covering provider only

No office practice

Healthplan/Network provider (Kaiser)

Veterans Medical System employee (VA)

State hospital employee

University/student physicians

No private practice

Deceased

[IF INTRO=’RESPONDENT ON PHONE’, GO TO QB1]

[IF INTRO=’ALREADY RETURNED SURVEY’, GO TO QB2]

[IF INTRO=’NOT AVAILABLE’, INTERVIEWER SHOULD ASK ‘Do you know when the person familiar with billing and insurance for this provider will be available?’] SET CALLBACK.

[IF INTRO=ANY OTHER RESPONSE NOT LISTED ABOVE, RESCREEN FOR NEXT AVAILABLE PROVIDER. IF NO ADDITIONAL PROVIDERS, THANK AND END.]

QB1. [PROGRAMMING NOTE: DISPLAY THE FOLLOWING TEXT: Congress has directed the TRICARE program to survey civilian providers across the U.S. to determine the adequacy of private health care access for its military beneficiaries. The Department of Defense has contracted Ipsos to conduct this very short survey. [Insert Provider Name] was randomly selected to participate in this very important survey.]

[GO TO QB3]

QB2. [PROGRAMMING NOTE: DISPLAY THE FOLLOWING TEXT: Thank you for returning the survey. For verification purposes we would like to ask a few questions.]

(INTERVIEWER NOTE: READ IF NEEDED: On behalf of the Department of Defense, I’m calling from Ipsos, the healthcare survey firm contracted to perform this survey. Congress has directed the TRICARE program to survey civilian providers across the U.S. [Insert Provider Name] was randomly selected to participate in this very important survey.)

[GO TO QB3]

QB3. [PROGRAMMING NOTE: DISPLAY THE FOLLOWING TEXT: Your participation will help the Department of Defense gain valuable aggregated input to help improve the Military Health System.]

(INTERVIEWER NOTE: READ PRIVACY ADVISORY IF NEEDED: Information collected for this Survey will be used to help TRICARE health policy makers gauge civilian provider awareness and acceptance of the TRICARE Standard health care benefit option, and provide aggregated input to improve the Military Health System. All information will be de-identified prior to being reported. Completing the Survey is voluntary; you may stop the Survey at any time and skip any questions you choose. There is no penalty if you choose not to respond, although maximum participation is encouraged so the data will be complete and representative. Let me assure you that I am not trying to sell anything. Do you have a few minutes to answer some questions regarding how your office works with the TRICARE program?)

[GO TO Q1]

Q1. Does [Insert Provider Name] provide treatment or counseling to patients through private practice?

(INTERVIEW NOTE: READ IF NEEDED: Is he/she working in a setting where providers, individually or as a group, decide or influence which health insurance to accept?)

Yes

No, does not provide treatment or counseling, or has retired

No, not in private practice

DK

REF

[IF Q1=YES, GO TO Q2]

[IF Q1=’NO, DOES NOT PROVIDE TREATMENT OR COUNSELING, OR HAS RETIRED’, GO TO INSTRUCTIONS AFTER Q11]

[IF Q1=’NO, NOT IN PRIVATE PRACTICE’, DK, OR REF, GO TO Q1A]

Q1a. What type of practice is [Insert Provider Name] in?

Government: Federal, State or other municipality

School, University or other academic institution

Hospital staff

Contractor providing services exclusively to government clients

Rehab Facility, Nursing Home, or Home Health Provider

Closed Panel HMO

Other (SPECIFY)

DK

REF

Q1ab. What type of health care provider is [Insert Provider Name]?

[SELECT ALL THAT APPLY]

Certified Clinical Social Worker

Certified Psychiatric Nurse Specialist

Clinical Psychologist

Certified Marriage and Family Therapist

Pastoral Counselor

Mental Health Counselor

Other (SPECIFY)

DK (exclusive)

REF (exclusive)

Q2. Is [Insert Provider Name] aware of the TRICARE health care program?

Yes

No

DK

REF

Q3. As of today, is [Insert Provider Name] a contracted member of the TRICARE network of health care providers?

Yes

No

DK

REF

Q4. As of today, is [Insert Provider Name] accepting new TRICARE STANDARD patients?

No

Yes, on a claim by claim basis only

Yes, for all claims

DK

REF

[IF Q4=NO, GO TO Q5]

[IF Q4=’YES, ON A CLAIM BY CLAIM BASIS ONLY’, ‘YES, FOR ALL CLAIMS’, DK, REF, GO TO Q6]

Q5. Why is [Insert Provider Name] not accepting new TRICARE STANDARD patients?

(INTERVIEWER NOTE: RECORD ANSWERS VERBATIM. PROBE FOR CLARITY AND ADDITIONAL INFORMATION. Example: What did you mean by…? Why else does [Insert Provider Name] not accepting new TRICARE STANDARD patients?)

Q6. What percentage of patients seen by [Insert Provider Name] use any form of TRICARE?

(INTERVIEWER NOTE: If necessary, say, “Please give your best guess. Please use a whole number and not a range”.)

(INTERVIEWER NOTE: IF RESPONSE IS ‘NONE’, ENTER ‘0’)

[PROGRAMMING NOTE: COLLECT DATA AS A NUMERIC VARIABLE, NOT AS AN OPEN-END. RESERVE ‘998’ FOR DK AND ‘999’ FOR REF].

None/0

1-100 Percent

DK (998)

REF (999)

Q7. Does [Insert Provider Name] accept Medicare patients?

Yes

No

DK

REF

Q8. As of today, is [Insert Provider Name] accepting NEW Medicare Patients?

Yes

No

DK

REF

[IF Q8 = YES, SKIP TO INSTRUCTIONS AFTER Q11]

[IF Q8 = NO, DK, OR REF, GO TO Q9]

Q9. Why is [Insert Provider Name] not accepting new Medicare patients?

(INTERVIEWER NOTE: RECORD ANSWERS VERBATIM. PROBE FOR CLARITY AND ADDITIONAL INFORMATION. Example: What did you mean by…? Why else does [Insert Provider Name] not accepting new MEDICARE patients?)

Q10. Does [Insert Provider Name] accept payment from government or private health insurance plans?

Yes

No

DK

REF

Q11. As of today, is [Insert Provider name] accepting new patients?

Yes

No

DK

REF

[ASK Q1-11 FOR NEXT Provider listed for this phone number]

[If NONE] That concludes our survey. Thank you for taking the time to complete this survey.

(INTERVIEWER NOTE: IF RESPONDENT HAS ANY QUESTIONS ABOUT TRICARE, IT’S SPECIFIC

HEALTH PLANS, OR THE BENEFITS IT PROVIDES, PLEASE MENTION THAT THEY CAN VISIT

THE TRICARE WEB SITE AT www.tricare.mil)