VA Community Care Network Provider Satisfaction Survey for Regions 1, 2, 3 and 4

Community Care Network Program

Region 2

Provider Satisfaction Survey

OMB No. 2900-0770
Estimated Burden: 10 minutes

Expiration Date: 9/30/2020

The Paperwork Reduction Act of 1995: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this survey will average 10 minutes. This includes the time it will take to follow instructions, gather the necessary facts and respond to questions asked. Customer satisfaction is used to gauge customer perceptions of VA services as well as customer expectations and desires. The results of this online/mail survey will lead to improvements in the quality of service delivery to community providers from Department of Veterans Affairs (VA) Medical Center staff and from health care networks staff through the Community Care Network Program. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

VA Form 10-
APR 2014

Privacy Act Statement: This survey is not a collection of personal information; please do not enter any personal information in the open text fields. By voluntarily providing information on <_____TPA PROVIDERS SURVEY WEB ADDRESS____>, you are consenting to VA’s use and disclosure of that information in the manner described in this limited policy. The VA general Web privacy policy is available at www.va.gov/privacy.

TPA will add text introducing themselves, the survey, etc.

Unique Identifier Code (UIC)

Please enter the UIC that is printed under your business name on the survey invitation letter (7-8 characters): ______________________________

The statements and questions in this survey are regarding your experience in the last three months as a Provider within the Community Care Network (CCN) Program in Region 2.

Please respond to this survey from the perspective of your relationship and experiences when providing care to Veterans under your contractual relationship with us, (insert name of TPA).

The following questions are regarding your interactions with the Community Care Network Contractor’s customer service department when providing care to Veterans under your contractual relations with <insert name of TPA>.

The majority of the interactions with customer service were questions around:

Ο Referral Ο Payment status Ο ADD OTHER Ο Other

Interactions with the customer service department were courteous.

Ο Always Ο Most of the Time Ο Sometimes Ο Rarely Ο Never

Customer service department had the knowledge to answer CCN Program related questions.

Ο Always Ο Most of the Time Ο Sometimes Ο Rarely Ο Never

Customer service department was adequately accessible for advice and assistance.

Ο Always Ο Most of the Time Ο Sometimes Ο Rarely Ο Never

What is your level of satisfaction or dissatisfaction for responses to inquiries using telephone customer service?

Ο Very Ο Satisfied Ο Somewhat Ο Somewhat Ο Dissatisfied Ο Very

Satisfied Satisfied Dissatisfied Dissatisfied

What is your level of satisfaction or dissatisfactions for response to inquiries using website customer service.

Ο Very Ο Satisfied Ο Somewhat Ο Somewhat Ο Dissatisfied Ο Very

Satisfied Satisfied Dissatisfied Dissatisfied

The following questions are regarding transfer of documentation and Billing and Payments with the Community Care Network Contractor when providing care to Veterans under your contractual relations with <insert name of TPA>.

Clinical Documentation

Do you use the HealthShare Referral Manager (HSRM)?

Ο Yes Ο No Ο Unsure (If No or Not Applicable, please skip to Billing and Payments)

It was easy to use the HSRM.

Ο Always Ο Most of the Time Ο Sometimes Ο Rarely Ο Never

If HSRM ease of use was Rarely or Never, please describe issue(s) you had: ___________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

__________________________________________________________________________________

Billing and Payments

I understand the billing process to submit claims to the CCN Contractor.

Ο Always Ο Most of the Time Ο Sometimes Ο Rarely Ο Never

Payments by the CCN Contractor for “clean claims” were issued within 30 days of receipt.

Ο Always Ο Most of the Time Ο Sometimes Ο Rarely Ο Never

The EOB I receive from the CCN Contractor fully explains the adjudication of the claim(s).

Ο Always Ο Most of the Time Ο Sometimes Ο Rarely Ο Never

The EOB I receive from the CCN Contractor is easy to understand.

Ο Always Ο Most of the Time Ο Sometimes Ο Rarely Ο Never

The EOB I receive from the CCN Contractor provides what I need to reconcile my Accounts Receivables.

Ο Always Ο Most of the Time Ο Sometimes Ο Rarely Ο Never

The next questions are regarding any Problems and Complaints you may have encountered with the Community Care Network Contractor when providing care to Veterans under your contractual relations with <insert name of TPA>.

Have you experienced a problem with, or had a complaint about, the CCN Contractor?

Ο Yes Ο No (Please skip to the next section, Overall Satisfaction)

Problems or complaints with the CCN Contractor were resolved quickly.

Ο Always Ο Most of the Time Ο Sometimes Ο Rarely Ο Never

Problems or complaints were resolved within:

Ο 0 to 3 day Ο 4 to 7 days Ο 7 to 10 days Ο 10 days or longer Ο Never

Problems with the CCN Contractor were resolved with minimal effort on your part?

Ο Always Ο Most of the Time Ο Sometimes Ο Rarely Ο Never

Describe the problem(s) and how the problem(s) was resolved. ______________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

________________________________________________________________

The following questions are about your overall experience with the Community Care Network Contractor when providing care to Veterans under your contractual relations with <insert name of TPA>.

Please tell us how you feel about the following statements:

I received the service I needed.

Ο Strongly Ο Agree Ο Neither Agree Ο Disagree Ο Strongly

Agree nor Disagree Disagree

It was easy to get the service I needed.

Ο Strongly Ο Agree Ο Neither Agree Ο Disagree Ο Strongly

Agree nor Disagree Disagree

I felt like a valued customer.

Ο Strongly Ο Agree Ο Neither Agree Ο Disagree Ο Strongly

Agree nor Disagree Disagree

I trust the CCN Contractor to fulfill our country’s commitment to Veterans.

Ο Strongly Ο Agree Ο Neither Agree Ο Disagree Ο Strongly

Agree nor Disagree Disagree

The following questions are about your overall satisfaction with the Community Care Network Contractor.

Overall, how satisfied are you with your interaction with CCN Contractor regarding the CCN Program?

Ο Very Ο Satisfied Ο Somewhat Ο Somewhat Ο Dissatisfied Ο Very

Satisfied Satisfied Dissatisfied Dissatisfied

Will you continue to provide care to Veterans on behalf of VA using the CCN program?

Ο Definitely Yes Ο Probably Yes Ο Probably No Ο Definitely No Ο Not Sure

Is there anything you would like to share about your experience with the CCN Program or the CCN Contractor?

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Miscellaneous questions follow.

I receive adequate training.

Ο Strongly Ο Agree Ο Neither Agree Ο Disagree Ο Strongly

Agree nor Disagree Disagree

If your answer is “Disagree” or “Strongly Disagree” what could be clarified:

Ο Payment Process Ο Referral/Authorization Ο Veteran Culture Ο Other

Process

Is other please state what training could be clarified:_____________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Please tell us about you.

Where do you work?

Ο Independent Medical Office Ο Private Hospital

Ο University Hospital Ο Other – please specify _________________________

What is your occupation?

Ο Clinician Ο Billing and Accounts Receivable Personnel

Ο Office Manager or Office Staff Ο Other – please specify _________________________

Within the last 3 months how many Veterans did you provide care for?

Ο Fewer than 10 Ο 10-39 Ο 40-69 Ο 70-99 Ο 100 or more Ο Do not know

How would you describe the geographic area where you provide care?

Ο Rural Ο Urban Ο Highly Rural

END OF SURVEY Thank you for your time!

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Author	Jimmy Kimmitz
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