Beneficiaries

Form Approved
OMB No. 0990-0330
Exp. Date 09/30/2011

U.S. Department of Health and Human Services
Office of Medicare Hearings and Appeals
Medicare Administrative Law Judge Hearings Survey
Case Information:

Interview Date: __________________ Sample ID # __________

Appeal Case #: _________________ Hearing Date: _______ Appellant Name:___________________________
Survey Respondent Name: ___________________________________ Phone #: ______________
No. of Appeals in last 6 months: _______ Appellant Type: _____________ Medicare Appeal Type: ________
OMHA Field Office:  Arlington  Cleveland  Irvine  Miami
Actual Hearing Format:  In-person  Phone  VTC

Sample Type:  Provider/Supplier  Beneficiary

SECTION I - INTRODUCTION & APPELLANT INFORMATION
I am calling on behalf of the Office of Medicare Hearings and Appeals within the U.S. Department of
Health and Human Services. The purpose of my call is to ask some questions about your experience with
the Medicare Administrative Law Judge hearing process to learn more about the level of customer service
you received.
OMHA has asked my firm, Coray Gurnitz Consulting, to administer the survey in order to keep your
answers completely anonymous. We will not reveal your name or other personal identifying information
with your comments to the survey in any report to the government.
If you would like to make a comment about this survey or confirm that this is a valid collection, please
contact the OMHA Survey Team at 1-866-207-4466.
Do you have any questions for me before we begin the survey?
As we go through the survey, when we say “OMHA” we mean the Office of Medicare Hearings and
Appeals. When we say “A.L.J.” we mean the Administrative Law Judges within OMHA who preside over
hearings.
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(to be included in internet version and read upon request for telephone version)
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., S.W., Suite 537-H, Washington D.C. 20201,
Attention: PRA Reports Clearance Officer

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Survey Respondent Information:
1. We show that you participated in a hearing with
OMHA on [date]. Do you recall that case?
a. Yes
b. Not specifically, but I have had recent
experience with OMHA hearings
c. I’ve never had experience with OMHA. This
case was handled by (attorney, representative,
other, N/A): ___________________, whose
telephone number is: _________________ and
address is: ___________________________.
2. Approximately how many OMHA hearings have
you participated in during the last six months?
a. 1
b. 2 to 10
c. Greater than 10

4. Are you the actual appellant?
a. Yes [Go to question 7]
b. No [Go to question 5]
5. What is your relationship to the appellant?
a. Third party or outside counsel
b. Employee of appellant
c. Hired representative on behalf of State
d. Hired representative or an organization
e. A family member or friend
f. An estate executor
g. Other. Please specify: _________________

3. [If question 2 response is b or c, i.e. > 1, then
switch to multiple hearing phrasing throughout and
read:] Please respond to the survey questions based on
the aggregate of your hearings experience with OMHA
over the last six months.

SECTION II – OVERALL EXPERIENCE
7. 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? (old 10)
a.
b.
c.
d.
e.

Very great extent - fully heard and considered
Great extent - heard and considered
Some extent - heard and considered
Very little extent - heard and considered
Not heard and considered at all

8. Independent of the judge’s decision, how
satisfied were you with your experience with
OMHA overall (i.e. the full process from
requesting an ALJ hearing through receipt of
decision)? (old 11)
a.
b.
c.
d.
e.

Very satisfied
Satisfied
Neither satisfied nor dissatisfied, it was okay
Dissatisfied
Very dissatisfied

[If answer to question 8 is d or e, then read:]
For now, please hold your comments on why you
were not satisfied. You will have multiple
opportunities to provide further explanation later
in the survey.

9. Overall, were OMHA staff courteous and
professional when they assisted you with the
ALJ hearing process (i.e. the full process from
requesting an ALJ hearing through receipt of
decision)? (old 12)
a.
b.
c.
d.
e.

Very courteous and professional
Quite courteous and professional
Somewhat courteous and professional
Not very courteous or professional
Very discourteous and unprofessional

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SECTION III – HARD COPY AND INTERNET INFORMATION
[Do not read the second sentence, i.e. the definition in “Type of Information” below, to responders with multiple cases
(question 2 answer greater than 1.]

For each document listed indicate its clarity.

Check if

Type of Information

Didn’t
Receive/
Don’t
Know

Very
Clear



 

 





 

 






 
 

 
 




10. Appeal Rights within the Notice of Decision from the
second-level of appeals conducted by Qualified Independent
Contractors (QIC) (i.e. the Level II QIC). This is the cover
letter attached to the unfavorable or partially unfavorable
decision from the Level II QIC. (old 13)
11. Information Sheet on What to Expect In a Video
Teleconference (Sent with the acknowledgement letter or the
notice of hearing) (old 16)
12. Exhibit List. Included in the case record and often contains
the medical record evidence. (old 18)
13. [Skip if Disposition is Fully Favorable] In the Notice of
Decision were your rights to appeal the OMHA ALJ
decision to the next higher level (i.e. to the HHS
Departmental Appeals Board, Medicare Appeals Council)
clear? (old 21)

Generally
Clear

Somewhat
Clear

Generally
Unclear

Not
at all
clear

14. Have you used the Office of Medicare Hearings
and Appeals website?
a. No, I did not try [Skip to question 15a]
b. I do not have access to a computer [Skip to
question 15a]
c. No, I tried to but could not find it [Skip to
question 15a]
d. Yes [Skip to question 15b]
15a. [If no, 14a, 14b, or 14c then] If you could
access the website, what types of information or
content would be useful for you to find listed on the
site? (new)
15b. [If yes, 14d, then] What suggestions do you
have for improving the website?

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SECTION IV- EXPERIENCE SCHEDULING YOUR HEARING
The next questions are about scheduling your hearing.
16. Did (do) you schedule the hearing(s) yourself?
(old 30)

a. Yes
b. No, my staff or others scheduled the
hearing(s) for me [Skip to #18]
17. Which hearing options were described to you by
OMHA staff or were you aware of? (select as
many as apply) (old 31)
a. VTC
b. Telephone
c. In-Person
d. On the Record
e. Don’t Know/Don’t Remember
18. Overall, how well did OMHA staff explain the
different hearing format option(s) to you? (old
32)

a. Very well, I understood all of my options
b. Generally well
c. Somewhat well, I understood some of my
options
d. Not very well
e. Not well at all, I couldn’t understand my
options

19. [If hearing format was not in-person] Did you
request (or for responder with multiple
hearings, “In the last 6 months have you
requested”) an in-person hearing? (old 33)
a. Yes and it was (typically) granted
b. Yes, but it was not (never) granted
c. No
20. If you requested that your hearing be
rescheduled, was your request (typically)
accommodated? (old 34)
a. I did not request to have (any of) my
hearing(s) rescheduled
b. Yes, it was (they were typically)
rescheduled to my satisfaction
c. No, it was not (they were never) rescheduled
to my satisfaction
21. Overall, how satisfied would you say you were
with the scheduling process associated with the
ALJ hearing(s)? (old 35)
a. Very satisfied
b. Satisfied
c. Neither satisfied nor dissatisfied, it was okay
d. Dissatisfied
e. Very dissatisfied
22. [If answer to prior question is d or e] Please
specify: (old 36)

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SECTION V – INTERACTION WITH OMHA BETWEEN SCHEDULING AND HEARING
23. Did you have any [for responders with >1
hearing]: “Do you typically have”] interaction
with OMHA staff after the hearing was
scheduled, but before the hearing was
conducted? (old 37)
a. Yes
b. No [Go to Hearing Sections Branching
Logic below.]

25. [If answer to question 24b was d, or e] Please
describe why your interaction with OMHA staff
was less than helpful? (old 39)

24a. Overall, how satisfied were you with your
interaction with OMHA staff after scheduling
the hearing and prior to the hearing itself? (new)
a. Very satisfied
b. Satisfied
c. Neither satisfied nor dissatisfied, it was okay
d. Dissatisfied
e. Very dissatisfied

26. Did you request a copy of the record or case
file? (Multiple hearing version: “Within the last
6 mo’s have you ever requested a copy of the
record or case file?”) (old 40)
a. Yes
b. No, but it was automatically sent to me
c. No

24b. Did your interaction with OMHA staff after
scheduling the hearing and prior to the hearing
itself help to make the hearing more effective?

27. [Multiple hearing only if answer “a” to 26] In
what percent of the appeals did you request the
record or case file? (old 41)
____ %. Please fill in the blank

(old 38)

a. Very helpful in making hearing more
effective
b. Generally helpful
c. Neither helpful nor unhelpful, just okay
d. Generally unhelpful
e. Not helpful at all

28. What was the purpose of the interaction
between you and OMHA staff [please check all
that apply]? (old 42)
a. Get evidence not in the record on the record
b. Preparation of the exhibits
c. Discuss procedural matters
d. Get general questions about the hearing
process answered
e. Other, please specify:

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HEARING SECTIONS
Branching Logic:
If answer to question 2 is “ a) 1” and Hearing Format in Case Information is:
[Continue to Section VI]
Telephone hearing
Video Teleconference hearing
[Skip to Section VII]
In-person hearing
[Skip to Section VIII]

SECTION VI – TELEPHONE HEARING. Next are questions about your telephone conference hearing.
29. [Single hearing only] During the telephone
hearing, what percent of the time were you able
to hear people clearly when they were speaking?
(old 44)

a.
b.
c.
d.
e.

100% [skip to 33]
75%-99%
50%-74%
25%-49%
0%-24%

29a. [Multiple hearings only] For what portion of
hearings over last 6 months did you experience
difficulties hearing people clearly when they
were speaking? (old 44a)
a. 0%
b. 1% - 25%
c. 26%-50%
d. 51%-75%
e. 75%-100%
30. [Only ask if answered b, c, d, or e to question
29 or 29a] Did you notify the ALJ of the
technical difficulties? (old 45)
a. Yes
b. No

32a. [Multiple hearings only] Were the technical
difficulties resolved? (old 47a)
a. Technical difficulties were almost always
resolved
b. Technical difficulties sometimes continued
c. Technical difficulties were seldom resolved
32. [Only if ‘b, c, d, e’ to question 29 or 29a] Did
these technical difficulties [for multiple
hearings: “ever”] result in the need to
reschedule the hearing? (old 47)
a. Yes
b. No
33. Overall, how satisfied were you with the use of
the telephone to conduct your ALJ hearing(s)?
(old 48)

f.
g.
h.
i.
j.

Very satisfied
Satisfied
Neither satisfied nor dissatisfied, it was okay
Dissatisfied
Very dissatisfied

34. [If d or e to question33] Please specify:

(old 49)

31. [Single hearing only] Were the technical
difficulties resolved? (old 46)
a. Yes, completely
b. More or less, some technical difficulties
continued
c. No
Go on to Section IX if video teleconference or in-person hearing format was not experienced.
Otherwise continue with appropriate section(s) below.

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SECTION VII – VIDEO TELECONFERENCE HEARING. Next are questions about your video
teleconference hearing.

35. What type of video teleconferencing facility was
used for [for multiple hearings: “the majority of”]
your VTC hearing(s)? (old 52)
a. Federal building or court house
b. FedEx Kinko’s
c. Stratosphere
d. Courtroom Connect
e. ACT Proximity
f. Other: ______________
36. Approximately how many miles did you travel to get
to the [for multiple hearings: “most frequently
used”] video teleconferencing facility? (old 53)
a. 15 miles or less
b. 16-45 miles
c. 46-75 miles
d. Over 75 miles

39. [Single hearing only] If so, were the technical
difficulties resolved? (old 56)
c. Yes, completely
d. More or less, some technical difficulties
continued
c. No
39a. [Multiple hearings only] If so, were the technical
difficulties resolved? (old 56a)
a. Technical difficulties were almost always
resolved
b. Technical difficulties sometimes continued
c. Technical difficulties were seldom resolved
40. [Only if ‘b, c, d, e’ to question 37] Did these
technical difficulties [for multiple hearings:
“ever”] result in the need to reschedule the hearing?
(old 57)

37. During the video teleconference hearing(s), what
percent of the time were you able to hear and/or see
people clearly when they were speaking? (old 54)
a. 100%
b. 75%-99%
c. 50%-74%
d. 25%-49%
e. 0%-24%
38. [Only ask if answered b, c, d, or e to question 37]
Did you notify the ALJ of the technical difficulties?

c. Yes
d. No
41. Overall, how satisfied were you with the use of
video teleconferencing to conduct your ALJ
hearing(s)? (old 58)
a. Very satisfied
b. Satisfied
c. Neither satisfied nor dissatisfied, it was okay
d. Dissatisfied
e. Very dissatisfied

(old 55)

a. Yes
b. No

42. [If d or e to question 41] Please specify: (old 59)

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Go on to Section IX if in-person hearing format was not experienced. Otherwise continue if in-person
hearing format was experienced.
SECTION VIII – IN-PERSON HEARING. Next are questions about your in-person hearing. [Carry
whether judge traveled to appellant site]
43. Approximately how many miles did you travel
[Multiple hearings: “do you typically travel”] to
get to the hearing? (old 60)
a. 15 miles or less
b. 16-45 miles
c. 46-75 miles
d. Over 75 miles

44. Overall, how satisfied were you with the use of
an in-person conference to conduct your
Medicare ALJ hearing(s)? (old 61)
a. Very satisfied
b. Satisfied
c. Neither satisfied nor dissatisfied, it was okay
d. Dissatisfied
e. Very dissatisfied
45. [If d or e to question 44] Please specify:
(old 62)

SECTION IX – Final Questions for ALL Appellants
46. Independent of the administrative law judge’s decision, were you satisfied with the nature of your
interaction with the judge? (new)
a. Very satisfied
b. Satisfied
c. Neither satisfied nor dissatisfied, it was okay
d. Dissatisfied
e. Very dissatisfied
47. Please respond to the following statements about the
administrative law judge(s) for your hearing(s) experience. (old

Always

Often

Sometimes

Never

Don’t
know









































63)

a. The judge clearly understood the record in my case(s) (old 63bhalf)
b. The judge clearly understood the issue(s) in my case(s) (old 63bhalf)
c. The judge was professional (old 63c)
d. The judge was courteous (old 63d)
e. The judge was an effective listener (old 63e)
f. The judge was prepared (old 63f)
g. The judge ran an orderly hearing(s) (old 63g)

48. Is there anything else you would like to tell us about your Medicare ALJ hearing experience that you
haven’t already told us? (old 64)
END, closing statement►
These are all the questions we have today. Thank you very much for taking the time to speak with us.
Again, if you would like to make a comment about this survey or confirm that this is a valid collection,
please contact the OMHA Survey Team at 1-866-207-4466.

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