Health Care Providers and Suppliers

Appendix B1.
Appellant Climate Survey

Telephone-English

U.S. Department of Health and Human Services

Office of Medicare Hearings and Appeals

_{Medicare Administrative Law Judge Hearings}

_{Telephone Survey}

Form Approved

OMB No. 0990-0330

Exp. Date xx/xx/2021

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 15 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. SW, Suite 537-H, Washington, DC 20201, Attention: PRA Reports Clearance Officer.

Section I. Hearings History

1. Approximately how many OMHA hearings have you participated in during the last 12 months?

a. 0

b. 1

c. 2 to 10

d. More than 10

[If answer to q1=c or d, i.e., >1, then switch to multiple hearing phrasing throughout and read:] Please respond to the survey questions based on your most recent hearing experience with OMHA.

When answering this question, think of the last hearing you participated in, which we show as [date].

2. Are you the actual appellant or did you represent the appellant?

a. Actual appellant [Go to q4]

b. Represented the appellant [Go to q3]

3. 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 or administrator

g. Other - Please specify:

Section II. Overall Experience

4. 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?

a. Very great extent

b. Great extent

c. Some extent

d. Very little extent

e. Not heard and considered at all

5. Next, think about the entire process of working with OMHA, from requesting an Administrative Law Judge hearing up to receiving a final decision. Regardless of the outcome of that decision, how satisfied were you with the process of working with OMHA overall?

a. Very satisfied

b. Satisfied

c. Neither satisfied nor dissatisfied

d. Dissatisfied

e. Very dissatisfied

[If answer to q5=d or e, then read only if the respondent begins to offer feedback:] Your feedback is important to us and there is a place later in the survey where I can note it. But first, I have a few more specific questions to ask you.

6. How satisfied were you with the professionalism of OMHA staff when they assisted you with the Administrative Law Judge hearing process? [interviewer, remind if needed: from requesting an Administrative Law Judge hearing up to receiving a final decision]

a. Very satisfied

b. Satisfied

c. Neither satisfied nor dissatisfied

d. Dissatisfied

e. Very dissatisfied

Section III. Hard Copy, Internet, and Phone Information

_[Do not read the second sentence (i.e., the definition in “Type of Information”) below to responders with multiple cases _{(q2 answer greater than 1).]}

7. I am going to describe for you some documents that you may have received during the appeals process. For each document listed, indicate its clarity on a scale of Very Clear, Generally Clear, Somewhat Clear, Generally Unclear, to Not at All Clear.

	Check if
Type of Information	Didn’t Receive/ Don’t Know		Very Clear		Generally Clear		Some- what Clear	Generally Unclear	Not at All Clear
The first document is the Acknowledgement of a Request for a Hearing before an Administrative Law Judge (Form OMHA-110). You would have received this document after making your request for a hearing before the Administrative Law Judge. This document confirmed that OMHA had received your request for hearing and included a record number for your appeal. Was this document…									
The next document is the Notice of Assignment to an Administrative Law Judge. This document provided you with information about the Administrative Law Judge who was assigned to your appeal. Was this document…									
The next document is the Notice of Hearing (Form OMHA-1024). This document specified the date and time that the hearing was scheduled, the type of hearing, instructions about what to do next, and other instructions. Was this document…									
The next one is called the Response to Notice of Hearing (Form OMHA-102). This is a document you would have received with the notice of hearing; it required you to provide information about the hearing, the responding party, and your representative, if you had one. Was this document…									
The next document is the Notice of Nondiscrimination (Form OMHA-001). This form included instructions in a variety of languages on how to obtain free aid and services for people with disabilities and how to obtain free language services. Was this document…									
The next document is called the Exhibit List (Form OMHA-156) and was part of the case record. The Exhibit List may have listed medical record evidence, among other things. Was this document…									
[Skip if Disposition is Fully Favorable] The last document refers to your rights to appeal the Administrative Law Judge’s decision. You would have received this information with the decision letter after participating in the Administrative Law Judge hearing. Would you say that this document that explained your rights to appeal was. . . [interviewer, read if needed: to the HHS Departmental Appeals Board, Medicare Appeals Council]									

8. Have you used the online Administrative Law Judge Appeal Status Information System, or AASIS? This feature of the OMHA website allows you to look up the status of appeals you have filed with OMHA.

a. Yes

b. No [Go to 10]

9. [If answer to Q8=a, then ask] How satisfied are you with the online capability to check the status of your appeal?

a. Very satisfied [GO TO Q11B]

b. Satisfied [GO TO Q11b]

c. Neither satisfied nor dissatisfied [GO TO Q11b]

d. Dissatisfied

e. Very dissatisfied

[If answer to Q9=d or e, then ask] Why were you dissatisfied?

[GO TO Q11B]

10. Have you accessed OMHA’s website?

a. No, I did not try [Skip to q11a]

b. No, I do not have access to a computer and/or the Internet [Skip to q11a]

c. No, I tried to but could not find it [Skip to q11a]

d. Yes [Skip to q11b]

11a. [IF answer to Q10=A, B, OR C, THEN ASK] If you could access the website, what types of information or content would be useful for you to find listed on the site? [Probes: can you explain? Anything else?] [GO TO Q12]

11B. [If Answer to Q10-=yes (d), then ask] What suggestions do you have for improving the OMHA website? [Probes: can you explain? Anything else?]

12. Did you ever use the toll-free helpline to contact OMHA?

a. Yes [Go to Q13]

b. No [Go to Q14]

13. How satisfied were you with the customer service provided by OMHA through the toll-free helpline?

a. Very satisfied

b. Satisfied

c. Neither satisfied nor dissatisfied

d. Dissatisfied

e. Very dissatisfied

Section IV. Experience Scheduling Your Hearing

_{Next, I will ask you some questions about your satisfaction with scheduling your hearing.}

14. There were four different phases of the scheduling process, starting with your initial request for a hearing up to when you actually participated in the hearing and received the Administrative Law Judge’s decision. The first is ____________. Would you say that you were very satisfied, satisfied, neither satisfied nor dissatisfied, dissatisfied or very dissatisfied with _______________? The next phase was____________. Were you…

	Very Satisfied	Satisfied	Neither Satisfied nor Dissatisfied	Dissatisfied	Very Dissatisfied
a. The timeframe between filing your request for hearing and when you were notified that your case had been assigned to an Administrative Law Judge					
b. The amount of time you waited until your hearing was scheduled					
c. The timeframe between scheduling the hearing and the hearing itself					
d. The timeframe between the hearing and receiving a decision					

15. Overall, how satisfied were you with the process to schedule the Administrative Law Judge hearing?

a. Very satisfied

b. Satisfied

c. Neither satisfied nor dissatisfied

d. Dissatisfied

e. Very dissatisfied

[If answer to Q15 is d or e] Please explain why you were not satisfied:

16. After your hearing was scheduled, was it ever rescheduled?

1. Yes [ask Q17 and Q18]

2. No [Go to Q19]

17. Did you request the hearing to be rescheduled or did the Administrative Law Judge change the time and/or place of the hearing? [CHECK ALL THAT APPLY]

a. Respondent requested a rescheduling of the hearing

b. The Administrative Law Judge, or staff, changed the time and/or place of the hearing as it was originally scheduled

18. How satisfied were you with the rescheduling process?

1. Very satisfied

2. Satisfied

3. Neither satisfied nor dissatisfied

4. Dissatisfied

5. Very dissatisfied

NONBEN1. [FOR NON-BENEFICIARIES ONLY] Were you made aware of the volume of appeals that OMHA was processing other than yours?

a. Yes

b. No

Section V. Interaction with OMHA Between Scheduling and Hearing

19. Did you have any interaction with OMHA staff after the hearing was scheduled, but before the hearing was conducted?

a. Yes

b. No [GO TO Q23]

20. During the period after the hearing was scheduled but before it was held, how satisfied were you with your interaction with OMHA staff overall?

a. Very satisfied

b. Satisfied

c. Neither satisfied nor dissatisfied

d. Dissatisfied

e. Very dissatisfied

21. During this period [IF NEEDED: after the hearing was scheduled but before it was held], did your interaction with OMHA staff help to make your hearing more effective? Would you say it was. . .

a. Very helpful in making hearing more effective

b. Generally helpful

c. Neither helpful nor unhelpful

d. Generally unhelpful

e. Not helpful at all

21OPEN. [If answer to q21 was d or e] Please describe why your interaction with OMHA staff was less than helpful.

22. What was the purpose of the interaction between you and OMHA staff [please check all that apply]?

a. To get evidence that was not in the record on the record

b. Prepare exhibits

c. Discuss procedural matters

d. Get general questions about the hearing process answered

e. Other - Please specify:

_{Section V}I. Telephone Hearing

_{Next are questions about your telephone hearing.}

23. [DO NOT SHOW FOR VIDEO CONFERENCING] During the telephone hearing(s), how much of the time were you able to hear people clearly when they were speaking? Would you say. .

a. All of the time

b. Most of the time

c. Some of the time

d. None of the time

24. Overall, how satisfied were you with the use of the telephone [insert “video conferencing” when applicable] to conduct your Administrative Law Judge hearing(s)?

a. Very satisfied

b. Satisfied

c. Neither satisfied nor dissatisfied

d. Dissatisfied

e. Very dissatisfied

24OPEN. [If answer to Q24 was d or e] Please specify:

Section VII. Final Questions for ALL Appellants

25. Regardless of the judge’s decision, how satisfied were you with the interaction you had with the judge?

a. Very satisfied

b. Satisfied

c. Neither satisfied nor dissatisfied

d. Dissatisfied

_{e. Very dissatisfied}

26. Regardless of the judge’s decision, was the decision written in language that you could clearly understand? Was the language…

a. Very clear

b. Generally clear

c. Somewhat clear

d. Generally unclear

_{e. Not at all clear}

27. Please respond to the following statements about the Administrative Law Judge(s) for your hearing(s) experience.	Always	Often	Some- times	Never	Don’t Know
a. The judge clearly understood the issue(s) in my case(s).					
b. The judge was professional.					
c. The judge was an effective listener.					
d. The judge was prepared.					
e. The judge conducted an orderly hearing(s).					

28. Based on your experience with the OMHA appeals process, do you have any suggestions for improvement?

Section VIII. Final Questions for Non-Beneficiaries Only

As part of a broader effort to improve the Medicare appeals process, OMHA has offered alternative methods instead of the hearing process to seek review of appeals. The next two questions describe these Special Initiatives and ask about your awareness of them.

	YES	NO
29. OMHA’s Settlement Conference Facilitation (SCF) program is an alternative dispute resolution process at OMHA that gives certain providers and suppliers an opportunity to resolve their eligible Part A and Part B appeals through mediation with the Centers for Medicare & Medicaid Services (CMS). Are you aware of this program?

30. [ASK IF Q29=YES] Have you participated in the Settlement Conference Facilitation Program?

a. Yes [GO to 31]

b. No [GO TO CLOSING STATEMENT]

31. How satisfied were you with your settlement conference experience?

1. Very satisfied

2. Satisfied

3. Neither satisfied nor dissatisfied

4. Dissatisfied

5. Very dissatisfied

	YES	NO
32. OMHA’s Statistical Sampling program provides appellants with an option for addressing large volumes of claim disputes at the Administrative Law Judge Hearing level of the Medicare claim appeals process. Are you aware of this program?

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 it meets the necessary requirements as a valid information collection tool under the Paperwork Reduction Act, please contact the OMHA Survey Team at 1-866-207-4466.