CMS 1880 and 1882 Supporting Statement

Supporting Statement

for the CMS 1880/1882

Certification as a Supplier of Portable X-Ray

and Portable X-Ray Survey Report Form

and Supporting Regulations at 42 CFR Part 486.100-486.110

A. BACKGROUND

This is a request for OMB approval of the Centers for Medicare & Medicaid Services (CMS)-1880, Request for certification as a Supplier of Portable X-ray services and the CMS-1882, Medicare/Medicaid Portable X-ray Survey Report.

The form CMS-1882 implements regulations under 42 CFR Part 486.100 through 486.110.

B. JUSTIFICATION

1. Need and Legal Basis

This activity is authorized by Title XVIII of the Social Security Act, Section 1861(s)(3). The collection of this information is authorized by 42 CFR Part 486.100-486.110 pursuant to Sections 1864 and 1875 of the Social Security Act. Section 1861(s)(3) requires that providers of Medicare services meet such requirements as the Secretary finds necessary to ensure the health and safety of individuals who are furnished services. For Medicare purposes, certification is based on the State survey agency’s reporting of a provider’s or supplier’s compliance or noncompliance with the health and safety requirements published in regulations. To determine compliance with these requirements, the Secretary has authorized States through contacts to conduct surveys of health care providers.

The form CMS-1880, Request for Certification as a Supplier of Portable X-Ray Services under the Medicare program, is utilized as an application to be completed by suppliers of portable X-ray services requesting participation in the Medicare program. This form initiates the process of obtaining a decision as to whether the conditions of coverage are met as a portable X-ray supplier. It also promotes data reduction or introduction to, and retrieval from, the Online Survey, Certification and Reporting System (OSCAR) by the CMS Regional Offices (ROs).

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The survey report form CMS-1882 is an instrument used by the State survey agency to provide data collected during an on-site survey of a supplier of portable X-ray services to determine compliance with the applicable conditions of participation and to report this information to the Federal Government. The form is primarily a coding worksheet designed to facilitate data reduction and retrieval into the OSCAR system at the CMS ROs. The form includes basic information on compliance (i.e., met, not met, explanatory statements) and does not require any descriptive information regarding the survey activity itself. CMS has the responsibility and authority for certification decisions which are based on supplier compliance with the applicable conditions of participation. The information needed to make these decisions is available to CMS only through the use of information abstracted from the survey report form.

2. Information Users

The information from this form will be used by CMS in making certification decisions. The information on the form serves as a screen for the State survey agency to determine if the portable X-ray supplier has the basic capabilities to participate in the Medicare program, and whether a survey is appropriate. The basic identifying information from this form is coded into OSCAR and serves as the information based for the creation of a record for future Federal certification and for monitoring activity.

3. Improved Information Technology

The certification form lists minimum criteria that must be met in order to be approved as a supplier of portable X-ray services for Medicare participation. The standardized format and simple checkbox method provide for consistent reporting by State survey agencies. Recording this information would be no easier for State surveyors using direct access equipment.

4. Duplication

The application and survey forms do not duplicate any information collection. The forms address specific requirements for certification as a portable X-ray supplier. State survey agencies conduct these reviews with Federal funds under contract with CMS. The survey form is a basic

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deliverable under these contracts and is the only one of its kind collected by CMS for portable X-ray suppliers. The survey form is the only standardized mechanism available for reporting the basic preliminary requirements for portable X-ray suppliers wishing to participate in the Medicare program.

5. Small Business

These information collection requirements do not affect small businesses.

6. Less Frequent Collection

Submission of the survey form is based on the frequency of portable X-ray supplier surveys. These surveys, in turn, depend on the frequency specifications of regulations and the availability of survey funds. Currently, 15 percent of Medicare-approved suppliers of portable X-ray services are surveyed annually. All new applicants are surveyed.

7. Special Circumstances

There are no special circumstances for this information collection.

8. Federal Register/Outside Consultation

CMS published a 60-day Federal Register notice on October 24, 2008. This form represents the simplest method available for screening portable X-ray suppliers before performing a full scale survey. We solicited public comments via the Paperwork Reduction Act in the past and have not received any comments.

9 Payment/Gifts to Respondent

There are no payment/gifts to respondent.

10. Confidentiality

We do not pledge confidentiality.

11. Sensitive Questions

There are no questions of a sensitive nature associated with this form.

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12. Estimate of Burden (Total Hrs. & Wages)

Initially the application form is completed by the supplier expressing an interest in participating in the Medicare program and thereafter it is completed by the State agency surveyor. We estimate based on the simplicity of the form and past usage that it takes approximately 15 minutes to complete.

Read Instructions 5 minutes

Gather and Compile Data 5 minutes

Clerical Time 5 minutes

TOTAL TIME 15 minutes

The respondent burden will vary on initial submission but thereafter the 15 minutes is a conservative estimate.

The survey report form is completed by a State surveyor upon request for approval and every eight years thereafter for recertification purposes. We estimate, based on the simplicity of the form and past usage, that it takes approximately 1.50 hours to complete. We estimate an additional 15 minutes is required for the supplier to complete the form.

68 Portable X-ray suppliers

x 1.75 Hours to complete form

119 Hours of burden annually to State surveyors for

completion of form

The cost to collect this information is as follows: 119 hours @ $40 per hour = $4,760. CMS pays this amount; there is no cost to the States.

13. Capital Costs of Burden

There are no capital costs of burden.

14. Federal Cost Estimates

All costs associated with form CMS-1882 are incurred by the Federal Government. Due to budget constraints, only 12 percent of the facilities will be surveyed.

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Number of facilities in the universe 544

Number of facilities surveyed 68

Contracting costs to complete form

($35.00/hr) $6002

Printing and Distri-bution 650

$6652

TOTAL COSTS

All costs associated with completion of form CMS-1880 are incurred by the portable X-ray supplier.

15. Changes in Burden/Program Changes

There are no program changes. The decrease in burden is due to fewer respondents.

16. Publication and Tabulation Dates

There are no publication and tabulation dates with this collection.

17. Expiration Date

CMS would like to display the expiration date.

18. Certification Statement

There are no exceptions to the certification statement.

C. Collections of Information Employing Statistical Methods

There are no statistical methods employed in this information collection.