Supporting Statement – Part A
Medicare Quality of Care Complaint Form (CMS-10287)
0938-New
Specific Instructions
A. Background
Since 1986, Quality Improvement Organizations (QIO) have been responsible for conducting appropriate reviews of written complaints submitted by beneficiaries about the quality of care they have received. In order to receive these written complaints, each QIO has developed its own unique form on which beneficiaries can submit their complaints. Recently, CMS has initiated several efforts aimed at increasing the standardization of all QIO activities, and the development of a single, standardized Medicare Quality of Care Complaint Form beneficiaries can use to submit complaints is a key step towards attaining this increased standardization.
B. Justification
1 . Need and Legal Basis
In accordance with Section 1154(a)(14) of the Social Security Act, Quality Improvement Organizations (QIOs) are required to conduct appropriate reviews of all written complaints submitted by beneficiaries concerning the quality of care received. This form will establish a standard form for all beneficiaries to utilize and ensure pertinent information is obtained by QIOs to effectively process these complaints.
2. Information Users
The Medicare Quality of Care Complaint Form will be used by Medicare beneficiaries to submit quality of care complaints.
3. Use of Information Technology
This form will be available in electronic format as a pdf document.
*To comply with the Government Paperwork Elimination Act (GPEA), you must also include the following information in this section:
- Is this collection currently available for completion electronically? No.
- Does this collection require a signature from the respondent(s)? Yes.
- If CMS had the capability of accepting electronic signature(s), could this collection be made available electronically? Yes.
- If this collection isn’t currently electronic but will be made electronic in the future, please give a date (month & year) as to when this will be available electronically and explain why it can’t be done sooner. N/A
- If this collection cannot be made electronic or if it isn’t cost beneficial to make it electronic, please explain. N/A
4. Duplication of Efforts
This information collection does not duplicate any other effort and the information cannot be obtained from any other source.
5. Small Businesses
N/A
6. Less Frequent Collection
This is a voluntary form.
7. Special Circumstances
There are no special circumstances associated with this information collection request.
8. Federal Register/Outside Consultation
The 60-day Federal Register notice published on June 19, 2009.
9. Payments/Gifts to Respondents
Respondents will not receive any payments or gifts as a condition of complying with this information collection request.
10. Confidentiality
The information collected will be kept confidential to the extent provided by law. CMS will not disclose any confidential patient information unless authorized to do so by section 42 CFR 480.132 entitled “Disclosure of information about patients” or section 42 CFR 480.135 entitled “Disclosure necessary to perform review responsibilities.”
11. Sensitive Questions
There are not sensitive questions associated with this information collection request.
12. Burden Estimates (Hours & Wages)
Provide estimates of the hour burden and wages of the collection of information. The statement should:
CMS receives approximately 3,500 beneficiary complaints each year. This form is one page and requests commonly provided identification information as well as a short summary of the beneficiary complaint. Typically, we do not receive more than one response per respondent per year. We estimate that it would take a respondent no more than 10 minutes to complete this form. Therefore, we estimate the total annual burden associated with this information collection request to be 583 hours. In fact, this collection will represent a reduction in burden compared to current process requirements since this simplified form will replace the more cumbersome process and forms some QIOs currently use to initiate the complaint review process.
The respondents are Medicare beneficiaries, most of whom are retired. Reliable wage rates or methods to estimate the value of their leisure time were not available at the time of this ICR submission.
13. Capital Costs
While a stamp costs $.44, the form is normally mailed to the beneficiary in response to a call with the QIO, and the QIO provides the beneficiary with a postage paid self-addressed stamped envelope. Thus, the cost would be relegated to the estimated 1% of beneficiaries who mail complaint forms/letters to the QIO. This would roughly amount to no more than $20 based on current complaint volumes (3500 complaints per year). It is likely that additional costs will be associated with the implementation of the electronic version of the form available through CMS’ webpage, but at this time, we have no way of estimating these costs. The cost to the QIOs for the remaining 99% would roughly be $2500. This includes approximately $1,550 for postage and another $750 for envelopes, and another $200 for address labels.
14. Cost to Federal Government
The cost to the Federal government is approximately $2800 per case. The $2,800 per case was calculated using historical beneficiary complaint volume and cost. CMS calculated the average cost per case for every QIO. After calculating the average cost per case for each QIO we calculated the median average cost per case. The median average cost per case was $2,788 or about $2,800 per case.
15. Changes to Burden
This is a new information collection.
16. Publication/Tabulation Dates
N/A
17. Expiration Date
CMS would like an exemption from displaying the expiration date on the paper forms as these forms are used on a continuing basis. To include an expiration date would result in having to discard a potentially large number of forms. However, CMS will display the expiration date on the electronic version of the form.
18. Certification Statement
There are no exceptions to the certification statement.
| File Type | application/msword |
| File Title | Supporting Statement – Part A |
| Author | CMS |
| Last Modified By | CMS |
| File Modified | 2010-07-27 |
| File Created | 2010-07-27 |