CMS-1856 and -1893 Supporting Statement [rev 06-21-11]

Supporting Statement for Request for Certification in the Medicare/Medicaid Program for Providers of Outpatient Physical Therapy and/or Speech-Language Pathology and the Outpatient Physical Therapy and/or Speech-Language Pathology Survey Report Form CMS-1856 and CMS-1893 and Supporting Regulations in 42 CFR Part 485.701 - 485.729

A. BACKGROUND

This is a request to extend OMB approval for the CMS-1856, Request for Certification in the Medicare/Medicaid Program to Provide Outpatient Physical Therapy and/or Speech-Language Pathology Survey Report Form and for the CMS-1893, Outpatient Physical Therapy-Speech Pathology Survey Report.

These forms implement 42 CFR 485.701-485.729, Conditions of Participation for Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and/or Speech-Language Pathology Services.

B. JUSTIFICATION

1. Need and Legal Basis

This activity is authorized by Title XVIII of the Social Security Act, Section 1861(p). The collection of this information is authorized by 42 CFR Part 485.701-485.729 pursuant to Sections 1864 and 1875 of the Social Security Act. This section requires that providers and suppliers of Medicare services meet such requirements as the Secretary finds necessary to ensure the health and safety of individuals who are furnished their 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 contracts to conduct surveys of health care providers.

The form CMS-1856, Request for Certification in the Medicare/Medicaid Program to Provide Outpatient Physical Therapy and/or Speech-Language Pathology, is utilized as an application to be completed by providers of outpatient physical therapy and/or speech-language pathology services requesting participation in the Medicare/Medicaid programs. This form initiates the process of obtaining a decision as to whether the conditions of participation are met as a provider of outpatient physical therapy and/or speech-language pathology services. It is used by the State Agencies (SAs) to enter the new provider into the ASPEN (Automated Survey Process Environment).

The survey report form CMS-1893 is an instrument used by the State survey agency to record data collected during an on-site survey of a provider of outpatient physical therapy and/or speech-language pathology 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 ASPEN system. 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 provider compliance with the applicable conditions for 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 the form CMS-1856 is used by CMS in making certification decisions. The information on the form serves as a screen for the State agency to determine if the provider of outpatient physical therapy and/or speech-language pathology services has the basic capabilities to participate in the program, and whether a survey is appropriate. The basic identifying information from this form is coded into aspen and serves as the information base for the creation of a record for future Federal certification and for monitoring activity.

3. Improved Information Technology

The survey form lists minimum criteria that must be met in order to be approved as a provider of outpatient physical therapy and speech-language pathology 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 and Similar Information

The application and survey forms do not duplicate any information collection. The forms address specific requirements for certification as a provider of outpatient physical therapy and speech-language pathology services. State survey agencies conduct these reviews with Federal funds under contract with CMS. The survey form is a basic deliverable under these contracts and is the only one of its kind collected by CMS for providers of outpatient physical therapy and speech-languages services.

The survey form is the only standardized mechanism available for reporting the basic preliminary requirements for providers of outpatient physical therapy and speech-language pathology services wishing to participate in the Medicare program.

5. Small Business

These requirements do not affect small businesses.

6. Less Frequent Collection

Completion of the survey form is based on the frequency of these provider surveys. These surveys, in turn, depend on the frequency specifications of regulations and the availability of survey funds. Currently providers of outpatient physical therapy and speech-language pathology services are surveyed every six years.

7. Special Circumstances for Information Collection

This information collection complies with the general guidelines in 5 CFR 1320.6.

8. Federal Register and Outside Consultation

The 60-day Federal Register notice published on April 8, 2011 (76 FR 19776). CMS has given the public opportunities to comment on these information collection requirements (ICR) via the Paperwork Reduction Act of 1995. We have not received any negative comments on these ICRs.

9. Payment/Gifts to Respondent

There are no payments or gifts involved in this information collection.

10. Confidentiality

We do not pledge confidentiality.

11. Sensitive Questions

There are no questions of a sensitive nature on the form.

12. Estimate of Burden (Hours & Wages)

Initially the form CMS-1856 is completed by the provider expressing an interest in participating in the Medicare program and thereafter it is completed by the State agency survey. 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 PER PROVIDER 15 minutes

Form CMS-1893 is completed by a State surveyor during the initial survey process 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. (NOTE: We estimate an additional 15 minutes is required for the provider to complete the request form so our calculation is based on 1.75 hours.)

495 Providers of outpatient physical therapy and speech-language pathology services (divided total # of respondents by 6)

x 1.75 Hours to complete request and form

866 Hours of burden annually to providers and State surveyors for completion of form

We estimate that these ICR’s will cost the public $12,990 (866 hours X $15 per hour).

13. Capital Cost of Burden

There are no capital costs associated with this collection.

14. Federal Cost Estimates

All costs associated with the form CMS-1893 are incurred by the Federal Government.

Number of facilities in universe 2968

Number of facilities surveyed annually 495

Contracting costs to complete form

($ 40 /hr.) 19,800

Printing and distribution (CMS-1893) $850

TOTAL COSTS

All costs associated with completion of form CMS-1856 are incurred by the provider of outpatient physical therapy and speech-language pathology services.

15. Changes in Burden/Program Changes

There are no program changes or adjustments

16. Publication and Tabulation Dates

There are no publication and tabulation dates associated with this collection.

17. OMB Expiration Date

CMS does not object to displaying the OMB 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.