Probable Fraud Measurement Pilot

Forms and Documents

Document Name	Status
Form CMS-10406 Referring Providers Form and Instruction	New
Form CMS-10406 HHA's Form and Instruction	New
Form CMS-10406 Beneficiaries Form and Instruction	New
CMS-10406.Supporting Statement - Part B__2012-12-01.docx Supporting Statement B	2013-05-16
CMS-10406.Supporting Statement - Part A__2012-12-01_Pre....doc Supporting Statement A	2013-05-16

IC Document Collections

IC ID	Document Title	Status
203015	Referring Providers Form and Instruction	New
203014	HHA's Form and Instruction	New
203013	Beneficiaries Form and Instruction	New

ICR Details

OMB Control No: 0938-1192	ICR Reference No: 201207-0938-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Probable Fraud Measurement Pilot
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 05/16/2013
	Date Received in OIRA: 07/05/2012
Terms of Clearance: Approved consistent with the following terms of clearance, upon completion of the pilot CMS will report to OMB on the results of the study, addressing response rates, analysis of results, and conclusions based on the data collected.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2016	36 Months From Approved
Responses	6,000	0	0
Time Burden (Hours)	7,500	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The goal of this pilot is to develop the first nationally representative estimate of the extent of probable fraud in payments for home health care services in the fee-for-service Medicare program. The instruments will be used to conduct interviews with Medicare beneficiaries, home health agency (HHA) staff, and referring providers.

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Authorizing Statute(s): US Code: 42 USC 1395ddd Name of Law: Medicare Integrity Program
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 13337	03/06/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 38836	06/29/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Beneficiaries	CMS-10406	Instrument
HHA's	CMS-10406	Instrument
Referring Providers	CMS-10406	Instrument

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	6,000	0	0	6,000	0	0
Annual Time Burden (Hours)	7,500	0	0	7,500	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection request.

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Annual Cost to Federal Government: $4,550,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/05/2012

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