CMS-10287 Final Supporting Statement

Supporting Statement – Part A

Medicare Quality of Care Complaint Form (CMS-10287)

_0938-1102

_{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. The Medicare Quality of Care Complaint Form (Complaint Form) is a paper form that is mailed to Medicare beneficiary once he/she contacts the Quality Improvement Organization (QIO) in order to file an written beneficiary complaint. The beneficiary is required to sign the Complaint Form in order to consent for the QIO to conduct its Quality of Care review and issue a formal determination. Currently, the Complaint Form is not available for electronic submission.

However, if CMS has the capacity to accept electronic signature(s), this collection could be submitted electronically.

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}

This collection does not impact small businesses.

6. Less Frequent Collection

This is a voluntary form. Medicare beneficiaries are required to fill out this form in order to give the Quality Improvement Organization (QIO) consent to conduct its Quality of Care review. If the beneficiary chooses not fill out the Medicare Quality of Care Complaint form, the QIO is not authorized by the beneficiary to conduct the Quality of Care review investigation and render a formal decision.

In addition, the QIO is required to obtain the beneficiaries written consent in order to disclose the beneficiary’s personal information (address and/or telephone number) to the entity that conducts beneficiary satisfaction surveys. See 42 CFR § 480.132. The entity that conducts beneficiary satisfaction surveys will mail the beneficiary a survey in order to determine the beneficiary’s level of satisfaction with the level of service the beneficiary received from the QIO. If the beneficiary does not wish to receive a satisfaction survey, they may check “no” on the Medicare Quality of Care Complaint 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 May 10, 2013. .}

_{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 (.16666 X 3,500).

There is no wage rate associated with this form. The respondents are Medicare beneficiaries not, government employees. The cost of collecting and processing these complaints is included in the CMS contract with the Quality Improvement Organizations receiving these forms.

13. Capital Costs

_{There are no capital costs associated with this information collection request.}

_{14. Cost to Federal Government}

All Federal costs associated with this rule will be incurred by CMS through their

contracts with QIOs.

15. Changes to Burden

There have been minor changes made to the collection instrument how the burden hours have not changed.

16. Publication/Tabulation Dates

There is no schedule for doing this project.

17. Expiration Date

CMS would like an exemption from displaying the expiration date 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.

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