Medicare Self-Referral Disclosure Protocol

Forms and Documents

Document Name	Status
Form CMS-10328 Financial Review Form and Instruction	Modified
Form CMS-10328 Legal Review Form and Instruction	Modified
CMS-10328_Supporting_Statement_Part_A.docx Supporting Statement A	2014-05-16

IC Document Collections

IC ID	Document Title	Status
194183	Financial Review Form and Instruction	Modified
194182	Legal Review Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1106	ICR Reference No: 201405-0938-004
Status: Historical Active	Previous ICR Reference No: 201103-0938-015
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Self-Referral Disclosure Protocol
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/26/2014
	Date Received in OIRA: 05/16/2014
Terms of Clearance: OMB is approving this information collection request for a period of three years during which time CMS will request approval to extend or revise the collection if the Agency seeks to continue the information collection activity beyond the period approved under this action.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2017	36 Months From Approved	08/31/2014
Responses	200	0	100
Time Burden (Hours)	5,000	0	1,200
Cost Burden (Dollars)	0	0	0

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Abstract: The Affordable Care Act (ACA) was enacted on March 23, 2010. Section 6409 of the ACA requires the Secretary of the Department of Health and Human Services (the "Secretary"), in cooperation with the Office of Inspector General of the Department of Health and Human Services (the "Inspector General"), to establish a Medicare self-referral disclosure protocol ("SRDP") that sets forth a process to enable providers of services and suppliers to self-disclose actual or potential violations of the physician self-referral statute, section 1877 of the Social Security Act (the Act). In accordance with the ACA, the SRDP was established on September 23, 2010, six months after the date of enactment, and information concerning how to disclose an actual or potential violation of section 1877 of the Act was posted on the CMS website.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 6409 Name of Law: Medicare self-referral disclosure protocol.
   US Code: 42 USC 1395nn Name of Law: Limitation on Certain Physician Referrals
  

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:
	79 FR 10161	02/24/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 25133	05/02/2014
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Financial Review	CMS-10328	Medicare Self-Referral Disclosure Protocol
Legal Review	CMS-10328	Medicare Self-Referral Disclosure Protocol

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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	200	100	0	100	0	0
Annual Time Burden (Hours)	5,000	1,200	0	3,800	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: There are no new burden requirements; however, we adjusted the burden due to an adjustment in our estimate of the burden per disclosure. We also adjusted our estimated number of disclosures.

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Annual Cost to Federal Government: $349,900

Does this IC contain surveys, censuses, or employ statistical methods? No

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]? Yes

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: 05/16/2014

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