CMS-1856 and -1893 Supporting Statement

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

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 requiring that providers and suppliers of services to Medicare beneficiaries meet such requirements as the Secretary finds necessary to ensure the health and safety of individuals who are furnished such 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 federal regulations. To determine compliance with these requirements, the Secretary has authorized CMS to contract with State survey agencies to conduct surveys of providers and suppliers.

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. The form is used by the State Agencies (SAs) to enter the new provider into the ASPEN (Automated Survey Process Environment) database.

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 for entry 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 of 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 the Aspen database and serves as the information base for the creation of a record for future Federal certification and monitoring activity. Form CMS-1893 is also utilized by SAs for verifying compliance with the Medicare conditions of participation for OPTs. This information is also recorded into the ASPEN database for monitoring activity.

3. Use of 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. Information collected in the minimum required.

5. Small Business

It is anticipate that the majority of providers affected this information collection will be small businesses. The information collected in the minimum required in order to participate in the Medicare program as a provider of outpatient physical therapy and/or speech-language pathology services. The frequency of surveys for existing providers is once every six years and is one of the least frequent for Medicare participating providers.

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 once 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 was published on June 9, 2014. There were no comments received.

9. Payment/Gifts to Respondent

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

10. Confidentiality

Information collected will be utilized by CMS and its agents for certification and enforcement actions. This information is publicly disclosable. Any identifiable data subject to the Privacy Act is deleted prior to disclosure.

11. Sensitive Questions

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

12. Estimate of Burden (Hours & Wages)

Form CMS-1856 is completed by a prospective provider requesting to participate in the Medicare program and existing providers at the time of resurvey. We estimate based on the simplicity of the form and past usage that it will take approximately 15 minutes to complete the form. This time includes 5 minutes to read the instructions, 5 minutes to compile information, and 5 minutes of clerical time. We anticipate this form to be completed by the equivalent of an Administrative Services Manager with a mean hourly wage $43.36 based on the 2013 Bureau of Labor Statistics National Occupational Employment and Wage Estimates. We estimate this form will be completed 350 times annually at a cost of $10.84 per provider. The total annual hours and cost for is 88 hours and $3794.

Form CMS-1893 is completed by a State surveyor during the initial survey process and every six years thereafter for recertification purposes. We anticipate this form to be completed by the equivalent of a state examiner / investigator with a mean hourly wage $27.11 based on the 2013 Bureau of Labor Statistics National Occupational Employment and Wage Estimates. We estimate based on the simplicity of the form and past usage that it takes approximately 1.50 hours to complete with total cost of $40.67 per form. There are approximately 350 surveys conducted annually. We estimate the annual time and cost to complete all 350 surveys to be 525 hours and $14,233.

13. Capital Cost of Burden

There are no capital costs associated with this collection.

14. Federal Cost Estimates

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

All costs associated with the form CMS-1893 are incurred by the Federal Government. Then annual cost estimate to the federal government includes $14,233 to complete the forms and an additional $245 for printing ($0.05 per page) of the form. The total annual cost is $14,478.

15. Changes in Burden/Program Changes

There are no program changes however, we are reporting an adjustment to the burden. The burden adjustment results from two factors. First, the frequency of use of these forms has decreased in recent years. The estimated annual number of respondents has decreased from 495 to 350. Second, the cost burden has increased due to an adjustment in the estimated hourly wage of workers completing these forms. We have updated the hourly wage to reflect anticipated cost that is based on data from the Bureau of Labor Statistics National Occupational Employment and Wage Estimates.

The previous burden estimate for forms CMS-1856 and CMS-1893 was based on an estimated 495 surveys being conducted annually. Our data from the past several years indicate this value has changed to approximately 350 surveys. We are revising this number accordingly. We are also revising the cost burden associated with these forms. The previous cost burden was based on a $15 hourly wage. We are revising this number to make it current with the expected burden. We have based our cost estimates on the May 2013 Bureau of Labor Statistics National Occupational Employment and Wage Estimates. For form CMS-1856, we are using the average hourly wage of $43.36 per hour for an Administrative Services Manager. For form CMS-1893, we are using the average hourly wage of $27.11for a State examiner or investigator. Overall, these adjustments have decreased the annual hourly burden due to decreased volume and have increased the cost burden due to a change in the hourly wage.

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.