CMS-265-11 Supporting Statement Part A

SUPPORTING STATEMENT FOR FORM CMS-265-11

INDEPENDENT RENAL DIALYSIS FACILITY COST REPORT

_{A. BACKGROUND}

CMS is requesting the Office of Management and Budget (OMB) review and approve this extension request for the Form CMS-265-11, Independent Renal Dialysis Facility Cost Report. These cost reports are filed annually by independent renal dialysis facilities participating in the Medicare program to determine the reasonable costs incurred for furnishing dialysis services to Medicare beneficiaries and to effect the year-end cost settlement for Medicare bad debts.

_{B. JUSTIFICATION}

_{1. Need and Legal Basis}

Providers of services participating in the Medicare program are required under sections

1815(a) and 1861(v)(1)(A) of the Social Security Act (42 U.S.C. 1395g) to submit annual information to achieve settlement of costs for health care services rendered to Medicare beneficiaries. In addition, regulations at 42 CFR 413.20 and 413.24 require adequate cost data and cost reports from providers on an annual basis.

The Form CMS-265-11 cost report is needed to determine a provider’s reasonable costs

incurred in furnishing medical services to Medicare beneficiaries.

_{2. Information Users}

The cost reports are required to be filed with the provider’s Medicare Administrative Contractor (MAC). The functions of the MAC are described in section 1816 of the Social Security Act.

The collection of data is a secondary function of the cost report. The data is used by CMS to support program operations, payment refinement activities, and to make Medicare Trust Fund projections.

_{3. Use of Information Technology}

Independent renal dialysis facilities are required to submit Medicare cost reports electronically for cost reporting periods ending on or after December 31, 2004.

_{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 Business}

These cost reporting forms have been designed with a view toward minimizing the reporting burden for small independent renal dialysis facilities. The form is collected as infrequently as possible (annually) and only those data items necessary to determine the appropriate reimbursement rates are required.

_{6. Less Frequent Collection}

If the annual cost report is not filed, CMS will be unable to determine whether proper payments are being made under Medicare. A provider who fails to file a cost report by the statutory due date is notified that interim payments will be reduced, suspended or deemed overpayments.

_{7. Special Circumstances}

This information collection complies with all general information collection guidelines in 5 CFR 1320.6 without the existence of special circumstances.

_{8. Federal Register Notice}

The 60 day Federal Register notice published on June 27, 2014.

_{9. Payment/Gift to Respondent}

There is no payment or gift to respondents.

_{10. Confidentiality}

Confidentiality is not assured. Medicare cost reports are subject to disclosure under the

Freedom of Information Act.

_{11. Sensitive Questions}

There are no questions of a sensitive nature.

_{12. Estimate of Burden (Hours & Wages)}

Number of Independent Renal Dialysis facilities required to file the form CMS-265

(as of April 28, 2014) ^5,677

Number of hours of reporting 15

Number of hours of record keeping 50

Hours burden per facility to complete the

cost report (15 hours + 50 hours) 65

Total hours burden (5,677 facilities x 65 hours) 369,005

Standard rate per hour $20.00

_{Total respondent cost estimate $7,380,100}

_{13. Capital Costs}

There are no capital costs.

_{14. Cost to Federal Government}

Annual cost to Medicare Contractors:

Annual costs incurred are related to processing information contained on the forms, particularly associated with achieving settlements. Medicare contractors' processing costs are based on estimates provided by the Office of

Financial Management (OFM). $22,707,000

Annual cost to CMS:

Total CMS processing cost is from the HCRIS Budget: 42,000

_{Total Federal Cost $22,749,000}

_{15. Changes To Burden}

The change in burden is due to two factors: 1) the number of respondents increased from 5,654 in 2011 to 5,677 in 2014; and 2) the standard rate increased from $15.00 per hour in 2011 to $20 per hour in 2014.

_{16. Publication and Tabulation Dates}

The data submitted on the cost report is not published or tabulated.

_{17. Expiration Date}

CMS would like an exemption from displaying the expiration date as these forms are used on a continuing basis and change infrequently.

_{18. Certification Statement}

There are no exceptions to the certification statement.

_{C. STATISTICAL METHODS}

There are no statistical methods employed in this collection.