Request for Nonsubstantive Change

Request for Non-Substantive Change to CMS 855A

On April 21, 2014, OMB approved the CMS 855POH (Annual Report of Physician-Owned Hospital Ownership and/or Investment Interest), control number 0938-1231. Currently the CMS 855A (Institutional Providers), (OMB number 0938-0685, approved for renewal on May 22, 2013) captures basic ownership/managerial information on providers. The CMS 855A was revised in July 2011 and a specific attachment designed to capture physician-owned hospital ownership and investment interest data was added to the form. With OMB approval of the CMS 855POH, as stated in the supporting statement in the PRA package of the CMS 855POH, Attachment 1 is no longer necessary and is being removed from the CMS 855A application.

The primary function of the Annual Report of Physician-Owned Hospital Ownership and/or Investment Interest (CMS 855POH) is to gather information from a physician-owned hospital that reports to Medicare specific ownership, investment and managerial information to determine whether the physician-owned hospital meets specific information that identifies of the owners of the hospital and other information necessary to meet the annual reporting requirements established per the Affordable Care Act Ownership Disclosure Provisions. The annual reporting requirement for physician-owned hospitals is not required for Medicare enrollment processing. Additionally, the ACA prohibits the expansion of current physician-owned hospitals and banned the establishment of new ones making the CMS 855A the improper method to collect this required annual report.

Attached is the revised PRA Supporting Statement for the renewal of the CMS 855A, B, I and R forms (approved May 22, 2013). It has been revised to remove the burden of the physician-owned hospitals, which revises the total burden hours for the CMS 855A. Also attached is the revised CMS 855A. Attachment 1 (pages 53 – 58) has been removed from the CMS 855A as well as all references to Attachment 1 (page 9 - 6^th bullet note, page 25 – 4^th paragraph and page 33 – 4^th paragraph). The physician-owned checkbox has not been deleted in section 2 as Medicare needs this information to identify the physician-owned hospitals. This is also reflected in the revised Supporting Statement burden. Specifically, the revisions to the Supporting Statement are outlined in the following table:

Location in Supporting Statement	Revision
p.1, sec. A1	Deleted 2nd paragraph
p.8, sec. BA, number 13	Deleted number 13 (Organizations with an Interest in a Physician-Owned Hospital
p.9, sec. BA, number 14	Deleted number 14 (Individuals with an Interest in a Physician-Owned Hospital
p.10, sec. BA, Table 1	Deleted line item 13 for “Physician-Owned Hospitals (Organizations)”
p.10, sec. BA, Table 1	Deleted line item 14 for “Physician-Owned Hospitals (Individuals)”
p.10, sec. BA, Table 1	Recalculated line item for “TOTAL” to subtract burden hours from lines 13 and 14, above