CMS -10406 Supporting Statement Part A__41106 Pilot

Supporting Statement – Part A
CMS-10406/OMB Control Number 0938-1192

Supporting Statement For Paperwork Reduction Act Submissions
A. Background
This request is for OMB approval for a set of instruments to be used in a probable fraud
measurement pilot by the Centers for Medicare & Medicaid Services (CMS). The goal of this
pilot is to develop the first nationally representative estimate of the extent of probable fraud in
payments for home health care services in the fee-for-service Medicare program. The estimate
will help senior leaders within the Department of Health and Human Services (DHS), Congress,
and the White House make more informed decisions related to combating fraud, and it will
provide a baseline probable fraud estimate for CMS to track probable fraud over time. The
instruments will be used to conduct interviews with Medicare beneficiaries, home health agency
(HHA) staff, and referring providers. This is the first submission related to these instruments,
which were developed for use in this pilot.
Fraud in Medicare
Health care fraud is a source of considerable concern in the Medicare program, but a statistically
valid estimate of the rate of fraud in Medicare does not currently exist. Documenting the baseline
amount of fraud in Medicare is of critical importance as it allows officials to evaluate the success
of ongoing fraud prevention activities. These data will improve CMS’s ability to evaluate the
extent to which anti-fraud activities prevent or reduce fraudulent payments in Medicare.
Probable Fraud Measurement Pilot
CMS, in collaboration with the Office of the Assistant Secretary for Planning and Evaluation
(ASPE), developed a pilot to estimate the percentage of national Medicare fee-for-service
payments in home health made based on claims that are probable fraud. CMS has designated
revalidating home health agencies as having a “moderate categorical risk” of fraud, waste or abuse,
while newly enrolling home health agencies are one of two service areas that CMS has designated
as having a “high categorical risk” of fraud, waste, and abuse.1
This pilot focuses on probable fraud rather than “actual fraud” because determining fraud requires
legal proof of intent. The False Claims Act, which applies to most payments made by the federal
government, provides civil and criminal remedies for a provider or supplier who “knowingly
presents, or causes to be presented, a false or fraudulent claim for payment or approval.”2 The
1

The other area named by CMS is newly enrolling durable medical equipment, prosthetics, orthotics, and supplies
(DMEPOS) suppliers. 42 C.F.R. § 424.518.
2
False Claims Act of 1863, 31 U.S.C. § 3729(a)(1)(A) (2011).

1

requirement of establishing intent must be met by a court of law and cannot be met through a data
collection effort alone. In addition, it would be infeasible to wait for the resolution of individual
legal proceedings to establish intent in the context of a large-scale data collection, particularly
when the goal is to produce a timely estimate of fraud. Although intent cannot be proven based on
an examination of secondary data sources, an estimate of the extent of probable fraud is possible.
This pilot defines a claim as “probable fraud” if a member of a Review Panel composed of
experienced health care fraud investigators determines that a review of the information
surrounding the claim uncovered sufficient evidence to warrant a referral to law enforcement for
further investigation of the provider’s conduct. The Review Panel will consult with health care
analysts, clinicians, and policy experts to aid the Review Panel members in their decision-making.
While law enforcement agencies may decline to investigate claims below a certain dollar amount,
the Review Panel will not take into account such constraints when evaluating each case. This
definition establishes a reasonable bar for the determination of “probable fraud,” given the gravity
of law enforcement involvement, and also initiates the formal process for a determination of actual
fraud, which only law enforcement can make.
The Review Panel will make probable fraud determinations for a random sample of home health
claims that are selected for this pilot. To make these determinations, the Review Panel will rely on
several sources of evidence related to each sampled claim. One of the most important sources is
the set of completed interview instruments for the sampled beneficiary, home health agency, and
referring provider listed on the claim; these instruments are described in greater detail below.
In addition to the completed interview instruments, the Review Panel will rely on collected
documentation related to the sampled claim and on observations made by the interviewers during
their visit with their interview subjects. The Review Panel also considers a summary of the
service history of the HHA, the referring provider, and the beneficiary, and information about
whether the sampled HHA or referring provider is the subject of an active investigation by law
enforcement agencies.
The pilot will use Review Panel findings to calculate a national estimate of probable fraud in
Medicare fee-for-service home health services. Weights derived from the sampling procedure will
be used to translate the results from the sample into results that represent the population of home
health claims. The pilot will estimate the percentage of total payments that are associated with
probable fraud and the percentage of all claims that are associated with probable fraud.
Interview Instruments Overview
The interview instruments under consideration in the current PRA submission are designed to
answer four questions related to the claims sampled for this pilot:
•
•

Was the service indicated on the claim provided to the beneficiary?
Was the service medically necessary?

2

•
•

Was the beneficiary eligible to receive the service?
Is there evidence of intent to defraud Medicare on the part of the HHA and/or the referring
provider?

This pilot will use three different instruments to conduct interviews with the three primary parties
identified on the home health claim: the beneficiary3, the HHA, and the referring provider. CMS
will send trained interviewers with knowledge of the Medicare program and experience in
investigating fraud to conduct unannounced interviews with the beneficiaries and HHAs listed on
the sampled claim. The pilot uses unannounced interviews to reduce the opportunity for
fraudulent providers to alter or fabricate records or to coach the beneficiary in answering
questions. CMS will conduct scheduled interviews with the referring providers listed on the
sampled claims; half of these interviews will be conducted in person, and half will be conducted
by phone.
CMS developed each of the three instruments for this pilot based on extensive consultation with
experts in Medicare home health benefit policy and fraud investigation. The instruments contain
questions for the interview subjects as well as requests to collect documentation related to the
services provided on the sampled claim. The collected documentation includes provider
operational documentation and beneficiary medical records. The interviews will be conducted by
personnel with experience interviewing Medicare beneficiaries and providers, and the interviewers
will be trained to follow a set of interview protocols developed for this pilot.
Future Activities Following Completion of Pilot
CMS plans for activities following completion of the pilot are conditional on two factors: i) the
results of the pilot and ii) lessons learned about the logistics of pilot implementation.
CMS will utilize the results of the pilot to inform future fraud prevention and detection activities.
CMS will compare the baseline rate probable fraud rate calculated during the pilot to future
probable fraud estimates to track the change in the level of probable fraud over time. Additionally,
while the pilot does not have sufficient sample size to calculate statistically significant differences
across regions, CMS will use pilot data as an informal information source about the regional
distribution of fraud. CMS will also utilize pilot data to identify new fraud schemes and
incorporate this knowledge into future fraud prevention and detection efforts. Finally, CMS will
use evidence of fraudulent activity uncovered during the investigation to either open investigations
or make referrals to law enforcement.
Moreover, CMS will utilize the lessons learned during implementation of the pilot to inform future
efforts at fraud estimation. Based on the experience of conducting the pilot, CMS may choose to
move forward with additional implementations of the pilot focused on probable fraud in durable
medical equipment (DME) and other service areas. Additionally, CMS may use lessons learned
3 In cases when the beneficiary is unable to respond due to cognitive impairment, death, or another factor, the
interviewer will seek out a proxy, such as a family member or other caregiver, to complete the interview.

3

during the pilot to revise the pilot design to improve its effectiveness.
CMS will evaluate the pilot according to several criteria to decide whether to adopt the pilot as an
ongoing probable fraud measurement strategy going forward. First, CMS will consider feasibility,
determining whether the data collection procedures were successful in generating a high response
rate and in collecting the information necessary to aid the Review Panel in making a probable
fraud determination. Second, CMS will review the pilot’s precision, tracking the share of probable
fraud cases over time that result in a legal determination of actual fraud and/or action by law
enforcement or Medicare contractors against the provider in question. Finally, CMS will assess
the pilot’s replicability, testing whether future implementations produce consistent estimates of
probable fraud.
B. Justification
1.

Need and Legal Basis

The Probable Fraud Measurement Pilot aims to establish an estimate of the amount of probable
fraud in the Medicare fee-for-service home health benefit. CMS will use this estimate as a
baseline to measure the relative effectiveness of initiatives or programs intended to prevent fraud.
The statutory authority for the pilot is section 1893 of the Social Security Act (“the Act”), 42
U.S.C. 1395ddd, entitled, “Medicare Integrity Program.” In pertinent part, this section of the Act
requires the Secretary of the Department of Health and Human Services (HHS) to promote the
integrity of the Medicare program by entering into contracts with private organizations, or
otherwise, to carry out the following activities:
Review of activities of providers of services or other individuals and entities furnishing
items and services for which payment may be made under this title (including skilled
nursing facilities and home health agencies), including medical and utilization review and
fraud review (employing similar standards, processes, and technologies used by private
health plans, including equipment and software technologies which surpass the capability
of the equipment and technologies used in the review of claims under this title as of the
date of the enactment of this section).4
2.

Information Users

The Review Panel selected for the pilot will use the information collected via the interview
instruments, along with the collected supporting documentation and interviewer observations, to
aid in determining whether each of the sampled claims represents probable fraud. The personnel
conducting the interviews, the Zone Program Integrity Contractors (ZPICs), may use evidence of
4

Section 1893(b)(1) of the Social Security Act, 42 U.S.C. 1395ddd(b)(1).

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fraudulent activity obtained during data collection to initiate an investigation. HHS staff will
subsequently use information obtained from the pilot to improve fraud prevention and detection
efforts and to design future fraud measurement efforts in other Medicare service areas.
3.

Use of Information Technology

The administration of the interview instruments to Medicare beneficiaries, HHAs, and referring
providers cannot be made entirely electronic. Unannounced interviews and in-person observation
are essential to the success of the pilot. For these reasons it would not be feasible to conduct
interviews via an online survey or other electronic administration method to minimize burden.
Depending on resource availability, some interviewers may use electronic Adobe Acrobat PDF
fillable versions of the instruments stored on laptops or other devices to record responses, and
others may use paper versions.
Interviewer observations and on-site visits are essential to the success of the pilot. Observations
recorded by the interviewer during the beneficiary visit provide valuable information to be used by
the Review Panel in making their determination of probable fraud. The interviewer notes will
include but not be limited to: the beneficiary’s apparent cognitive abilities, mobility, and other
conditions that would inform the beneficiary’s eligibility for services.
Interviews with HHAs must be conducted in person in order to limit the opportunity for the
provider to alter or fabricate medical records and other documentation. Interviewer observations
also provide important information for the Review Panel. During the visit, the interviewer will
assess whether the HHA has an appropriate record-keeping system and reasonable staffing levels.
Additionally, the interviewer will identify evidence of document alteration, duplication, or
fabrication, indicators of an irregular relationship between the HHA and either the referring
provider or the beneficiary, as well as other potential indicators of intent to defraud.
For referring provider interviews, CMS believes that interviewer observations could aid the
Review Panel in making a probable fraud determination, but the marginal benefit of conducting
these interviews in person compared to over the phone is unknown. Since half of the sampled
claims will include an on-site visit to the referring provider and half will include administration of
the interview instrument by phone with documentation collected by mail, CMS will be able to use
the pilot to determine the marginal benefit of conducting these interviews in person, which may
impact future pilots. If the benefit is low, CMS may determine that future fraud measurement
efforts may include interviews of referring providers by phone or by other means.
For all of these reasons, the information collection cannot be completed electronically. This would
remain the case even if CMS had the capability of accepting electronic signatures.
4.

Duplication of Efforts

This information collection does not duplicate any other effort and the information cannot be
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obtained from any other source.
5.

Small Businesses

This pilot requires collection of financial and operational documentation from medical providers
that may be designated as small businesses. CMS has estimated that 98 percent of HHAs are small
businesses.5 To mitigate the burden on small businesses, documentation for all HHAs will be
collected during a single unannounced on-site visit. The interviewer will scan or copy the required
documentation, which will reduce the burden on the HHA. Similarly, for half of the sampled
claims, documentation will also be collected from the referring provider via on-site visits. Unlike
site visits to HHAs, visits to referring providers may be scheduled in advance for a time that is
convenient to the provider. For the other half of the sample, documentation must be collected via
mail, meaning the referring provider will be responsible for assembling and mailing all required
documentation either by paper or electronic media (i.e., CD or DVD). This is necessary to allow
researchers to determine the relative effectiveness of in-person versus telephone interviews for
referring providers for the purpose of measuring probable fraud. The pilot reduces the burden on
both HHAs and referring providers by requesting documentation related only to one recent claim.
This pilot does not burden HHAs or referring providers with any additional documentation
maintenance requirements beyond what these providers already observe as required by Medicare
regulations and/or in accordance with accepted HHA or provider record-keeping practices. The
Code of Federal Regulations (42 CFR 424.516(f)) requires both HHAs and referring providers to
maintain documentation related to the provision of or referral to home health services for seven
years and to make such documentation available to CMS or a Medicare contractor upon request.
Section 1833(e) of the Social Security Act states that providers of health services must furnish
“information as may be necessary in order to determine the amounts due” to receive payment for
services provided to Medicare beneficiaries.
6.

Less Frequent Collection

CMS may repeat this information collection in future years based on the success of the pilot, but
few beneficiaries, HHAs, or referring providers in the pilot sample are likely to face an added
burden as a result of any future information collection activities because the sample size is small
relative to the population of beneficiaries, HHAs, and referring providers. The probability that any
beneficiary, HHA, or referring provider in the pilot sample will be selected for an interview in
future years is well under 0.01 percent.
The information provided to CMS via this information collection is necessary to establish an
estimate of the amount of probable fraud in fee-for-service home health payments in the Medicare
program. Lack of this information hinders CMS’s ability to evaluate the relative effectiveness of
programs and initiatives intended to prevent home health Medicare fraud. In addition, if the
5

Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2012, 76 FR 68526,
68601 (Nov. 4, 2011).

6

information collection does not take place CMS will be unable to complete the pilot and to use
that information to inform the design and implementation of potential future initiatives to estimate
the level of fraud in other Medicare services.

7.

Special Circumstances

There are no special circumstances associated with this collection.

8.

Federal Register/Outside Consultation

A Technical Expert Panel (TEP) was convened on August 10, 2011 to provide feedback on
sampling methods, instrument development, interview protocol design, and the general application
of survey methods to health care services and fraud measurement. The TEP consisted of seven
panelists external to CMS with expertise in large government health care surveys, statistical
properties of survey sampling methods, instrument development and protocol design, and fraud
investigation and measurement. During the TEP, these panelists were given the opportunity to
discuss and offer feedback on the details of the Probable Fraud Measurement Pilot design.
In addition, personnel from the HHS OIG and contractors with expertise in Medicare home health
benefit policy and fraud investigation were consulted regarding interview protocols and the content
of the instruments used to interview HHAs, referring providers, and beneficiaries. These experts
confirmed that the instruments collect information necessary to make a determination on whether
the service billed corresponds to the service provided, whether that service was medically
necessary, and whether the beneficiary was eligible to receive the service.
CMS did not consult representatives of those from whom the information is to be obtained. This
pilot requires collection of documentation from HHAs and beneficiaries, neither of whom will
receive advance notice of the collection. Unannounced visits and interviews are crucial to this
pilot to reduce the opportunity for fraudulent providers to alter or fabricate records or to coach the
beneficiary in answering questions.
A 60-day notice published in the Federal Register on February 5, 2016 (81 FR 6275). CMS
received two comments. A 30-day notice will publish in the Federal Register on _________.
9.

Payments/Gifts to Respondents

There are no payments or gifts to respondents.
10. Confidentiality
CMS will comply with all Privacy Act, Freedom of Information laws and regulations that apply to
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this collection. Privileged or confidential commercial or financial information is protected from
public disclosure by Federal law 5 U.S.C. 522(b)(4) and Executive Order 12600.
The confidentiality of beneficiaries’ medical information will be protected in compliance with the
Health Insurance Portability and Accountability Act of 1996 (HIPAA).
11. Sensitive Questions
There are no sensitive questions.
12a. Burden Estimates (Hours & Wages)
For each of the 2000 claims in the sample, investigators will conduct interviews with the
beneficiary, staff from the HHA, and the referring provider. Estimating the total burden in hours
and wages for this information collection requires (i) estimating the burden for each of these three
separate groups of interview subjects, and (ii) summing each of these estimates to produce a total
burden estimate. Because the interview instruments have only been used in practice for the nine
claims in the pilot field test (described in Statement B), there is uncertainty in the estimates of the
duration of each interview. To account for this uncertainty, each of the hour and wage burden
estimates below includes a lower and upper bound as well as an average of the two. The wage
burden estimates rely on data from the Bureau of Labor Statistics (BLS) May 2014 National
Industry-Specific Occupational Employment and Wage Estimates.
Beneficiary Interview Hour and Wage Burden
Based on the results of the pilot field test as well as interviews with subject matter experts (SMEs),
interviews with beneficiaries are expected to take from 0.25 to 1 hour, with an average duration of
0.625 hours.6 To calculate the estimated total hour burden for all beneficiaries in the sample the
individual hour burden estimates are multiplied by 2000. The estimated hour burden per
beneficiary as well as the estimated hour burden for the entire sample of beneficiaries is presented
in Table 1.
Table 1: Beneficiary Burden Estimate in Hours
Upper Bound
Individual Beneficiary Hour
Burden

1

6

The initial field test of the pilot conducted by the Center for Program Integrity (CPI) Los Angeles Field Office found
that interviews took an average of 0.25 hours, but SMEs with experience in home health fraud detection reported that
such interviews may take about an hour. Given the small sample size of the initial field test and the minimal training in
the pilot instruments given to interviewers in the Los Angeles Field Office, CMS is treating the time estimate from the
initial field test as a lower-bound estimate and using the estimates from the SMEs as an upper bound.

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Total Beneficiary Hour Burden
(Indi. Burden x 2000 Claims)

2000

The beneficiary wage burden is calculated using an estimated wage of $21.05 per hour, which is
the BLS mean hourly wage for all occupations. This hourly wage burden may overestimate the
cost to the beneficiary, since many home health beneficiaries may be out of the labor force.
However, there may be some beneficiaries who are employed, and there may also be beneficiary
caregivers who participate in the interviews (for beneficiaries who are cognitively impaired or
otherwise unable to respond) and who are employed. Multiplying this wage by the hour burdens
reported in Table 1 produces estimates of the wage burden per beneficiary as well as for all
beneficiaries in the sample. The beneficiary wage burden estimates are reported in Table 2.

Table 2: Beneficiary Burden Estimate in Wages
Total with Fringe Benefits
Occupational Code 31-1011
Individual Beneficiary Wage
Burden (Individual Hour
Burden x $21.35)
$21.05
Total Beneficiary Wage
Burden (Total Hour Burden x
$21.35)
$42,100.00

The hour and wage burden to the beneficiaries is estimated based on the following assumptions:
• Beneficiaries only need to answer questions to the best of their recollection.
• The instruments are completed by trained and experienced CMS and contractor staff, rather
than the beneficiary.
• Beneficiaries are not required to maintain additional records to support this information
collection.
HHA Interview Hour and Wage Burden
Based on the results of the pilot field test as well as interviews with SMEs, interviews with HHAs
are expected to take from between one to two hours, with an average duration of 1.5 hours. To
calculate the total hour burden for all HHAs in the sample the individual hour burden estimates are
multiplied by 2000. The estimated hour burden per HHA as well as the estimated hour burden for
the entire sample of HHAs is presented in Table 3.

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Table 3: HHA Burden Estimate in Hours
Upper Bound
Individual HHA Hour Burden

2

Total HHA Hour Burden
(Individual Burden x 2000
Claims)

4000

The wage burden estimates for HHAs rely on BLS wage data for occupations listed under NAICS
621600 – Home Health Care Services. The estimated wage for HHA staff interviewed for the pilot
is $92.78 per hour. This wage is the average of the mean hourly wages of three different BLS
home health occupation categories: General and Operations Manager, Administrative Services
Manager, and Medical and Health Services Manager. These occupation categories were selected
based on feedback from the interviewers who conducted the pilot field test. Multiplying this wage
by the hour burden estimates reported in Table 3 produces the wage burden estimates for
individual HHAs as well as for all of the HHAs in the sample, reported below in Table 4.

Table 4: HHA Burden Estimate in Wages
Occupational Codes 11-1021;
11-3011; 11-9111
Individual HHA Wage Burden
(Individual Hour Burden x
$92.78 )
Total HHA Wage Burden
(Total Hour Burden x $ 92.78)

Total with Fringe Benefits

$92.78
$371,120.00

The hour and wage burden to the HHAs is estimated based on the following assumptions:
• The home health agency interviews will be administered by trained and experienced CMS
and contractor staff.
• The estimated completion time includes the time spent by administrative staff locating and
collecting requested documentation.

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Referring Provider Interview Hour and Wage Burden
Based on the results of the pilot field test as well as interviews with SMEs, interviews with
referring providers are expected to create a burden both for the physician and for an administrative
staff member at each referring provider practice. Interviews with the physicians are estimated to
take between 0.75 to 2 hours, with an average interview duration of 1.375 hours. Additionally, the
administrative staff member is expected to spend between 0.167 and 0.333 hours collecting the
requested documentation, with an average documentation collection time of 0.25 hours. The total
hour burden estimate for the referring provider practice is the sum of the hour burden estimates for
the physician and administrative staff member. The hour burden estimates for individual referring
provider practices are reported in Table 5.
Table 5: Individual Referring Provider Practice Burden Estimate in Hours
Upper Bound
Physician Hour Burden
Administrative Staff Hour
Burden

2
0.333

Referring Provider Practice
Hour Burden (Physician Hour
Burden + Administrative Staff
Hour Burden)

2.333

The wage burden estimates for referring providers rely on BLS wage data for occupations listed
under NAICS 621100 – Office of Physicians. The estimated wage for physicians interviewed for
the pilot is $176.25 per hour, which is the mean hourly wage for the occupation category Family
and General Practitioners. The estimated wage for administrative staff that assemble
documentation is $32.17 per hour, which is the mean hourly wage for the occupation category
Administrative Services Manager. Multiplying these wages by the hour burden estimates reported
in Table 5 produces the estimated wage burden estimates for both the physician and administrative
staff member in a given referring provider practice, and the sum of those two estimates is the
estimated wage burden for each referring provider practice. The wage burden estimates per
referring provider practice are presented in Table 6.

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Table 6: Individual Referring Provider Practice Burden Estimate in Wages
Occupational Code 29-1062;
43-9199
Physician Wage Burden (Hour
Burden x $176.25)
Administrative Staff Wage
Burden (Hour Burden x
$32.17)

Total with Fringe Benefits
$176.25

$32.17

Referring Provider Practice
Wage Burden (Physician Wage
Burden + Administrative Staff
Wage Burden)

$ 208.42

Multiplying the referring provider practice hour and wage burden estimates reported in Table 5
and 6 respectively by 2000 claims produces hour and wage burden estimates for the entire sample
of referring provider practices. Those estimates are reported in Table 7.

Table 7: Total Referring Provider Practice Burden Estimate in Hours and Wages
Total with Fringe Benefits
Occupational Codes
Total Referring Provider
Practice Hour Burden
(Referring Provider Practice
Hour Burden x 2000 Claims)

4666

Total Referring Provider
Practice Wage Burden
(Referring Provider Practice
Wage Burden x 2000 Claims)

$ 972,487.72

The cost to referring providers is estimated based on the following assumptions:
• The referring provider interviews will be administered by trained and experienced CMS
and contractor staff, and
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•

The estimated completion time includes the time spent by administrative staff locating and
collecting requested documentation.

Total Hour and Wage Burden Estimates
The total hour and wage burden estimates for this information collection are the sum of the hour
and wage burden estimates for the three sets of interview subjects described above. Table 8
provides the total hour burden estimate for this information collection.
Table 8: Total Information Collection Hour Burden
Upper Bound
Total Beneficiary Hour Burden
Total HHA Hour Burden
Total Referring Provider Practice
Hour Burden

2000
4000
4666

Total Information Collection Hour
Burden

10666

Table 9 provides the total wage burden estimate for this information collection.

Table 9: Total Information Collection Wage Burden
Total with Fringe Benefits
Total Beneficiary Wage
Burden
Total HHA Wage Burden
Total Referring Provider
Practice Wage Burden

$42,100.00
$371,120.00
972,487.72

Total Information Collection
Wage Burden

$1,385,707.77

12b. Pre-Pilot Burden Estimates (Hours & Wages)
For each of the 130 claims in the pre-pilot sample, investigators will conduct interviews with the
beneficiary, staff from the HHA, and the referring provider, as in the full pilot. Estimating the
total burden in hours and wages for the pre-pilot requires (i) estimating the burden for each of
these three separate groups of interview subjects, and (ii) summing each of these estimates to
produce a total burden estimate. The process for completing these two steps is identical to the
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process for calculating the burden estimate for the full pilot (described above in Section 12).
Beneficiary Interview Hour and Wage Burden
As in the full pilot, interviews with beneficiaries are expected to take from 0.25 to 1 hour, with an
average duration of 0.625 hours. To calculate the estimated total hour burden for all beneficiaries
in the sample the individual hour burden estimates are multiplied by 130. The estimated hour
burden per beneficiary as well as the estimated hour burden for the entire sample of beneficiaries is
presented in Table 9.
Table 9: Pre-Pilot Beneficiary Burden Estimate in Hours
Upper Bound
Individual Beneficiary Hour
Burden
Total Beneficiary Hour Burden
(Individual Burden x 130
Claims)

1

130

The beneficiary wage burden is calculated using an estimated wage of $21.05 per hour, as in the
full pilot. Multiplying this wage by the hour burdens reported in Table 9 produces estimates of the
wage burden per beneficiary as well as for all beneficiaries in the pre-pilot sample. The
beneficiary wage burden estimates are reported in Table 10.
Table 10: Pre-Pilot Beneficiary Burden Estimate in Wages
Total with Fringe Benefits
Individual Beneficiary Wage
Burden (Individual Hour
Burden x $21.05)
Total Beneficiary Wage
Burden (Total Hour Burden x
$21.05)

$21.05

$2,736.50

HHA Interview Hour and Wage Burden
As in the full pilot, interviews with HHAs are expected to take from between one to two hours,
with an average duration of 1.5 hours. To calculate the total hour burden for all HHAs in the
sample the individual hour burden estimates are multiplied by 130. The estimated hour burden per
HHA as well as the estimated hour burden for the entire sample of HHAs is presented in Table 11.

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Table 11: Pre-Pilot HHA Burden Estimate in Hours
Upper Bound
Individual HHA Hour Burden

2

Total HHA Hour Burden
(Individual Burden x 130
Claims)

260

The estimated wage for HHA staff interviewed for the pilot is $92.78 per hour, as in the full pilot.
Multiplying this wage by the hour burden estimates reported in Table 11 produces the wage
burden estimates for individual HHAs as well as for all of the HHAs in the sample, reported below
in Table 12.
Table 12: Pre-Pilot HHA Burden Estimate in Wages
Total with Fringe Benefits
Individual HHA Wage Burden
(Individual Hour Burden x
$92.78 )
Total HHA Wage Burden
(Total Hour Burden x $ 92.78)

$185.56
$ 24,122.80

Referring Provider Interview Hour and Wage Burden
As in the full pilot, interviews with referring providers are expected to create a burden both for the
physician and for an administrative staff member at each referring provider practice. Interviews
with the physicians are estimated to take between 0.75 to 2 hours, with an average interview
duration of 1.375 hours. Additionally, the administrative staff member is expected to spend
between 0.167 and 0.333 hours collecting the requested documentation, with an average
documentation collection time of 0.25 hours. The total hour burden estimate for the referring
provider practice is the sum of the hour burden estimates for the physician and administrative staff
member. The hour burden estimates for individual referring provider practices are reported in
Table 13.

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Table 13: Pre-Pilot Individual Referring Provider Practice Burden Estimate in Hours
Upper Bound
Physician Hour Burden
Administrative Staff Hour
Burden

2
0.333

Referring Provider Practice
Hour Burden (Physician Hour
Burden + Administrative Staff
Hour Burden)

2.333

The estimated wage for physicians interviewed for the pilot is $176.25 per hour, and the
estimated wage for administrative staff that assemble documentation is $32.17 per hour, as in the
full pilot. Multiplying these wages by the hour burden estimates reported in Table 13 produces the
estimated wage burden estimates for both the physician and administrative staff member in a given
referring provider practice, and the sum of those two estimates is the estimated wage burden for
each referring provider practice. The wage burden estimates per referring provider practice are
presented in Table 14.
Table 14: Pre-Pilot Individual Referring Provider Practice Burden Estimate in Wages
Upper Bound
Physician Wage Burden (Hour
Burden x $86.09)
Administrative Staff Wage
Burden (Hour Burden x
$32.17)

$176.25

$32.17

Referring Provider Practice
Wage Burden (Physician Wage
Burden + Administrative Staff
Wage Burden)

$208.42

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Multiplying the referring provider practice hour and wage burden estimates reported in Table 13
and 14 respectively by 130 claims produces hour and wage burden estimates for the entire pre-pilot
sample of referring provider practices. Those estimates are reported in Table 15.
Table 15: Pre-Pilot Total Referring Provider Practice Burden Estimate in Hours and Wages
Upper Bound
Total Referring Provider
Practice Hour Burden
(Referring Provider Practice
Hour Burden x 130 Claims)

303

Total Referring Provider
Practice Wage Burden
(Referring Provider Practice
Wage Burden x 130 Claims)

$27,094.60

Total Hour and Wage Burden Estimates
The total hour and wage burden estimates for the pre-pilot sample are the sum of the hour and
wage burden estimates for the three sets of interview subjects described above. Table 16 provides
the total hour burden estimate for the pre-pilot sample.
Table 16: Total Pre-Pilot Hour Burden
Upper Bound
Total Beneficiary Hour Burden
Total HHA Hour Burden
Total Referring Provider
Practice Hour Burden

130
260
303

Total Information Collection
Hour Burden

693

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Table 17 provides the total wage burden estimate for the pre-pilot sample.
Table 17: Total Pre-Pilot Wage Burden
Upper Bound
Total Beneficiary Wage
Burden
Total HHA Wage Burden
Total Referring Provider
Practice Wage Burden

$2,736.50
$24,679.48
$27,094.60

Total Information Collection
Wage Burden

$54,510.58

13. Capital Costs
There is no annual cost burden to respondents or record keepers resulting from the collection of
information beyond that described in item 12. All records collected from HHAs and referring
providers are already maintained as required by 42 C.F.R. 424.516(f) paragraphs 1 and 2 and/or in
accordance with accepted HHA or provider record-keeping practices.
14. Cost to Federal Government
CMS estimates that data collection will cost the government between $3.6 million and $5.5
million depending on where the beneficiaries in the random selection are located in the country.
This estimate is based on the resources required to train interviewers, conduct the interviews, and
support the infrastructure for centralizing the information collected.
15. Changes to Burden
Because the Probable Fraud Measurement Pilot is a new initiative, this calculation is not
applicable.
16. Publication/Tabulation Dates
Specific information collected using the instruments will not be published. The resulting
measurements of probable fraud may be published in summary form.
17. Expiration Date
CMS would like to display the expiration date.

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