CMS-10287 Supporting Statement - Final 5-10-17

Supporting Statement – Part A

Medicare Quality of Care Complaint Form (CMS-10287)

_0938-1102

_{A. Background}

Since 1986, Quality Improvement Organizations (QIO) have been responsible for conducting appropriate reviews of written complaints submitted by beneficiaries about the quality of care they have received. In order to receive these written complaints, each QIO has developed its own unique form on which beneficiaries can submit their complaints. CMS has initiated several efforts aimed at increasing the standardization of all QIO activities, and the development of a single, standardized Medicare Quality of Care Complaint Form beneficiaries can use to submit complaints is a key step towards attaining this increased standardization.

_{B. Justification}

_{1. Need and Legal Basis}

In accordance with Section 1154(a)(14) of the Social Security Act, Quality Improvement Organizations (QIOs) are required to conduct appropriate reviews of all written complaints submitted by beneficiaries concerning the quality of care received. This is a standard form for all beneficiaries to utilize and ensure pertinent information is obtained by QIOs to effectively process these complaints.

2. Information Users

The Medicare Program works to ensure that beneficiaries get the best care possible. The Medicare Quality of Care Complaint Form will be used to ensure that we process your concerns in an efficient manner. Quality Improvement Organizations (QIOs) , are under contract with Medicare and are required to conduct reviews of all written and or emailed complaints from beneficiaries about the quality of services not meeting professionally recognized standards of health care.

_{3. Use of Information Technology}

The Medicare Quality of Care Complaint Form (Complaint Form) is a paper form that is mailed to Medicare beneficiary once he/she contacts the Quality Improvement Organization (QIO) in order to file a written beneficiary complaint. The beneficiary is required to sign the Complaint Form in order to consent for the QIO to conduct its Quality of Care review and issue a formal determination. Currently, the Complaint Form is not available for electronic submission. However, if CMS has the capacity to accept electronic signature(s), this collection could be submitted electronically.

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 Businesses}

This collection does not impact small businesses.

6. Less Frequent Collection

This is a voluntary form. Medicare beneficiaries are required to fill out this form in order to give the Quality Improvement Organization (QIO) consent to conduct its Quality of Care review. If the beneficiary chooses not to fill out the Medicare Quality of Care Complaint form, the QIO is not authorized by the beneficiary to conduct the Quality of Care review investigation and render a formal decision.

In addition, the QIO is required to obtain the beneficiaries written consent in order to disclose the beneficiary’s personal information (address and/or telephone number) to the entity, that conducts beneficiary satisfaction surveys. See 42 CFR § 480.132. The entity that conducts beneficiary satisfaction surveys will mail the beneficiary a survey in order to determine the beneficiary’s level of satisfaction with the level of service the beneficiary received from the QIO. If the beneficiary does not wish to receive a satisfaction survey, they may check “no” on the Medicare Quality of Care Complaint form.

_{7. Special Circumstances}

There are no special circumstances associated with this information collection request.

8. Federal Register/Outside Consultation

_{The 60-day Federal Register notice published on September 8, 2016 (81 FR 62140). There were no comments received.}

_{The 30-day Federal Register notice published on November 16, 2016 (81 FR 80665). There were no comments received.}

_{9. Payments/Gifts to Respondents}

Respondents will not receive any payments or gifts as a condition of complying with this information collection request.

10. Confidentiality

The information collected will be kept confidential to the extent provided by law. CMS will not disclose any confidential patient information unless authorized to do so by section 42 CFR

480.132 entitled “Disclosure of information about patients” or section 42 CFR 480.135 entitled “Disclosure necessary to perform review responsibilities.”

11. Sensitive Questions

_{There are no sensitive questions associated with this information collection request.}

_{12. Burden Estimates (Hours & Wages)}

Provide estimates of the hour burden and wages of the collection of information. The statement should:

CMS receives approximately 4,350 beneficiary complaints each year. This form is one page and requests commonly provided identification information as well as a short summary of the beneficiary complaint. Typically, we do not receive more than one response per respondent per year. We estimate that it would take a respondent no more than 10 minutes to complete this form. Therefore, we estimate the total annual burden associated with this information collection request to be 725 hours (.16666 X 4,350).

We determined the average hourly rate for the individual responsible for collecting the benefit complaint form. The professional and analytical skills required to perform this function are similar to those of office and administrative support occupations with an hourly wage of $17.47. To account for fringe benefits and overhead costs, the adjusted hourly rate for this position is $34.94. We then multiplied this adjusted hourly rate ($34.94) by the number of hours for data collection (725 hours) to arrive at the annual wage burden of $25,332 per year.

13. Capital Costs

There are no capitals costs associated with these information collection requirements.

_{14. Cost to Federal Government}

All Federal costs associated with this rule will be incurred by CMS through their contracts with QIOs

15. Changes to Burden

There are no changes associated with burden.

16. Publication/Tabulation Dates

CMS does not plan to publish this data. The data is for CMS internal use.

17. Expiration Date

CMS will display the expiration date.

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