The Security Consent and Surrogate
Authorization form replicates business service agreements between
Medicare providers/suppliers and Surrogates providing enrollment
services. We are proposing one version of the Security Consent and
Surrogate Authorization Form. The form, once signed, mailed and
approved, grants a Surrogate access to all current and future
enrollment data for the Individual or Organization
Provider.
US Code:
42
USC 1395l(e) Name of Law: PAYMENT OF BENEFITS
US Code: 42
USC 1395m(j) Name of Law: SPECIAL PAYMENT RULES FOR PARTICULAR
ITEMS AND SERVICES
US Code: 42
USC 1395f(a) Name of Law: CONDITIONS OF AND LIMITATIONS ON
PAYMENT FOR SERVICES
US Code: 42
USC 1395g(a) Name of Law: PAYMENT TO PROVIDERS OF SERVICES
US Code: 42
USC 1395u(u) Name of Law: PROVISIONS RELATING TO THE
ADMINISTRATION OF PART B
US Code: 42
USC 1395u(r) Name of Law: PROVISIONS RELATING TO THE
ADMINISTRATION OF PART B
US Code:
42 USC 1395cc(j)(1)(C) Name of Law: AGREEMENTS WITH PROVIDERS
OF SERVICES; ENROLLMENT PROCESSES
PL:
Pub.L. 105 - 33 4313 Name of Law: The Balanced Budget Act of
1997
PL:
Pub.L. 104 - 134 31001(I) Name of Law: Debt Collection
Improvement Act of 1996
The burden has increased for
three reasons. The first is we are using more accurate data from
NPPES to estimate respondents who use the Security Consent and
Surrogate Authorization Form to complete and submit the form to
grant a surrogacy connection between two individuals or
organizations or between an individual and an organization. By
doing so, we have increased the number of respondents from 88,650
respondents to 226,100 respondents. This means our burden cost is
now $42,981,610 for these respondents. The second is the previous
estimate assumed that approximately 90 percent of individuals
(i.e., physicians, non-physician practitioners) and 50 percent of
organization providers and suppliers would use an entity other than
themselves to complete their Medicare enrollment application and
CMS therefore extended the assumption that approximately 90 percent
of individuals and 50 percent of organization providers and
suppliers would use an entity other than themselves to complete
their Security Consent and Surrogate Authorization Form. This has
been proven to be an incorrect assumption. NPPES currently reports
providers are the respondents who complete and submit the Security
Consent and Surrogate Authorization Form. In addition, it was
previously estimated that the Security Consent and Surrogate
Authorization Form took 15 minutes to complete. Using that figure,
the previous burden hour estimate was approximately 22,162 hours.
It is now estimated that completion and submission of this form
takes approximately one hour. That increases the burden hour
estimate by 203,938 hours (from 22,162 to 226,100 hours). Thirdly,
the wage data used in the previous estimates are not the same wage
data we currently use (now taken from the BLS wage tables). In the
previous version, the wage estimate was $20.00 per hour
(administrative wage) and $150.00 per hour (professional wage). Due
to the incorrect assumption of who the respondents were for this
form and the incorrect amount of time used to calculate the
completion and submission of this form, it was calculated that the
total cost for completing and submitting the Security Consent and
Surrogate Authorization Form was $1,421,250. Using the correct wage
data, number of respondents, and amount of time for completion and
submission of the Security Consent and Surrogate Authorization
Form, this increases the cost by $41,560,360 from $1,421,250 to
$42,981,610. Combined, the increase in burden hours is 203,938
(from 22,162 to 226,100 hours) and the increase in cost is
$41,560,360 (from $1,421,250 to $42,981,610). The combined increase
in the number of respondents is 137,450 (from 88,650 to
226,100).
$0
No
No
No
No
No
No
Uncollected
Jamaa Hill 301 492-4190
No
On behalf of this Federal agency, I certify that
the collection of information encompassed by this request complies
with 5 CFR 1320.9 and the related provisions of 5 CFR
1320.8(b)(3).
The following is a summary of the topics, regarding
the proposed collection of information, that the certification
covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a
benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control
number;
If you are unable to certify compliance with any of
these provisions, identify the item by leaving the box unchecked
and explain the reason in the Supporting Statement.
Form CMS-10220 Security Consent and Surrogate Authorization Form - Providers
CMS-10220 - Crosswalk.xlsx
CMS-10220 - Supporting Statement PECOS Final.docx
Security Consent and Surrogate Authorization Form - Providers