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