Supporting Statement – Part A
Request for Certification in the Medicare/Medicaid Program for Providers of Outpatient Physical Therapy and/or Speech-Language Pathology Form CMS-1856
A. BACKGROUND
This is a request to reinstate CMS-1856, Request for Certification in the Medicare/Medicaid Program to Provide Outpatient Physical Therapy and/or Speech-Language Pathology Survey Report Form. This form implements 42 CFR 485.701-485.729, Conditions of Participation for Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and/or Speech-Language Pathology Services.
Surveyors are no longer required to use CMS-1893, Outpatient Physical Therapy-Speech Pathology Survey Report form. Surveyors are now able to access survey resources electronically from the ASPEN database, as a result, the need for surveyors to carry printed copies of the survey information data is no longer efficient. Given this improvement in survey process, there is no need to reinstate form CMS-1893.
B. JUSTIFICATION
1. Need and Legal Basis
This activity is authorized by Title XVIII of the Social Security Act, Section 1861(p). The collection of this information is authorized by 42 CFR Part 485.701-485.729 pursuant to Sections 1864 and 1875 of the Social Security Act requiring that providers and suppliers of services to Medicare beneficiaries meet such requirements as the Secretary finds necessary to ensure the health and safety of individuals who are furnished such services. For Medicare purposes, certification is based on the State survey agency’s reporting of a provider’s or supplier’s compliance or noncompliance with the health and safety requirements published in federal regulations. To determine compliance with these requirements, the Secretary has authorized CMS to contract with State survey agencies to conduct surveys of providers and suppliers.
Form CMS-1856, Request for Certification in the Medicare/Medicaid Program to Provide Outpatient Physical Therapy and/or Speech-Language Pathology, is utilized as an application to be completed by providers of outpatient physical therapy and/or speech-language pathology services requesting participation in the Medicare/Medicaid programs. This form initiates the process of obtaining a decision as to whether the conditions of participation are met as a provider of outpatient physical therapy and/or speech-language pathology services. The form is used by the State Agencies (SAs) to enter the new provider into the ASPEN (Automated Survey Process Environment) database.
2. Information Users
The information from the form CMS-1856 is used by CMS in making certification decisions. The information on the form serves as a screen for the State agency to determine if the provider of outpatient physical therapy and/or speech-language pathology services has the basic capabilities to participate in the program, and whether a survey is appropriate. The basic identifying information from this form is coded into the Aspen database and serves as the information base for the creation of a record for future Federal certification and monitoring activity.
3. Use of Information Technology
Providers are able to access form CMS-1856 electronically. The survey form lists minimum criteria that must be met in order to be approved as a provider of outpatient physical therapy and speech-language pathology services for Medicare participation. The standardized format and simple checkbox method provide for consistent reporting by State survey agencies. Recording this information would be no easier for State surveyors using direct access equipment.
4. Duplication and Similar Information
The application form does not duplicate any information collection. The form address specific requirements for certification as a provider of outpatient physical therapy and speech-language pathology services.
5. Small Business
It is anticipated that the majority of providers affected by this information collection will be small businesses. The information collected is the minimum required in order to participate in the Medicare program as a provider of outpatient physical therapy and/or speech-language pathology services.
6. Less Frequent Collection
The form is required to be completed only once.
7. Special Circumstances for Information Collection
There are no special circumstances for this information collection.
8. Federal Register and Outside Consultation
The 60-day Federal Register notice published on February 7, 2018 (83 FR 5427). There were no comments received.
The 30-day Federal Register notice published on April 13, 2018 (83 FR 16103).
9. Payment/Gifts to Respondent
There are no payments or gifts involved in this information collection.
10. Confidentiality
Information collected will be utilized by CMS and its agents for certification and enforcement actions. This information is publicly disclosable. The information collection does not include collection of social security number. However, any identifiable data subject to the Privacy Act is deleted prior to disclosure.
11. Sensitive Questions
There are no questions of a sensitive nature on the form.
12. Estimate of Burden (Hours & Wages)
Form CMS-1856 is completed by a prospective provider requesting to participate in the Medicare program and existing providers at the time of resurvey. We estimate based on the simplicity of the form and past usage that it will take approximately 15 minutes to complete the form. This time includes 5 minutes to read the instructions, 5 minutes to compile information, and 5 minutes of clerical time. We anticipate this form to be completed by the equivalent of an Administrative Services Manager with a mean hourly wage $47.56, excluding fringe benefits, based on the 2016 Bureau of Labor Statistics National Occupational Employment and Wage Estimates (https://www.bls.gov/oes/2016/may/oes113011.htm). We estimate this form will be completed 350 times annually at a cost of $11.89 per provider. The total annual hours and cost for is 88 hours (350 providers X .25 hours) and $4,161.50.
13. Capital Cost of Burden
There are no capital costs associated with this collection.
14. Federal Cost Estimates
All costs associated with completion of form CMS-1856 are incurred by the provider of outpatient physical therapy and speech-language pathology services.
15. Changes in Burden/Program Changes
The burden adjustment results from increase in the estimated hourly wage of workers completing these forms. We have updated the hourly wage to reflect anticipated cost that is based on data from the Bureau of Labor Statistics National Occupational Employment and Wage Estimates for May, 2016. For form CMS-1856, we are using the average hourly wage of $47.56 per hour for an Administrative Services Manager. Overall, these adjustments have increased the cost burden due to a change in the hourly wage. The total burden hours decreased from 613 hours to 88. This is due to the deletion of Form CMS-1893 from this information collection.
16. Publication and Tabulation Dates
There are no publication and tabulation dates associated with this collection.
17. OMB Expiration Date
CMS will display the expiration date.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | CMS |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |