CMS-1856 Supporting Statement (CLEAN 6-1-21)

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 extend 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-1856, Outpatient Physical Therapy-Speech Pathology Survey Report form. Surveyors are now able to access survey resources electronically from the national surveyor database, as a result, the need for surveyors to carry printed copies of the survey information data is no longer efficient.

Providers of Outpatient Physical Therapy and/or Speech-Language Pathology are required to complete this form for initial enrollment and recertification.

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 prospective provider into the national surveyor database. The form is also used for recertification of the provider.

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 national surveyor 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 the prospective providers. State surveyors enter the information into the national surveyor database directly into corresponding fields which have been made available in their technology system.

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 June 4, 2021 (86 FR 30049). There were two public comments received but they were out of the scope of the information collection.

The 30-day Federal Register notice published on August 13, 2021 (86 FR 44730).

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. The average new OPTs per year is 76. Additionally, there are approximately 119 recertification surveys of existing OPTs per year.

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 a Healthcare Support Staff (Healthcare Support Occupations) with a mean hourly wage of $15.50 which is$31.00, including fringe benefits, based on the 2020 Bureau of Labor Statistics National Occupational Employment and Wage Estimates (https://www.bls.gov/oes/current/oes_stru.htm#00-0000).

We estimate this form will be completed 195 times annually, based on the average new prospective providers enrolling as Medicare-certified OPTs and recertification of existing providers to complete the form in 15 minutes

Therefore, the total annual hours is 49 (195 providers X .25 hours) and total cost for is $1,519.00 (49 hours X $31).

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 decrease 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, 2020. For form CMS-1856, we are using the average hourly wage of $31.00 per hour for a healthcare support staff (Healthcare Support Occupations). We have adjusted the individual completing this form to be an administrative support person, not a manager. Overall, the adjustments have decreased the cost burden based on these changes and based on our analysis that approximately 195 OPT/OSP providers which completed this form annually (initial and recertification surveys).

The respondents decreased from 350 to 195.

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.

18. Certification Statement

There are no exceptions to this certification.

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