Probable Fraud Measurement Pilot (CMS-10406)

Forms and Documents

Document Name	Status
Form CMS-10406 Referring Providers Form and Instruction	Unchanged
Form CMS-10406 HHA's Form and Instruction	Unchanged
Form CMS-10406 Beneficiaries Form and Instruction	Unchanged
CMS-10406 - PRA Response to comments.docx Supplementary Document	2016-04-29
CMS-10406.Supporting Statement - Part B.docx Supporting Statement B	2016-04-29
CMS -10406 Supporting Statement Part A__41106 Pilot.pdf Supporting Statement A	2016-04-29

IC Document Collections

IC ID	Document Title	Status
203015	Referring Providers Form and Instruction	Unchanged
203014	HHA's Form and Instruction	Unchanged
203013	Beneficiaries Form and Instruction	Unchanged

ICR Details

OMB Control No: 0938-1192	ICR Reference No: 201604-0938-016
Status: Historical Inactive	Previous ICR Reference No: 201410-0938-011
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Probable Fraud Measurement Pilot (CMS-10406)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn	Conclusion Date: 02/17/2017
	Date Received in OIRA: 05/03/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved	02/28/2017
Responses	0	0	6,000
Time Burden (Hours)	0	0	7,500
Cost Burden (Dollars)	0	0	0

---

Abstract: The goal of this pilot is to develop the first nationally representative estimate of the extent of probable fraud in payments for home health care services in the fee-for-service Medicare program. The instruments will be used to conduct interviews with Medicare beneficiaries, home health agency (HHA) staff, and referring providers.

---

Authorizing Statute(s): US Code: 42 USC 1395ddd Name of Law: Medicare Integrity Program
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 6275	02/05/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 25673	04/29/2016
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Beneficiaries	CMS-10406	Instrument
HHA's	CMS-10406	Instrument
Referring Providers	CMS-10406	Instrument

---

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $4,550,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 05/03/2016

---