Supporting Statement For
Provider Cost Report Reimbursement Questionnaire
and Supporting Regulations
Form CMS-339
A. Background
The purpose of Form CMS-339 is to assist the provider in preparing an acceptable cost report and to minimize subsequent contact between the provider and its Medicare Administrative Contractor (MAC). Form CMS-339 provides the basic data necessary to support the information in the cost report.
Exhibit 1 of the Form CMS-339 contains a series of reimbursement-oriented questions which serve to update information on the operations of the provider. It is arranged topically regarding financial activities such as independent audits, provider organization and operation, etc. The MAC responsible for the settlement of the Medicare cost report must determine the reasonableness and the accuracy of the reimbursement claimed. This process includes performing both, a desk review of the cost report and an analysis leading to a decision to settle the cost report with or without further audit. Form CMS-339 provides essential information to enable the MAC to make the audit/no audit decision, scope the audit if one is necessary, and to update the provider documentation (i.e., documentation to support the financial profile of the provider). If the information is not collected, then the MAC will have to go onsite to each provider to get this information. Consequently, it is far less burdensome and extremely cost effective to capture this information through the Form CMS-339.
Exhibit 2 is a listing of bad debts pertaining to uncollectible Medicare deductible and coinsurance amounts. Preparation of the listing is a convenient way for providers to supply the MAC with information needed to determine the allowability of the bad debts for reimbursement. Some items required to determine allowability that are included on this exhibit are patient’s name, dates of service, date first bill sent to beneficiary, and date the collection effort ceased. Supplying the MAC with this information may be all that is required for the MAC to determine whether or not the bad debt is allowable. This may eliminate a visit to the provider to gather this needed data.
Summary of the General Purposes of Each Exhibit in Form CMS-339:
Exhibit 1 - Provider Cost Report Reimbursement Questionnaire--Its purpose is to assist the provider in preparing an acceptable cost report, and to minimize direct contact between the provider and its MAC. The questionnaire is designed to answer pertinent questions about key reimbursement concepts relative to the Medicare cost report. Example - Questions regarding whether an independent audit had been performed will prevent duplication of work. It provides an update to the MAC’s permanent file that, in turn, completes the profile on that provider which is a valuable tool in scoping the audit.
Exhibit 2 - Listing of Medicare Bad Debts and Appropriate Supporting Data-- This exhibit requests a listing of bad debts and appropriate supporting data. Submission of this listing may provide the MAC with sufficient information upon which to base the acceptability of the bad debts claimed on the cost report without the necessity of an onsite visit.
We are currently working on elimination of Form CMS-339 and inclusion of the applicable questions on the individual cost report forms. To date, Form CMS-339 has been incorporated in the Form CMS-2552-10 (Hospital cost report), Form CMS-2540-10 (SNF cost report), Form CMS-265-11 (ESRD cost report), Form CMS-1984-14 (Hospice cost report), Form CMS-224-14 (Federally Qualified Health Center cost report), and Form CMS-1728-94 (HHA cost report). Because of the time required to include the questions in each of the remaining cost report reports, we are requesting a 3-year extension of the Form CMS-339 at this time.
B. Justification
1. Need and Legal Basis
The information collected in this form (Exhibits 1 and 2) is authorized under Sections 1815(a) and 1833(e) of the Social Security Act, 42 USC 1395g. Regulations at 42 CFR 413.20 and 413.24 require providers to submit financial and statistical records to verify the cost data disclosed on their annual Medicare cost report. Providers participating in the Medicare program are reimbursed for furnishing covered services to eligible beneficiaries on the basis of an annual cost report (filed with the provider's MAC) in which the proper reimbursement is computed.
Consequently, it is necessary to collect this documentation of providers’ costs and activities that supports the Medicare cost report data in order to ensure proper Medicare reimbursement to providers.
2. Information Users
Form CMS-339 must be completed by all Community Mental Health Centers (CMHC), Rural Health Clinic (RHC), and Organ Procurement Organization (OPO) providers that submit full cost reports to the Medicare MAC under Title XVIII of the Social Security Act. It is designed to answer pertinent questions about key reimbursement concepts found in the cost report and to gather information necessary to support certain financial and statistical entries on the cost report. The questionnaire is used by the MACs as a tool to help them arrive at a prompt and equitable settlement of those three types of provider cost reports and sometimes preclude the need for a comprehensive on-site audit. Since the Provider Cost Report Reimbursement Questionnaire is in reality a supporting statement of the CMS-2088 (Medicare CMHC Cost Report) OMB No. 0938-0037; CMS-222 (Medicare RHC Cost Report) OBM No. 0938-0107; and Form CMS-216 (Medicare OPO Cost Report) OMB No. 0938-0102 it also must be furnished on an annual basis.
3. Improved Information Technology
The processing of reimbursement questionnaire data through an electronic medium is in process. At the present time, we have approved several software packages to process the CMS-339. However, we are still requiring the submittal to be only in hard copy because we have not yet completed uniform specifications to be used by all software vendors.
4. Duplication of Similar Information
There is no specific duplicate information collection instrument pertaining to supplemental cost report documentation. The information in Form CMS-339 provides more detailed information to support the amounts reported on the cost report. This form was developed to curtail any additional amount of information being placed on the cost report and to facilitate its review without the need for an on-site audit. Only one of the questions in Form CMS-339 relates to an issue (i.e., change of ownership) that is also addressed in Form CMS-855 (Provider Enrollment). However, this specific information from Form CMS-855 may not always be available at the time the cost report is desk-reviewed, meaning this information must be obtained from Form CMS-339. We will consider this issue again when we incorporate the Form CMS-339 into the cost report.
5. Small Businesses
To a large extent, this information collection does not involve small businesses. However, where it does, efforts have been made to streamline its format and clarify its instructions.
6. Less Frequent Collection
If this information were collected less frequently it would deny the Federal Government financial profile data. Furthermore, all data collected ties into the cost reporting year, so the Form CMS-339 must correlate to the annual submission of the cost report.
7. Special Circumstances
There are no special circumstances.
Federal Register Notice/Outside Consultation
The 60-day Federal Register notice published on July 15, 2016(81FR46080). The 30-day Federal Register notice published October 31, 2016(81FR75409).
9. Payments/Gifts to Respondents
There were no payments/gifts to respondents.
10. Confidentiality
CMS does assure the confidentiality of information obtained through the Form CMS-339. However, we are informed by CMS's Privacy Act Officer that a Notice of System of Records encompassing this type of data already exists.
11. Sensitive Questions
This information collection does not contain any sensitive questions.
12. Burden Estimate (Total Hours & Wages)
Response time can vary depending on the type of provider and the size and complexity of the provider's operations. In addition, significant financial events (e.g., change of ownership) can also impact on response time. Exhibits 1 and 2 are required to be submitted by all the provider-types listed below that are filing full cost reports.
The number of respondents is calculated as follows:
CMHCs freestanding) 302
RHC (freestanding) 1,920
OPOs 51
Total number of respondents* 2,273
* Provider-based CMHCs, and RHC will have their Cost Report Reimbursement Questionnaire completed by the parent provider.
The breakdown of the Exhibit requirements and estimated hours to complete follow:
AVG. HOURS
EXHIBIT NUMBER OF TO COMPLETE TOTAL
NUMBER TO BE PREPARED BY RESPONDENTS EXHIBIT HOURS
1 All providers 2,273 3 6,819
2 All providers 2,273 4 9,092
TOTAL 15,911
As shown above, we estimate the annual burden to be 15,911 hours. This is an estimate of the average time required for all providers to prepare the questionnaires. The time will vary based on the size and type of provider.
Respondent Costs:
Average wage of respondent (including clerical cost) = $40.00/hour
Total Hours to Respond = 15,911
Total Annual Respondents Cost = $636,440
Preparation of Form CMS-339 contributes to the preparation of the cost report and allows the MAC to accomplish a quicker settlement with less need to obtain data on site. In some cases, there is less chance of an audit because needed data will already be available. Also, if the provider is audited, much of the data collected will be used by the 227; thus eliminating duplicate requests for information and expediting the performance of the audit.
The Medicare program shares in the cost of preparing Form CMS-339 based on the provider’s Medicare utilization either as part of the PPS payment rate or cost-based reimbursement.
13. Capital Costs
There are no capital costs.
14. Cost to Federal Government
Since the Form CMS-339 is available to be printed from the Internet, we expect the cost for printing and distribution to be minimal.
15. Program changes/Burden changes
The previous burden estimate was 75,625 hours. The difference is due to the decrease in the number of respondents required to complete Exhibits 1 and 2 due to the incorporation of the Form CMS-339 into Forms 1728-94 (HHA); 1984-14 (Hospice); and 224-14 (FQHC).
Revised: (see computation in Section 12 above) 15,911 hours
Prior: (see prior Form 83, Part II submitted
in May 2013) 75,625 hours
Decrease: 59,714 hours
16. Publication and Tabulation Dates
There are no publication or tabulation dates.
17. Expiration Date
CMS would like an exemption from displaying the expiration date as these forms are used on a continuing basis. To include an expiration date would result in having to discard a potentially large number of forms. Upon receiving OMB approval, CMS will publish a notice in the Federal Register to inform the public of both the approval as well as the expiration date.
18. Certification Statement
There are no exceptions to the certification statement.
Collections Of Information Employing Statistical Methods
This collection does not employ statistical methods.
| File Type | application/msword |
| Author | HCFA Software Control |
| Last Modified By | KAYLA WILLIAMS |
| File Modified | 2016-11-13 |
| File Created | 2016-07-01 |