[Federal Register: September 19, 2007 (Volume 72, Number 181)]
[Rules and Regulations]
[Page 53627-53649]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr19se07-18]
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Part II
Department of Health and Human Services
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Centers for Medicare & Medicaid Services
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42 CFR Parts 424, 488, and 489
Establishment of Revisit User Fee Program for Medicare Survey and
Certification Activities; Final Rule
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Parts 424, 488, and 489
[CMS-2268-F]
RIN 0938-AO96
Establishment of Revisit User Fee Program for Medicare Survey and
Certification Activities
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Final rule.
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SUMMARY: This final rule will establish a system of revisit user fees
applicable to health care facilities that have been cited for
deficiencies during initial certification, recertification, or
substantiated complaint surveys and require a revisit to confirm that
corrections to previously-identified deficiencies have been remedied.
Consistent with the President's long-term goal to promote quality of
health care and to cut the deficit in half by fiscal year (FY) 2009,
the FY 2007 Department of Health and Human Services' (HHS) budget
request included both new mandatory savings proposals and a requirement
that user fees be applied to health care providers that have failed to
comply with Federal quality of care requirements. The ``Revisit User
Fees'' will affect only those providers or suppliers for which a
revisit is required to confirm that previously-identified failures to
meet federal quality of care requirements have been remedied. The fees
are estimated at $37.3 million annually and will recover the costs
associated with the Medicare Survey and Certification program's revisit
surveys. The fees will take effect on the date of publication of the
final rule and will be in effect until the date that the continued
authority provided by Congress expires. At the time of publication of
this regulation the applicable date is September 30, 2007. If no
legislation is enacted, the fees are not retroactive to the beginning
of the fiscal year. Any provider or supplier that has a revisit survey
conducted on or after the date of publication will be assessed a
revisit user fee and will be notified of the assessment upon data
system reconciliation which can occur following the closing of the
fiscal year. The fees will be available to CMS until expended. The
revisit user fee is included in the President's proposed FY 2008
budget. We note through the publication of this final rule that if
authority for the revisit user fee is continued, we will use the
current fee schedule in this rule for the assessment of such fees until
such time as a new fee schedule notice is proposed and published in
final form.
DATES: Effective Date: These regulations are effective on September 19,
2007.
FOR FURTHER INFORMATION CONTACT: Carla McGregor, (410) 786-0663
SUPPLEMENTARY INFORMATION:
Table of Contents
I. Background
A. Overview
In the June 29, 2007 Federal Register (72 FR 35673), we published
the proposed rule entitled, ``Establishment of Revisit User Fee Program
for Medicare Survey and Certification Activities'' and provided for a
60 day comment period. This rule sets forth final requirements and the
final Fee Schedule for providers and suppliers who require a revisit
survey as a result of deficiencies cited during an initial
certification, recertification, or substantiated complaint survey.
The Centers for Medicare & Medicaid Services (CMS) has in place an
outcome-oriented survey process that is designed to determine whether
existing Medicare-certified providers and suppliers or providers and
suppliers seeking initial Medicare certification are actually meeting
statutory and regulatory requirements, conditions of participation, or
conditions for coverage. These health and safety requirements apply to
the environments of care and the delivery of services to residents or
patients served by these facilities and agencies. The Secretary of the
Department of Health and Human Services (``HHS'') has designated CMS to
enforce the conditions of participation/coverage and other requirements
with these programs. The revisit user fee will be assessed for revisits
conducted in order to determine whether deficiencies cited as a result
of carrying out CMS's survey process obligations have been corrected.
B. Requirements for Issuance of Regulations
Section 20615(b) of The Continuing Appropriations Resolution
(``Continuing Resolution'') budget bill passed by the Congress and
signed by the President directed HHS to implement the revisit user fees
in FY 2007. Section 20615(b) states as follows:
The Secretary of Health and Human Services shall charge fees
necessary to cover the costs incurred under `Department of Health
and Human Services, Centers for Medicare and Medicaid Services,
Program Management' for conducting revisit surveys on health care
facilities cited for deficiencies during initial certification,
recertification, or substantiated complaints surveys. Not
withstanding section 3302 of title 31, United States Code, receipts
from such fees shall be credited to such account as offsetting
collections, to remain available until expended for conducting such
surveys (Pub. L. 110-5, H.J.Res.20, Sec. 20615(b)(2007)).
As directed by the Secretary, in the June 29, 2007 Federal Register
(72 FR 35673), CMS established revisit user fees for revisit surveys
and put forth in regulation the definitions, criteria for determining
the fee, the fee schedule, collection of fees, reconsideration process
for revisit user fees, enforcement and regulatory language addressing
enrollment and billing privileges, and provider agreements. In the
proposed rule, cost projections were based on FY 2006 actual data and
were expected to amount to $37.3 million on an annual basis. These
calculations were included in section IV Regulatory Impact Analysis in
the proposed rule (72 FR 35678).
The fees will take effect on the date of publication of the final
rule and will be in effect until the date that the authority provided
by the Congress expires. At the time of publication of this regulation
the applicable date is September 30, 2007. As discussed thoroughly in
the proposed rule, based on the Congress' knowledge of section 1864(e)
of the Social Security Act and already established survey and
certification activities, the unambiguous nature of section 20615(b) of
the Continuing Resolution, and the principles of lex posterior derogate
legi priori or ``last-in-time'' rule, the Secretary has the authority
to implement this revisit user fee and establish a final fee schedule.
See 72 FR 35674-35675 (discussing section 1864(e) of the Social
Security Act).
II. Summary of the Proposed Provisions and Response to Comments
In the June 29, 2007 Federal Register (72 FR 35673), we published
the proposed rule entitled, ``Establishment of Revisit User Fee Program
for Medicare Survey and Certification Activities'' and provided for a
60 day comment period.
We received a total of 74 comments from various providers,
suppliers, health care associations, and individual health care
professionals and other individuals. The comments ranged from general
support of the survey process or general opposition to the proposed
provisions to very specific questions or comments regarding the
proposed new revisit user fee.
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Brief summaries of each proposed provision, a summary of the public
comments we received and our responses to the comments are set forth
below. Comments related to the paperwork burden and the impact analyses
are addressed in the Collection of Information and the Regulatory
Impact Analysis sections in this preamble.
General Comments
1. Time Period for Levying Fees
Comment: Several commenters suggested that CMS should not allow
user fees for nursing home revisits beyond the end of the fiscal year.
The commenters believe that nursing homes bear the brunt of the overall
survey process because surveys are conducted annually for nursing homes
and as such CMS should ensure that the fee is not renewed.
Response: The President's HHS budget for FY 2007, as enacted by the
Congress, directs the HHS Secretary to implement the revisit user fees
during FY 2007. Since the provisions for the revisit user fee were put
forth through the annual appropriations process, continuation of the
fees under this regulation beyond September 30, 2007 will depend on
Congressional renewal or extension of the time period under which fees
may be assessed. While nursing homes have the most frequent surveys,
they also have the largest number of revisits. Revisits in nursing
homes represent the largest single source revisit costs. While there
would be cost to some--but not all--nursing homes as a result of the
revisit fees, nursing homes also benefit from being able to reassure
prospective nursing home residents and their families that the nursing
home is federally certified and that there is an objective and
independent system of oversight to assure quality. The revisit survey
is an essential element of that quality assurance system. We also note
that the revisit fees are not restricted to nursing homes, but apply to
almost all providers and suppliers that require a revisit to confirm
that identified deficiencies are remedied.
2. Authority to Assess a Revisit User Fee
Comment: A few commenters expressed concern that revisit fees would
be imposed when the authority granted to levy fees expires on September
30, 2007 and that there does not appear to be legislation pending that
would extend CMS' authority to impose these fees beyond FY 2007. One
commenter stated that if the Congress does not extend this authority,
then it appears that this rule will be void. Another commenter
disagrees with CMS interpretation of section 1864(e) of the Social
Security Act (the Act) as giving HHS the ``authority to assess revisit
user fees.'' The commenter felt that clearly the inclusion and specific
wording in this section within the Act indicates Congress intended that
the Secretary ``may not impose'' any fee on any facility for any survey
(revisit or otherwise) for determining compliance ``with any
requirement of this title.''
Response: We are frequently expected to implement legislation that
is promulgated by the Congress and therefore has the force of law, as
in the passed FY 2007 appropriations bill. We strive to implement the
provisions in an efficient and effective manner once it becomes law.
The commenter is correct that the current authority to impose the
revisit user fee expires for revisits occurring after September 30,
2007, unless otherwise authorized via legislation or through the FY
2008 appropriations bill, as examples. The revisit user fee is included
in the President's proposed FY 2008 budget. We acknowledge the
commenter's disagreement with the Congress' intent as it relates to
authority to impose any fee based on the Social Security Act. However,
as we discussed in the Proposed Rule, we believe that Congress intended
to give the Secretary authority to implement this revisit user fee
program when Congress enacted section 20615(b) of the Continuing
Resolution.
3. ``Good Performers Versus Poor Performers''
Comment: Several commenters believed that those nursing homes
considered to be providing excellent care would be required to pay a
revisit user fee along with nursing homes that are considered poor
performers. The commenters believe that even minor infractions
uncovered during an annual survey for these higher quality nursing
homes would still lead to the imposition of a revisit user fee. A
commenter questioned whether or not those facilities going above and
beyond to provide higher level care through higher costs of operations
should be subjected to this user fee in the same manner as those
facilities that are performing at the bare minimum requirements with
lower costs of operations if the goal is to promote a better health
care environment.
Response: We believe that many nursing homes will pay no revisit
user fees because they consistently provide high quality care, have no
deficiencies identified through the survey process, and therefore will
require no revisits. Other nursing homes may require some revisits but
with minimal costs because the deficiencies are not serious, and the
revisit may be accomplished through an offsite survey. We have
established a much lower fee for offsite surveys since actual costs to
the survey program for these revisit surveys are much less than the
costs for onsite surveys, and the user fee is intended only to recoup
average actual costs. We believe we have designed the user fee program
to result in a positive correlation between quality of care and amount
of the fees--the better the quality of care, the lower the fees. We
also expect that the prospect of fees for revisits will promote greater
compliance with federal quality of care requirements, thereby making
for fewer revisits and fewer fees over time.
4. Revisit User Fee Compared to Penalty
Comment: Several commenters believe the revisit user fee
constitutes a penalty regardless of whether cited deficiencies are
appealed and overturned. They also stated that the revisit user fee
imposed additional penalties that may be assessed.
Response: The revisit user fee does have some similarities to a
quality of care penalty in so far as the revisit user fee only applies
to providers or suppliers for which deficiencies have been identified.
There are differences, however, between the revisit user fee and
traditional penalties. For example, a traditional penalty, such as a
civil monetary penalty, is assessed according to the scope and severity
of individual deficiencies that have been identified. A penalty amount
would be independent of the cost for the time required by surveyors to
revisit the provider in order to confirm that corrections have been
made. In contrast, the revisit user fee is designed only to replace the
average actual cost associated with the revisits themselves. Second,
currently only nursing homes are subject to civil monetary penalties;
no other Medicare-certified providers or suppliers affected by this
regulation are subject to CMS CMPs for quality of care deficiencies at
this time. Among nursing homes, only approximately 12 percent of
nursing homes are levied a CMP in any particular year, on average. If a
revisit survey is required, a user fee will be assessed; however this
does not necessarily mean a CMP will be levied as well.
5. Revisit User Fee Compared to Taxes
Comment: One commenter stated that the revisit user fee amounted to
a new tax. Another commenter felt that the revisit user fee was an
example of extortion and that the funding to
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administer the survey process including revisits is already in place.
They equated this fee to have the same effect as if the IRS was to
impose a fee when the individual's tax return is flagged for an audit.
A commenter felt the fee would amount to financial impropriety on the
part of the government.
Response: We believe that the commenter's characterization of the
revisit user fee as a ``tax'' is not accurate. Taxes are typically
imposed regardless of whether the taxed parties actually use the
services that the tax makes possible. Taxes must be paid regardless of
the extent of government services that are accessed. In contrast, the
revisit user fee will be levied only for those who fail to comply fully
with their responsibilities to provide quality care and to abide by
federal quality of care and related requirements under the Medicare
Provider Agreement and applicable regulations and laws for providers
and suppliers. Such failure obliges CMS to incur revisit survey costs
that would not otherwise have been incurred. The revisit user fee
amount is calibrated to match the additional resources required, on
average, for the surveyors to verify compliance with known federal
requirements subsequent to the provider's or supplier's initial failure
to meet those requirements fully.
6. Effects on Resident or Patient Care
Comment: Several commenters raised concern that the assessment and
payment of the user fee would remove several thousand dollars per
facility that otherwise would be available for resident care. Another
commenter felt the ethics of this proposal would adversely affect the
citizens of a State. The commenter felt that the revisit user fee was
unfair. Other commenters stated, in various ways, that the revisit user
fee would remove valuable resources that would otherwise be expended
for patient and employee resources. They felt that a direct drawdown
from funds used for patient care would occur, resulting in no
improvement to the quality of resident care. Finally, they felt that
there would be a direct adverse fiscal impact on smaller more
financially challenged facilities.
Response: CMS believes the providers and suppliers are the
controlling agents in managing the quality of care of services provided
in their healthcare facilities. Providers and suppliers may avoid
revisit fees by ensuring sustained compliance with federal quality of
care requirements. The revisit user fees simply compensate for the
costs of confirming that previously-identified problems have been
remedied. The certainty that a revisit will occur is a substantial
incentive for a provider to make the necessary corrections; therefore,
we believe that this quality assurance function will improve care and
safety for Medicare beneficiaries. In addition, we believe the
imposition of revisit user fees will likely encourage a sustained
commitment to management systems that improve quality of care provided
to all clients served by the provider. CMS does not believe that the
revisit user fee should harm quality of care provided, but can instead
become a valuable, additional incentive to encourage providers and
suppliers to commit to sustained compliance with federal quality of
care requirements. The quality of care message is that providers and
suppliers will have no user fees when quality of care meets the
appropriate federal standards. To the extent that there are
deficiencies, providers and suppliers will have only small fees to the
extent that the deficiencies are not serious or widespread. If quality
problems do occur, providers and suppliers will have greater incentives
to ensure that quality lapses are corrected more quickly than in the
past, since the revisit fees will be less if only one revisit is
required.
7. State Practices and Incentives for Revisits
Comment: Several commenters expressed a concern that State survey
teams would be instructed to find more violations if a revisit user fee
were in place, thus increasing the number of revisit surveys. One
commenter also raised the concern that the facility will have to pay a
revisit user fee for a revisit survey although the State may not
consider the deficiency severe. Another commenter raised concern that
there would be tremendous potential for abuse, that surveyors lacked
experience and that there existed too much financial control of the
facilities in the hand of the state surveyors. This commenter also
expressed concern as to whether there would be adequate monitoring of
State agencies for potential abuse of this program. Two commenters
believed the fee would increase the number of revisits currently being
done, putting an extra burden on staff as well as required additional
time for State surveyors. One commenter felt that the nursing home
revisits would increase to 100 percent because of what they consider a
financial incentive.
Response: We agree that any potential conflict of interest, and any
appearance of conflict of interest, must be addressed in the design and
operation of any user fee program. A number of safeguards will prevent
any such potential conflict from becoming a serious reality. First, the
revisit user fees will be collected nationally by CMS through a
contractor rather than by individual States. CMS makes allocations to
States based on the effects of inflation and on overall survey and
certification workload and performance for all survey and certification
functions, with revisits comprising just one of many functions. The
national survey and certification budget may not exceed the level
established by Congress, regardless of the level of revisit fee
collections. Second, all States must conduct revisits according to
policies and procedures established by CMS. Those policies and
procedures are publicly available in CMS' State Operations Manual (SOM)
and in numbered Survey & Certifications policy memoranda published on
the CMS Web site. Such policies and procedures define the circumstances
under which revisit surveys, both onsite and offsite, occur and when
they do not occur. CMS Regional Offices monitor State implementation of
the policies and procedures. We intend to increase CMS monitoring for
revisits. Third, States incur substantial costs in order to conduct
revisits. Such costs are not lightly undertaken, since there are
formidable natural and governmental constraints on a State survey
agency's ability to make use of any added funds that might conceivably
become available even if there were a direct fiscal connection between
revisits and the amount of money the State survey agency were to
receive. The single largest cost to a State survey agency, for example,
is personnel. The ability of a State survey agency to hire new staff
(even when new revenue becomes available) is either very limited or
there is a long delay between the availability of such funds and the
hiring of a surveyor. Once hired, the surveyor must typically undergo
about six months of training and observing before being entrusted to
conduct surveys. These constraints make it unlikely that a State survey
agency would incur the upfront staffing costs of conducting revisits
that were not required, or would seek to identify more deficiencies
simply to justify a revisit and hope that at some vague future date the
added costs might be recognized by CMS. To the extent that the revisit
user fee does create any type of new incentive, we expect that the main
incentive will be for providers and suppliers to maintain compliance
with federal quality of care and safety requirements, since such
compliance offers a clear pathway to the avoidance of revisit fees.
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Comment: One commenter stated that the proposed rule would increase
fees for facilities that had follow-up for routine licensure/
certification surveys as well as complaint visits.
Response: Revisit user fees will apply only to surveys that occur
after an initial certification, recertification, or substantiated
complaint survey has identified deficiencies. State licensures issues
that a State survey agency might address during a survey or a revisit
survey are separate activities not connected with the assessment of a
revisit user fee. Surveyor time spent on State-only issues must also be
cost-accounted for by State survey agencies to ensure that such costs
are not billed to the federal government. Thus, a survey or revisit
survey based solely on State licensure requirements would not create
the assessment of a revisit user fee. Only the need to conduct revisit
surveys regarding Federal conditions of participation, requirements, or
conditions for coverage would trigger a revisit user fee.
Comment: One commenter observed that State and federal regulations
require nursing facilities to report allegations of abuse and other
issues to the State survey agency. The commenter expressed concern that
such mandatory reports will result in a visit from the Survey Agency
inspectors, usually without any finding of regulatory deficiencies. The
financial impact of the proposal could be very burdensome for many
nursing facilities.
Response: An initial visit to investigate a complaint, such as the
allegation of abuse and or neglect mentioned by the commenter would not
trigger a revisit user fee. A revisit would be required only if a
deficiency is identified as a result of that complaint investigation.
The user fee would not apply to the initial complaint investigation; it
would apply only to the revisit once the provider has alleged to the
State survey agency that it has addressed the deficiency identified in
the original complaint investigation. Complaint investigations that
find no deficiencies will not require any revisits and will therefore
not occasion any revisit fees.
8. Revenue Seeking--Government Responsible for Funding Survey Process
Comments: Several commenters felt that this proposed rule and the
assessment of revisit user fees was a revenue seeking mechanism, that
it was a way to fund and pay for the survey process. Many of these same
commenters felt that the obligation of the survey process and the
conducting of revisit surveys was that of the Federal government, and
or the State Health Departments. The government has mandated these
surveys and as such the quality assurance checks are its obligation.
One commenter felt that the Federal government's role is to raise these
funds, as been often done through Federal taxes, although not
advocating a Federal tax increase, it is through these like efforts the
commenter suggested that funds should be derived to pay for the survey
process.
Response: The revisit user fee is designed simply to pay for actual
costs of conducting revisits, on average, rather than as a revenue
generating instrument that might be unconnected with the government
activity for which the revisit user fee is assessed. In addition, the
revisit user fees offer the ancillary benefit of encouraging providers
and suppliers to commit to sustained compliance with Federal quality of
care requirements and ensure that quality lapses are remedied quickly.
9. Creating Positive Incentives
Comment: Although some commenters felt the revisit user fee was
punitive in nature and not proactive, several commenters did support
added incentives to increase patient and resident safety, quality of
care, and compliance to standards. A couple of commenters went on to
state that a positive incentive would serve to strengthen the
relationship between regulators and providers and would establish CMS
as a partner rather than an adversary of the long-term care community.
A few commenters indicated strong support of the Medicare survey
process as one method to assure only providers and suppliers that offer
high quality services participate in the Medicare program. One
commenter went as far as offering three goals for which the collected
user fees should be directed, which included improving consistency of
the survey process, ensuring complete, provider-specific training for
surveyors, and improving communication between State survey agencies
and the provider community on survey rules and expectations. This
commenter went on to state that fees derived for these survey program
improvements should not be used to merely supplant the normal funding
stream but dedicated to specific programs.
Response: The intent of the revisit user fee program is to recover
the costs associated with conducting follow-up visits for deficiencies
cited during initial certification, recertification, and substantiated
complaint surveys. Although the commenter offers three additional goals
for the collected revisit user fee, we believe that those admirable
goals go beyond Congress' intended purpose of the revisit user fee
program.
Part 424--Conditions for Medicare Payment
Subpart P--Requirements for Establishing and Maintaining Medicare
Billing Privileges
Section 424.535 Revocation of Enrollment and Billing Privileges in the
Medicare Program
We proposed to amend Sec. 424.535(a)(1) by adding a new sentence
to the criteria for which a provider or supplier may be determined not
in compliance and for which we may revoke enrollment and billing
privileges in the Medicare program. We proposed to add that the
provider or supplier may also be determined not to be in compliance if
it has failed to pay any user fees as assessed under part 488 of this
chapter. The paragraph will continue to read that all providers and
suppliers are granted an opportunity to correct the deficient
compliance requirement before a final determination to revoke billing
privileges occurs.
Comment: Some commenters tied in the discussion of revocation of
billing and the termination for nonpayment as proposed in Sec.
488.30(f) and Sec. 489.53(a)(16). One commenter felt that termination
for nonpayment within 30 days is power disproportionate to the offense
and is unrelated to quality of care and safety issues. Another
commenter felt that this provision is reason not to participate in
Medicare, or to care for Medicare patients.
Response: While we proposed that a provider or supplier may also be
determined not to be in compliance if a revisit user fee payment has
not been received within 30 calendar days after receipt of the notice
that payment is due, we also state at Sec. 424.535(a)(1) that all
providers and suppliers are granted an opportunity to correct the
deficient payment compliance before a final determination is made to
revoke billing privileges. We further note that a payment-due notice
from CMS is preceded by a survey or complaint investigation that has
found deficiencies, a correction period afforded to the provider or
supplier, a revisit to confirm compliance, then a later issuance of the
payment-due notice, followed by the formal 30-day advance notice to the
provider. As soon as a revisit occurs, each provider or supplier will
know that a revisit user fee will follow at a later date, will know the
amount of the fee due from the fee schedule published in this rule, and
will know that the payment will be due
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within 30 calendar days. While the rule specifies that enforcement
action may occur if the bill has not been paid within 30 calendar days,
the total amount of planning time available to the provider or supplier
will have totaled much more than the 30 calendar day period before any
enforcement action may occur. Finally, the revocation of billing and
enrollment privileges is not an immediate action upon the failure of a
provider or supplier to remit the assessed revisit user fee. In this
final rule we therefore retain the time frames for which action will
occur regarding this process and retain the amended language to Sec.
424.535(a)(1) as final.
Part 488--Survey, Certification, and Enforcement
Subpart A--General Provisions
Section 488.30 Revisit User Fee for Revisit Surveys
We proposed a new Sec. 488.30 which set forth proposed regulations
that identifies the circumstances under which providers or suppliers be
assessed a user fee for revisit surveys connected with deficiencies
identified during surveys for initial certification, recertification,
or substantiated complaints. This proposed paragraph identifies the
assessment of fees, criteria for which the proposed fee schedule will
be based, and collection of fees.
Section 488.30(a)--Definitions
We proposed in Sec. 488.30(a) to define terms associated with this
paragraph. Those terms included: ``certification,'' ``complaint
surveys,'' ``substantiated complaint survey,'' ``provider of
services,'' ``provider,'' ``supplier,'' and ``revisit survey.'' Many of
the comments received for Sec. 488.30(a) dealt less with the wording
in the definitions and more with the survey and certification
activities and its process.
Certification (Initial or Recertification)
We proposed that ``certification'' (both initial and
recertification) would include those activities as defined in Sec.
488.1. ``Certification'' as currently defined in Sec. 488.1 is a
``recommendation made by the State survey agency on the compliance of
providers and suppliers with the conditions of participation,
requirements (SNFs and NFs), and conditions for coverage.''
Comment: One commenter proposed that home health agencies and
hospice facilities be removed from initial certifications since it can
take 2 or more years to get initial certifications. Another commenter
proposed that the revisit user fee should be expanded to include
initial surveys of ESRD facilities to allow more timely surveys that
now are delayed due to CMS budget, staff shortages, and other
priorities.
Response: Both commenters are referring to the issue of initial
certification surveys conducted for new providers or suppliers, rather
than the revisit surveys themselves.
While we appreciate the suggestion from one commenter that CMS
charge a fee for initial surveys so as to eliminate the current backlog
of unsurveyed and uncertified potential Medicare providers, we are
neither authorized by Congress nor prepared to charge such fees at this
time.
We also do not accept the suggestion from the other commenter that
home health agencies and hospices simply be exempt from initial
certification due to the survey backlog. We are not authorized to make
such exemption. We also believe an exemption would be inadvisable, as
it would permit those providers to begin to serve Medicare
beneficiaries without any assurance that they meet quality of care and
safety requirements. The proliferation of new home health and hospices
in a few States have also given rise to considerable concerns of fraud,
a concern that CMS is responding to through various anti-fraud
initiatives recently announced by the Secretary.
We do expect that the revisit user fee will indirectly help to
resolve the problem of surveying and certifying new providers. Revisit
costs represent a minority but still substantial portion of overall
survey and certification expenses. By defraying such costs through the
user fees, the States will then be in a better position to conduct tier
III and tier IV priority work, and will be able to conduct more initial
surveys than they have been able to conduct recently.
While we appreciate the comments, to adhere to the Congress intent
within the Continuing Resolution, we will not assess a fee for initial
certification, nor at this time can we remove providers or suppliers
based on when initial certifications are conducted. We will retain the
proposed definition of ``certification'' as final.
``Complaint Surveys''
We proposed that complaint surveys are those surveys conducted on
the basis of a ``substantial allegation of noncompliance,'' as defined
in Sec. 488.1. The term ``substantial allegation of noncompliance''
means:
A complaint from any of a variety of sources (including
complaints submitted in person, by telephone, through written
correspondence, or in newspaper or magazine articles) that if
substantiated, would affect the health and safety of patients and
raises doubts as to a provider's or supplier's noncompliance with
any Medicare condition. (42 CFR Sec. 488.1)
We further noted that the Continuing Resolution included the term
``substantiated complaints surveys.'' We proposed that ``substantiated
complaint survey'' means a complaint survey that results in the proof
or finding of noncompliance at the time of the survey, a finding that
noncompliance was proven to exist, but was corrected prior to the
survey, and includes any deficiency that is cited during a complaint
survey, whether or not the deficiency was the original subject of the
substantial allegation of noncompliance.
We proposed that a user fee would be assessed for revisit surveys
conducted to evaluate the extent to which deficiencies identified
during a substantiated complaint survey have been corrected.
Comment: Commenters requested clarification on the term
``substantial allegation of noncompliance,'' and felt that the
definition as a basis for the revisit fee is vague and open-ended.
Response: CMS proposed the definition for ``complaint surveys'' to
mean those surveys conducted on the basis of a substantial allegation
of noncompliance, as defined in Sec. 488.1. ``Substantial allegation
of noncompliance'' has been the term used in current survey,
certification, and enforcement procedures and as such we intended to
maintain a level of consistency by utilizing this definition as a means
to define ``complaint surveys.'' It is this process that generates the
action for which an investigation into the complaint should occur. It
is the substantiation of this complaint survey that will determine if a
revisit survey should be conducted and as a result a revisit user fee
should be assessed. As we provided in the discussion of the proposed
rule ``substantiated complaint survey'' means a complaint survey that
results in (1) the proof or finding of noncompliance at the time of the
survey, (2) a finding that noncompliance was proven to exist, but was
corrected prior to the survey, and (3) includes any deficiency that is
cited during a complaint survey, whether or not the deficiency was the
original subject of the substantial allegation of noncompliance. If any
of these 3 situations are determined and a revisit is required as a
result of the situation, then a revisit user fee will be assessed. It
will not simply be based on whether the complaint was substantiated. A
complaint may be substantiated without
[[Page 53633]]
being determined to be non-compliant with the regulations. The
substantiation of a complaint is a separate issue from the
determination of compliance with the regulations and thus the
triggering of a revisit user fee.
Comment: One commenter contends that accepting complaints from a
variety of sources is overly broad and permits the process to go
forward at great length. Another commenter felt that there is nothing
to prevent disgruntled employees from submitting complaints
anonymously, especially once they learn that the user fee will punish
the facility. Commenters felt that this provides incentive for
surveyors to substantiate the compliant that triggered the revisit or
substantiate another deficiency.
Response: We do not expect that either the quantity of complaints
received or the source of the complaints will affect revisit user fees
to any measurable extent. The revisit user fee does not apply to any
complaint investigation. Only complaints which have been substantiated
as showing non-compliance with Federal requirements will result in
citation of a deficiency. Only those deficiencies that require a
revisit survey will then trigger a revisit user fee. When multiple
complaints are received near the same point in time, State survey
agencies typically bundle those together in one complaint
investigation, this investigation is followed by a revisit survey only
if one or more of the complaints is substantiated and the agency finds
noncompliance to such an extent that a revisit is called for according
to CMS policy. Finally, the volume of complaints reaching CMS are to
some extent affected by the extent that the provider or supplier has an
effective system of inviting complaints internally, and responding to
complaints effectively such that beneficiaries or their families feel
that there is less need to file complaints with CMS or any external
party. We believe that beneficiary complaints represent a very
important source of feedback for providers, suppliers, CMS and States.
We hope such feedback can be effectively used by us and others to
identify areas of health care that merit serious attention.
Comment: One commenter disagreed that a ``substantiated complaint
survey'' can cite any deficiency regardless of whether that deficiency
was the original subject of the complaint. Two commenters raised
concerns that a revisit user fee will be imposed even in cases where a
``substantiated complaint'' is corrected prior to the survey or that
CMS would require a revisit user fee in this instance and this would
discourage a facility's internal quality assurance. A commenter raised
the questions as to whether a substantiated complaint included
condition and standard levels or just condition level. This commenter
proposes that it just include condition level since those levels result
in non-certification or decertification.
Response: CMS published condition of participation, condition for
coverage and other regulatory requirements typically take the form of
specific standards, with multiple standards related to a common topic
comprising a broader ``condition.'' Revisit surveys are almost always
required for condition-level deficiencies and are also often required
for standard-level deficiencies, depending on the extent and
seriousness of the noncompliance identified. As we provided in the
discussion of the proposed rule, ``substantiated complaint survey''
means a complaint survey that results in (1) the proof or finding of
noncompliance at the time of the survey, (2) a finding that
noncompliance was proven to exist, but was corrected prior to the
survey, and (3) includes any deficiency that is cited during a
complaint survey, whether or not the deficiency was the original
subject of the substantial allegation of noncompliance. If any of these
3 situations are determined and a revisit is required as a result of
the situation then a revisit user fee is assessed.
Although we disagree in part with the commenter who indicated that
any deficiency can not be cited during a complaint survey, we reiterate
and clarify that under our current policy for conducting complaint
surveys, we do require that if a State surveyor in the course of
conducting the complaint survey observes a situation that warrants
further investigation, that the State must seek input from the CMS
regional office to request permission to further pursue this additional
situation. See U.S. Centers for Medicare & Medicaid Services. State
Operations Manual, ``Complaint Procedures.'' ONLINE. 2006. CMS.
Available: http://www.cms.hhs.gov/manuals/downloads/som107c05.pdf
(``SOM-Complaint'').
With regard to the two commenters'' concern that a finding that
noncompliance was proven to exist, but was corrected prior to the
survey, this situation alone would not trigger a revisit user fee. In
addition, because a substantiated complaint survey can include the
above criteria we do not believe at this time that we should make a
distinction between a condition level deficiency and a standard level
deficiency. As a continued part of the survey and certification process
a complaint may be substantiated without being determined to be non-
compliant with the regulations. The substantiation of a complaint is a
separate issue from the determination of compliance with the
regulations and thus the triggering of a revisit user fee.
We appreciate the comments, however to adhere to consistency across
current survey and certification policy, we will retain the definition
of ``complaint surveys'' to mean those surveys conducted as the basis
of a substantial allegation of noncompliance, as defined in Sec. 488.1
as final.
``Provider of Services, Provider, or Supplier''
We proposed to retain the terms ``provider of services,''
``provider,'' or ``supplier'' as defined in Sec. 488.1. We proposed
that all ``provider of services,'' ``providers,'' or ``suppliers,'' as
defined in Sec. 488.1, will be subject to user fees, unless otherwise
exempted through the final rule. We proposed that a ``provider of
services'' or ``provider'' that may be assessed a user fee, as it
applies in this proposed rule, includes a hospital, critical access
hospital, skilled nursing facility, dually-participating nursing
facility (``SNF/NF''), home health agency (``HHA''), and hospice.
Transplant centers would also be subject to user fees and have been
defined in Sec. 482.70 of this chapter. We proposed that ``providers
of services'' or ``providers'' that will not be assessed a revisit user
fee as defined in the proposed rule to be comprehensive outpatient
rehabilitation facilities, transplant centers, and providers of
outpatient physical therapy or speech pathology services. These
providers are excluded from this rule because they are not subject to a
routine survey process as are other service providers. We stated that
Medicaid-only ``providers of services'' or ``providers'' will not be
assessed a user fee.
We proposed a ``supplier'' that may be assessed a user fee, as it
applies in the proposed rule includes an end-stage renal disease
center, a rural health clinic (``RHC''), and an ambulatory surgical
center (``ASC''). ASCs must have an agreement with CMS to participate
in Medicare and must meet conditions for coverage as defined in Part
416 of this chapter.
``Suppliers'' that would not be assessed a user fee under the
proposed rule are independent laboratories, portable x-ray centers,
physical therapists in independent practice, Federally Qualified Health
Centers (FQHCs), and chiropractors. These
[[Page 53634]]
suppliers are excluded because they are not subject to a routine survey
process as are other suppliers. We stated that Medicaid-only
``suppliers'' will not be assessed a user fee.
The proposed rule would not interfere with user fees associated
with clinical laboratories as established by the Congress, which passed
the Clinical Laboratory Improvement Amendments (CLIA) in 1988 and
established that outpatient clinical laboratory services are paid based
on a fee schedule in accordance with section 1833(h) of the Act.
We received several comments regarding our definition of ``provider
of services,'' ``provider,'' or ``supplier'' and we have included them
below.
Comment: One commenter indicated that Chiropractors status among
the Allied Health Care professions remains in dispute, this commenter
contends that Chiropractors should be excluded from any Medicare
provider list.
Response: Our current regulations found in Sec. 488.1 include
Chiropractors as identified as a supplier. This particular definition
section also has extensive implications in various parts of the
Medicare and Medicaid program and although we appreciate the
commenter's concern, we do not propose to remove chiropractors from the
definition of supplier. We do reiterate that Chiropractors are not
subject to the revisit user fees.
Comment: One commenter believed that the implementation of this
rule should not coincide with the publication of the final rule for
ESRD conditions of coverage. This commenter felt that revisits and
assignment of fees could very well be excessive during the ``learning
curve'' of the new regulation; if CMS has such discretion the commenter
suggests that this final rule should state that revisit user fees for
ESRD facilities will not apply for the first 12 months of
implementation of new conditions for coverage.
Response: The commenter is referring to the future publication of
the final CMS rule revising the Conditions for Coverage for end stage
renal disease facilities (ESRD). New rules or substantial revisions of
new rules are typically promulgated with future effective dates.
Considerable educational communications usually precede the effective
date, during which providers or suppliers have an opportunity to become
familiar with the rule and make necessary changes before the survey
process holds them accountable. Currently, ESRD surveys are conducted
about once every three to five years. We therefore believe that there
will be reasonable opportunities for providers to adjust to the new
rules before they are affected by surveys and the later revisits that
might follow some surveys. Finally, although we appreciate the
commenter's suggestion, we do not have the discretion at this time to
exclude ESRD facilities from this final rule. ESRD facilities and
revisits costs were included within the President's budget projections
and mandated by the Congress.
Comment: One commenter expressed concern that religious nonmedical
health care institutions (RHNCIs) would be subject to the revisit user
fees.
Response: We appreciate the comment received. We inadvertently did
not include religious nonmedical health care institutions (RHNCIs) in
the definitions. RHNCIs should have been included, as they are subject
to the survey and certification process. To adhere to the intent of the
Congress and maintain consistency of definitions across Medicare and
Medicaid programs, we will retain the definitions as proposed with the
exception that we will include RHNCIs in the definition. However, in
the fee schedule in this final rule we exempt them from the user fee
program due to the very small number of such facilities and their
relatively unusual nature. Any change to the exemption status would be
preceded by publication of a Federal Register notice. The final
definition of ``provider of services,'' ``provider,'' or ``supplier''
will read ``Provider of services, provider, or supplier'' as defined in
Sec. 488.1, and ambulatory surgical centers, transplant centers, and
religious nonmedical health care institutions subject to Sec. 416.2,
Sec. 482.70, and Sec. 403.702 of this chapter, respectively, will be
subject to user fees unless otherwise exempted.
``Revisit Survey''
In the Proposed Rule CMS defined the term ``revisit survey'' to
mean a survey performed with respect to a provider or supplier cited
for deficiencies during an initial certification, recertification, or
substantiated complaint survey and which is designed to evaluate the
extent to which previously cited deficiencies have been corrected. We
further proposed that for purpose of this rule revisit surveys include
both offsite and onsite. We also reiterated that regulations
established in Sec. 488.26 of this same part provided regulatory
requirements for conditions of participation, conditions for coverage,
or other regulatory requirements. Specifically Sec. 488.26 of this
part states that the compliance determination is made by the State
survey agency and includes a survey process that assesses compliance
with Federal health, safety, and quality standards.
We received only a few comments regarding the term ``revisit
surveys'' and received the majority of comments under this section
reflecting commenters concern regarding the survey process and the
manner in which revisit user fees will be assessed.
1. ``Revisit Survey'' Term
Comment: Several commenters requested that we redefine the term
``revisit survey'' so that the definition does not include desk reviews
or offsite surveys, that the offsite (desk) reviews be defined, that
fees only be imposed if the survey is done in accordance with already
established policies per provider type, that the definition include
criteria about when onsite revisits are required, and that we limit the
fees to ``onsite revisit surveys.''
Response: We included offsite revisit surveys (desk reviews)
because we wished to retain the option of the offsite revisit surveys
where warranted, since the cost to providers and suppliers under the
revisit fee program will be substantially less than for onsite revisit
surveys. The function of onsite and offsite (desk review) revisit
surveys is the same. We interpret both types to constitute revisits
within the meaning intended by Congress. The Continuing Resolution
requires fees to be assessed that are necessary to cover the costs
incurred for conducting revisit surveys on health care facilities cited
for deficiencies found during initial certification, recertification,
or substantiated complaint surveys. As we observed, we do not interpret
this to mean onsite revisit surveys only. Within the current survey
process itself there are distinctions made for when an onsite or
offsite revisit survey should occur and distinctions are made by
provider and supplier type. See U.S. Centers for Medicare & Medicaid
Services. State Operations Manual, ``Survey and Enforcement Process for
Skilled Nursing Facilities and Nursing Facilities,'' Online. 2004. CMS.
Available: http://www.cms.hhs.gov/manuals/downloads/som107c07.pdf, and
also ``Additional Program Activities,'' Online. 2007. CMS. Available:
http://www.cms.hhs.gov/manuals/downloads/som107c03.pdf.
We disagree that revisit surveys should only be those that were
conducted onsite, as there are situations in which offsite reviews are
required to verify that the contents of the plan of correction or the
corrective action took place. We do, however, agree that a review of a
plan of correction that does not require verification beyond the plan
[[Page 53635]]
of correction document itself would not constitute an offsite revisit
survey (as defined here), and thus the provider or supplier would not
be assessed a revisit user fee in such a circumstance. A provider or
supplier will be assessed a revisit user fee for an offsite revisit
survey if the deficiency or deficiencies cited are of a nature that the
content of the plan of correction and the statements made by the
provider or supplier require verification and offsite follow-up to
ensure that the corrective action has brought the provider back into
compliance with federal requirements.
We appreciate the comments received; however on the term ``revisit
survey,'' based on our discussion we will retain the proposed
definition of ``revisit survey'' as final.
2. Survey Process
CMS discussed the current revisit policy and survey and
certification process already established for all providers and
suppliers. We identified current policy for skilled nursing facilities
and dually-participating nursing facilities, performed at the
discretion of CMS or the State. This revisit policy indicates
circumstances for which onsite revisits must occur for certifying
compliance and circumstances when onsite revisits are discretionary.
Likewise, CMS generally permits only two revisits for hospitals, home
health agencies, hospices, ambulatory surgical centers, rural health
clinics, and end-stage renal disease centers. Of these two revisits
permitted by CMS, one revisit should occur within 45 calendar days of
the initial certification, recertification, or substantiated complaint
survey, and one revisit subject to CMS approval, between the 46th and
90th calendar days. See 72 FR 35676 (discussing revisit policy,
including discussion on revisits related to Immediate Jeopardy).
2A. Survey Process: Skilled Nursing Facilities and Dually-Participating
Nursing Facilities
Comment: Several commenters contended that the survey process is
inconsistent and subjective, and proposed that the revisit user fees be
postponed until these process issues are resolved. Another commenter
felt that revisit user fees represent punishment, especially when
deficiencies are erroneously cited. Two commenters requested assurances
that only legitimate deficiencies will be cited, that unnecessary
revisits will not be conducted, and that revisits will not be conducted
solely for the purpose of collecting user fees. One commenter felt that
the proposed rule will complicate the subjectivity and variability that
will always be part of the survey process. Another commenter indicated
that the survey process is broken and subjective, and as such, fees for
revisits would be unfair until those problems are resolved.
Response: CMS continuously works with States to ensure that surveys
are applied as consistently as possible. CMS also operates a national
internal consistency program in which validation surveys are conducted
by Federal surveyors to promote optimum consistency. For example,
Federal surveyors conduct validation surveys on a 5% sample of nursing
home surveys to check the accuracy and adequacy of State surveys. CMS
then works with the States to adjust for any significant disparities.
The issue of consistency is also monitored as part of CMS's review of
State performance. Because no system is perfect, nursing homes have an
opportunity to request review of any cited deficiency through a
structured informal dispute resolution process. CMS takes the issue of
consistency seriously, and we continue to develop additional methods to
analyze and address consistency issues, one example is the new Quality
Indicator Survey (QIS) process that has been pilot-tested in five
States. The QIS process utilizes customized software and is designed as
a staged process for use by surveyors to systematically review
requirements and objectively investigate all triggered regulatory areas
in an effort to meet several objectives, one of which is to improve
consistency and accuracy of quality of care and quality of life problem
identification. We believe that the revisit user fee will help address
those limitations and make more feasible a number of additional
consistency improvements that are underway.
Comment: One commenter feared that there are no constraints to
prevent a surveyor from citing an already corrected problem in order to
trigger a revisit. One commenter believed that the survey process is
already stressful for facility staff and this will only be made worse
for employees who fear any mistake could trigger a revisit and its
associated fee.
Response: If a problem has already been corrected at the time of a
standard survey or complaint investigation, the survey itself can
confirm that the correction has brought the provider or supplier back
into compliance with federal requirements and the surveyor would
document such a determination. In such a case no revisit would be
required unless the correction failed to assure compliance. We
appreciate that the survey process can be inherently stressful for
employees. We do not believe, however, that the amount of the revisit
fee is so much as to add measurably to the pre-existing stress level
for employees. The cost of a revisit fee can be compared favorably to
the larger cost to beneficiaries from poor quality of care, or to the
larger financial cost to providers from serious non-compliance with
federal requirements, such as civil monetary penalties or termination
of the provider agreement. Only in the case of multiple revisits would
we expect the cumulative cost of revisits fees to become a significant
expense for a particular provider. A large number of revisits would
occur when there is a persistent pattern of poor quality and documented
inability of a provider or supplier to sustain compliance with federal
requirements. Such providers face more serious consequences than
revisit user fees. We believe that the plain language of the Continuing
Resolution mandates that a fee be collected whenever a revisit occurs
as a result of a deficiency found during initial certification,
recertification, or substantiated complaint surveys. Documentation
requirements supporting deficiency citations are not being diminished,
eliminated or otherwise changed by this proposed rule to create the
scenario raised by the commenter.
Comment: One commenter proposed that onsite revisits be
discretionary for single ``G'' level deficiencies. Another commenter
indicated that it is unclear what level deficiency would necessitate a
revisit. A few commenters believed that oversight of correction of some
deficiencies could be done offsite and requested clarification about
when onsite revisits are required.
Response: Our current policy requires onsite revisits for condition
level citations. The current policy governing revisit surveys is
described in our online state operations manual. We will, however,
consider policy issues raised by several of the commenters for future
reconsideration. Some professional discretion on the part of State
survey agencies will always be required. CMS provides review and
oversight of State survey agencies through the CMS regional offices.
Our internal quality assurance system provides for regional office up-
front input or subsequent review when there is concern regarding
whether the revisit survey should be conducted onsite or offsite.
However we have always maintained that a condition level citation
requires an onsite revisit survey. ``G'' level deficiencies in nursing
homes are serious and are cited only when one or more nursing home
[[Page 53636]]
residents have been harmed. We will continue to conduct revisits in
such circumstances.
2B. Survey Process: Hospitals, Home Health Agencies, Hospices,
Ambulatory Surgical Centers, Rural Health Clinics, and End-Stage Renal
Disease Centers
Comment: One commenter felt that although survey teams work off the
same worksheets, there is variation in how different survey teams
assess similar situations. Therefore, the commenter felt that requiring
a ``revisit'' fee for all resurveys (either onsite or offsite) will
increase the number of times that home health agencies will contest the
survey findings, which then they may enter into an informal dispute
resolution process not only to avoid the revisit fee but also to
respond to the issue of survey variation.
Response: CMS continuously works with States to ensure that surveys
are as consistently applied as possible. CMS also operates a national
internal consistency program in which validation surveys are conducted
by Federal surveyors to promote optimum consistency. It is possible
that the revisit user fees may have the ancillary effect of increasing
the extent to which providers or suppliers dispute the findings of
surveys or complaint investigations. We believe this may occur whether
the revisits are offsite or onsite. We will monitor the effect of the
revisit fees to determine if any future adjustments are advisable.
Comment: One commenter requested clarification on whether user fees
will be imposed on accredited providers or suppliers for a revisit
following a sample validation survey.
Response: We will not charge a fee for a validation survey of a
provider or supplier that has been duly accredited by a CMS-approved
accrediting organization and deemed to meet Medicare requirements.
While we believe that a revisit fee pursuant to a validation survey has
basis, it is absent in the language of the Continuing Resolution. We
would view this as similar to a revisit survey conducted for a non-
accredited provider; we did not however specify such a charge in the
proposed rule. We will therefore not charge a revisit user fee in this
final rule for a revisit that follows a validation survey, provided
that the deemed status of the provider or supplier has not been removed
by CMS. However, any survey, including a validation survey, that finds
noncompliance with a Condition (compared to just a Standard), typically
requires removal of deemed status and a full survey of a provider. When
an accredited facility is found not to be in substantial compliance
with the Medicare Conditions of Participation or Conditions for
Coverage, it must remain under the jurisdiction of the State Survey
Agency until the State Survey Agency verifies through revisits that the
facility has corrected its deficiencies and demonstrated substantial
compliance. We believe in this case, the removal of deemed status that
initiated with a validation survey, that then remains under the
jurisdiction of the State survey agency is equivalent to any other
provider or supplier seeking recertification. In this case a provider
or supplier cited for a deficiency during a recertification survey that
requires a revisit survey would be assessed a revisit user fee.
Comment: One commenter requested clarification as to whether a full
survey following a substantiated complaint survey in a deemed provider
or supplier is a revisit as defined in proposed Sec. 488.30(a).
Response: A full survey that is conducted pursuant to a complaint
investigation of an accredited facility that has found condition-level
noncompliance is viewed as a revisit for the purposes of the revisit
fee. As discussed in the response above, noncompliance with a Federal
condition typically requires a removal of deemed status and a full
survey of a provider. The purpose of this full survey is two-fold: To
verify correction of the condition-level deficiencies identified on the
complaint investigation, and also to confirm that the facility is in
substantial compliance with all of the pertinent conditions for
participation before the State survey agency returns jurisdiction over
the facility to the accreditation organization. Thus we believe the
activities of the survey fall within the purposes of a revisit survey.
We appreciate all the comments received regarding our current
survey process for all providers and suppliers. CMS will maintain the
current policy process for the immediate future. We will take all of
these comments under consideration as we continue to work with States
and our national consistency program to provide continued oversight and
regulatory compliance guidance.
Section 488.30(b)--Criteria for Determining the Fee
We proposed in Sec. 488.30(b) to provide the criteria for
determining the user fee. We proposed that for initial implementation
of revisit user fees, we will use the criteria in proposed Sec.
488.30(b)(1)(i) and (ii): That a provider or supplier will be assessed
a revisit user fee based on the average cost per revisit survey per
provider or supplier type and the type of the revisit survey (onsite or
offsite). If costs change significantly in any future period for which
authority for the revisit user fee exists, we would publish a Federal
Register notice providing a revised fee schedule to the extent that
fees may be affected.
We also proposed that exceptions to the assessment of a revisit
user fee will be identified based on the type of visit conducted. For
example, we proposed that neither a provider nor a supplier will be
assessed a fee if the visit is considered a ``State monitoring visit''
unless the visit also meets the definition of a revisit, if the visit
is to confirm Medicare provider or supplier compliance with Life Safety
Code (LSC) requirements, if the visit is to conduct a Federal
Monitoring Survey, such as a Federal look-behind survey. See 72 FR
35677 (discussing ``state monitoring visit,'' LSC, and Federal
Monitoring Surveys).
We also proposed in Sec. 488.30(b)(1)(iii) through (b)(1)(v) that
CMS may adjust revisit user fees to account for the provider or
supplier's size, typically determined by capacity (such as the number
of beds), the number of follow-up revisits resulting from uncorrected
deficiencies, and/or the seriousness and number of deficiencies (such
as the scope and severity of cited deficiencies and the number of
deficiencies cited at each scope and severity level), as these criteria
pertain to particular provider types. Variance in provider/supplier
size, the number of follow-up revisits, and the type and number of
deficiencies cited may have an impact on the survey hours needed for a
revisit. We also proposed in Sec. 488.30(b)(2) that CMS may adjust the
fees to account for any regional differences in cost.
We received a variety of comments for this section, the majority of
which discussed quality of care and the concern that the user fee might
cause adverse incentives. We summarized all of these comments and
responded to them under the general comments section of this final
rule. The comments discussing the specific criteria proposed in Sec.
483.30(b) are provided below.
Comment: A few commenters stated that additional information was
needed about how the various factors (for example, a provider's size,
number of revisits, scope and severity of deficiencies) will impact the
amount being assessed. They asked whether CMS would notify providers in
advance of the actual amount that would be assessed, and whether
providers would be notified about how these factors were specifically
used to assess a given fee.
[[Page 53637]]
Response: We believe that the adjustment criteria outlined in this
regulation can be important factors affecting the number of survey
hours that would be required in a revisit survey and therefore the cost
of such revisit survey. However, the final fee schedule published in
this rule does not make use of all the potential factors that might
otherwise be used because we believe many of the factors require more
analysis. Of the criteria listed in 488.30(b), CMS is only using
488.30(b)(1)(i) and (ii) for the immediate future.
If Congressional authority for the revisit fee is renewed or
extended, and CMS changes the overall methodology for calculating and
collecting these fees, CMS will implement these changes through notice
and comment rulemaking in the Federal Register. If Congressional
authority for the revisit fee is renewed or extended but CMS will not
being implementing any methodological changes, CMS will publish
proposed and final notices in the Federal Register to announce and
solicit comment on planned updates, adjustments, or changes to the
criteria used, if changes are to be made.
For example, CMS does not plan to use criterion set forth at
488.30(b)(2)--regional differences in cost--in the immediate future.
However, if CMS should decide to use it in the future, CMS will publish
a notice in the Federal Register announcing CMS's intention to do so,
describing how CMS intends to use and operationalize 488.30(b)(2), and
to solicit public comment. Similarly, for technical adjustments or
updates to the fee schedule (e.g. adjustments for cost of living
increases), CMS will issue public notices in the Federal Register.
On the other hand, if CMS should decide in the future to use a
completely different criterion not described in these rules, CMS will
publish a notice of proposed rulemaking announcing this change in
methodology.
Such future notices would address the commenters' concern regarding
provider or supplier size, for example, and how the number of beds or
the number of patients or residents served might affect a revisit fee.
In this final rule we do reserve the right to adjust fees based on
the number of follow-up revisits conducted either decreasing or
increasing fees based on the costs that are incurred by state survey
agencies to conduct these multiple follow-ups. Any change to the
current fee schedule in which the same revisit user fee is applied for
each revisit, will be preceded by Federal Register notice of the
planned change. In this regulation we are providing the information
needed for each provider or supplier to know the amount that they would
be charged if a revisit occurs. These criteria incorporate the average
cost per provider or supplier for conducting a revisit survey and the
type of revisit survey conducted (onsite or offsite). We would charge
the same fee each time a revisit occurs, so if a revisit revealed that
the facility had not achieved full compliance and if a second revisit
were required, the provider would be charged the same amount again for
the second revisit.
Comment: One commenter suggested that the fee should be based on
the total or estimated hours of service, not by the actions performed
during a survey. Another commenter suggested that a ``cap'' be placed
on the total amount of user fees associated with a single revisit and
associated with a given provider. One commenter acknowledged the intent
of the proposed change and encouraged CMS to adjust revisit user fees
according to particularities of the states, such as staff travel time,
etc.
Response: We proposed in the June 29, 2007 Proposed Rule to use
criteria (b)(1)(i) (average cost per provider or supplier type) and
(b)(1)(ii) (revisit type: Onsite or offsite), and have retained those
criteria in this final rule and fee schedule. We agree with the
commenter that the fee should be based on the total or estimated hours
of service. We have utilized an average cost per provider or supplier
based on the average costs per hour for conducting revisit surveys. We
appreciate the comment regarding suggesting a ``cap'' on the total
amount of fees associated with a single revisit. We believe the
methodology in this rule conforms to the ``cap'' idea. As discussed in
the proposed rule, providers or suppliers will be assessed one fee per
revisit. As discussed in the Proposed Rule, when offsite preparation is
required, as it is in many cases, the provider or supplier would not be
assessed a separate revisit fee for this offsite preparation. Instead,
the entire preparation and actual onsite revisit will count as an
onsite revisit survey.
Based on current data analysis, CMS proposed to implement the
revisit user fee utilizing only criteria identified in Sec.
488.30(b)(1)(i) and (1)(ii). We appreciate the commenters encouragement
to look at differences in State costs for the revisits. In proposed
Sec. 488.30(b)(2) we reserved the right to adjust the fees to account
for regional differences in costs. It is our intent to conduct further
analysis on these additional criteria in proposing future fee
schedules. In this rule, the final fee schedule is based on a simpler
flat-rate methodology per provider type. If regional cost differences
were invoked in any future change to the fee schedule, we would publish
a proposed and final notice in advance of any such changes.
Comment: One commenter identified that CMS, on July 17, 2007,
stated that certain provider types in California's Orange, Riverside,
San Bernardino and Los Angeles Counties would be under a 2 year
demonstration to re-enroll in Medicare, as well as be subject to a
survey should the provider have had a Change of Ownership within the
last 2 years. The commenter asked that providers not be assessed a fee
if the visit is associated with this demonstration.
Response: We agree with the commenter and have specified that
neither a provider nor a supplier will be assessed a fee if the visit
is considered a ``State Monitoring visit'' unless the visit also meets
the definition of a revisit survey in this rule. In this case, a Change
of Ownership action, and other actions involved in this particular
State demonstration, are considered a ``State Monitoring visit'' for
purposes of this final regulation and final fee schedule. Therefore,
providers and or suppliers participating in the two year demonstration
would be exempt being assessed a revisit user fee if the revisit is
associated with visits conducted solely on behalf of this demonstration
and to the extent that they do not involve deficiencies in compliance
with the Conditions of Participation or Coverage.
We appreciate all of the commenters' suggestions on our proposed
criteria sections, and have clarifications in response to a number of
the commenters' concerns. We intend to provide the requested detail in
incorporating additional criteria when calculating any changes to the
fee schedule for revisit user fees, if authority is provided by the
Congress and through the notice and rulemaking process described
earlier. We believe we have addressed concerns raised in this section,
therefore we will retain the proposed language in Sec. 483.30(b)(1)
and (b)(2) as final. We accordingly have calculated the final fee
schedule based on selected criteria. The final fee schedule will
utilize criteria in Sec. 488.30(b)(1)(i) and (b)(1)(ii) as proposed
and finalized by this rule.
Section 488.30(c)--Fee Schedule
We proposed in Sec. 488.30(c) that CMS will publish in the Federal
Register the proposed and final notices of a uniform fee schedule
before it adopts this schedule. The proposed and final notices would
set forth the amounts of
[[Page 53638]]
the assessed fees based on the criteria as identified in paragraph (b)
of this subpart. In future notices, any changes to the amounts of the
assessed fees would include for example, adjustments based on increases
to cost of living, labor and overhead costs. The proposed rule also
constituted publication of the proposed fee schedule.
We based user fee calculations in the proposed rule and fee
schedule on the type of revisit (onsite vs. offsite); the type of
provider or supplier; the average number of hours that a revisit
requires; and the average per hour cost of a revisit. We have
identified the revisit survey costs below under section IV, Regulatory
Impact Analysis.
We have received varying comments raised under this section. The
majority of these comments referenced concerns also raised under
general comments, the current survey process, and the criteria for
determining the fee. We believe we have addressed these concerns in
other sections. Comments received on Sec. 488.30(c) are below:
Comment: One commenter believed that the Federal Register notice
contained a number of labels displaying data regarding estimated costs
and 2006 frequencies of revisit surveys, the commenter felt that based
on the proposed language in Section 488.30(b) that CMS intends to
exercise considerable latitude in the actual levying of fees in a
specific situation. Another commenter felt that it is unfair to
providers to impose fees without advance notification of the actual
costs based on any adjustment criteria.
Response: We will publish in the Federal Register the proposed and
final notices of a uniform fee schedule before we adopt this schedule.
Both notices would set forth the amounts of the assessed fees based on
the criteria as identified in section 488.30(b). It will also specify
which of the criteria listed in 488.30(b)(1)-(2) will be used and how
they will be operationalized.
In response to the nature of these comments, we have clarified the
regulatory language and thus adopt as final that Sec. 488.30(c) will
read: ``CMS must publish in the Federal Register the proposed and final
notices of a uniform fee schedule before it assesses revisit user fees.
The notices must set forth which criteria will be used and how, as well
as the amounts of the assessed fees based on the criteria, as
identified in paragraph (b) of this subpart.'' Language placed in bold
for emphasis on the changes. We also note through the publication of
this final rule that if authority for the revisit user fees is
continued, we will use the current fee schedule in this rule for the
assessment of such fees until such time as a new fee schedule notice is
proposed and published in final form.
The final fee schedule is identified below in Table A. Summation of
data and calculations regarding this final fee schedule is discussed in
section V, Regulatory Impact Analysis summary below.
Table A.--Final Fee Schedule for Revisits Surveys
[Onsite and offsite]
------------------------------------------------------------------------
Fee assessed per Fee assessed per
Facility offsite revisit onsite revisit
survey survey
------------------------------------------------------------------------
SNF & NF............................ $168 $2,072
Hospitals........................... 168 2,554
HHA................................. 168 1,613
Hospice............................. 168 1,736
ASC................................. 168 1,669
RHC................................. 168 851
ESRD................................ 168 1,490
------------------------------------------------------------------------
Section 488.30(d)--Collection of Fees
We proposed in Sec. 488.30(d)(1) that fees for revisit surveys
under this paragraph may be deducted from amounts otherwise payable to
the provider or supplier. We also proposed that fees will be deposited
as an offset collection to be used exclusively for survey and
certification activities conducted by State survey agencies pursuant to
section 1864 of the Act or by CMS, and will be available for CMS until
expended. We also proposed that CMS may devise other collection methods
as it deems appropriate. In determining these methods, CMS will
consider efficiency, effectiveness, and convenience for the providers,
suppliers, and CMS. In the Proposed Rule we stated that Methods may
include: Credit card; electronic fund transfer; check; money order; and
offset of collections from claims submitted.
1. Sec. 488.30(d)(1)--Collection Methods
Comments: Several commenters indicated that regarding the proposed
language that fees for revisits be deducted from amounts otherwise
payable to the provider, they raised concern that there were no
specifics as to whether these fees would be deducted all at once or on
a schedule.
Response: In the proposed language CMS identified a number of
methods for the collection of the revisit user fee. For the immediate
future, we will utilize a bill pay system. Providers or suppliers who
are assessed a fee will receive a notice in the mail which will include
the amount of the assessed revisit fee and the revisit survey for which
the fee is assessed. Included in the notice is the obligation that
payment is expected to be remitted within 30 calendar days of the date
of the notice. As a means of clarification and to expand on payment
methods that may be beneficial to providers and suppliers and based on
the various comments, CMS will modify the last sentence of Sec.
488.30(d)(1) by adding ``any method allowed by law, including credit
card; electronic fund transfer; check; money order; offset collection
from claims submitted.'' We will include all necessary details within
this coupon notice, including to whom to direct questions, and payment
remittance information. In addition, as a result of various comments
regarding the time frame for when we may collect fees, and the concerns
regarding the schedule of these fees, we will include an additional
subparagraph Sec. 488.30(d)(3) to this section that indicates: ``Fees
for revisit surveys will be due for any revisit surveys conducted
during the time period for which authority to levy a revisit user fee
exists.''
Comments: One commenter indicated that they would prefer that if
fees are needed, then providers should be charged an up-front fee that
does count
[[Page 53639]]
towards approved expenses of doing business/cost report based on bed
size.
Response: The revisit user fees are limited to fees for revisit
surveys conducted as a result of deficiencies cited during an initial
certification, recertification and substantiated complaint surveys. The
fee will only be applied when revisits are needed to assure substantial
compliance that requirements are met. Although we appreciate the
commenters statement, Congress' clear intent was that CMS assess a fee
only for revisits required as a result of deficiencies cited. It would
be out of the scope of our authority to assess fees for upfront survey
costs.
2. Sec. 488.30(d)(2)--Cost Report
Comment: One commenter raised concern regarding our statement: ``At
no time is the individual provider's cost borne by other patients.''
The commenter felt our statement disregards the nature of medical
transactions and that these revisit user fees, if extracted from the
provider's income stream, would directly impact the range and quality
of the services rendered by competing on a cash basis with all other
spending priorities in the practice.
Response: Each revisit user fee will arise from a provider's
documented failure to comply with federal requirements for quality of
care or safety. We hope that a provider would not respond to a fee
arising from such failure by decreasing quality of care. Such an action
could simply give rise to more quality compromises, more complaints,
more surveys or complaint investigations, more revisits, and more fees.
The result would not make economic or medical sense. We appreciate the
commenter's concern that a provider might respond to a revisit fee by
reducing services. This would represent a business decision on the part
of the provider. An alternative would be to invest in remedial action
so that quality would be improved and the prospect of future revisits
and revisit fees would be reduced. We hope that providers will adopt
the alternative approach.
Comment: Some commenters objected to the fee, but stated that if
the fee were adopted then it should be considered an allowable cost on
the cost report. The commenters expressed concern as to where the funds
would come from if the fees were not permitted as an allowable cost on
the cost report, particularly, in an industry already struggling to
continue to provide services.
Response: We proposed in Sec. 488.30(d)(2) that fees for revisit
surveys under this section are not allowable items on a cost report, as
identified in part 413, subpart B of this chapter, under title XVIII of
the Act. The revisit user fee will be levied only as a result of a
provider's failing to meet basic quality of care or safety standards
that are required as a condition of participation or coverage in the
Medicare program. As such, it is not appropriate for a revisit user fee
to be an allowable item for a cost report. To do so would lead to both
cost-shifting and the counterintuitive result that more quality
breakdowns could lead to more payment. For these reasons, the Secretary
has put in place the necessary mechanism for which cost-shifting would
be prevented. In addition, a significant number of providers and
suppliers are reimbursed through the prospective payment system; as a
result, only a small group of providers as compared to the overall
number of providers and suppliers receive cost based reimbursements.
While the user fee program is simply intended to defray costs of
the revisits, we believe that the design of the user fee program we
finalize will result in a positive correlation between quality of care
and amount of the fees--the better the quality of care, the lower the
fees. We also expect that the prospect of fees for revisits will
promote greater compliance with federal quality of care requirements,
thereby making for fewer revisits and fewer fees over time.
Comment: A commenter stated that as a result of the financial
burden of the revisit user fee, the expense for the payment of this fee
would be cost-shifted to private pay residents. The commenter stated
that, if the fee were to be advanced this should include a requirement
that would ensure increased Medicaid/Medicare reimbursement to avoid
shifting burden of added costs to private-pay residents. Another
commenter felt that the fee would also amount to a shifting of funds
and as a result either the money is withheld from the hospital up front
as part of budget cuts or the hospital has to pay it back as part of
their CMS certification process.
Response: We proposed in Sec. 488.30(d)(2) that fees for revisit
surveys under this section are not allowable items on a cost report, as
identified in part 413, subpart B of this chapter, under title XVIII of
the Act. Part 413 identifies CMS' formulating methods for making fair
and equitable reimbursement for services rendered to beneficiaries of
the program. Payment is to be made on the basis of current costs of the
individual provider, rather than costs of a past period or a fixed
negotiated rate. This cost report also designs this reimbursement
formulation so that the individual provider's costs are not borne by
other patients.
CMS believes that the assessed revisit user fee is not an allowable
item for a cost report, as it should not be figured into the services
provided to beneficiaries, nor should it be a cost shared amongst non-
Medicare patients. CMS employs several checks and balances to deter
this from occurring. CMS believes that this proposed language in Sec.
488.30(d)(2) would prevent the inclusion of the revisit user fee costs
in any future cost reports. This section will only apply to a small
group of providers who receive cost-based reimbursement. A significant
amount of providers and suppliers are reimbursed through the
prospective payment system (PPS).
As a result of comments received to Sec. 488.20(d)(1) and (d)(2)
and CMS' further consideration, we will modify the proposed language of
Sec. 488.30(d)(1) and retain the proposed language of Sec.
488.30(d)(2) as final. The proposed last sentence of Sec. 488.30(d)(1)
will be modified to read: ``Any method allowed by law, including credit
card; electronic fund transfer; check; money order; offset collection
from claims submitted.'' The remainder of the proposed language will be
retained as final.
Section 488.30(e)--Reconsideration Process for Revisit User Fees
We proposed in Sec. 488.30(e) that a reconsideration process shall
be available to providers or suppliers that have been assessed a
revisit user fee if a provider or supplier believes an error of fact,
such as a clerical error, has been made. We also proposed that a
request for reconsideration must be received by CMS within seven
calendar days from the date identified on the revisit user fee
assessment notice.
Comment: Several commenters believe that a reconsideration process
should be available for surveyor errors and substantial errors of
interpretation, and that it should not be limited to just clerical
errors. Another commenter indicated that the reconsideration process
should include unfounded citations. One commenter asked for
clarification on what was meant by ``error of fact,'' as a basis for
requesting a reconsideration. Another commenter asked whether a
provider could request a reconsideration of a fee if they were in the
process of appealing deficiencies.
Response: The reconsideration process for revisit user fees is
intended only for those situations in which a provider or supplier
believes that an error of fact has been made in the application of the
revisit user fee. These errors of fact would include such things
[[Page 53640]]
as clerical errors, billing for a fee already paid, inadvertent billing
for a revisit following a validation survey of a deemed provider, or
assessment of a fee when there was no revisit conducted. A request for
reconsideration of an assessed revisit user fee is a separate process
from any informal dispute resolution or appeal of the underlying
deficiency citations.
Comment: Several commenters thought that limiting the window for
revisit user fee reconsideration request to seven calendar days was
unrealistic and requested that the timeframe for reconsideration
requests be expanded to 30 calendar days. Another commenter requested
that the timeframe for a reconsideration request be extended to 10
calendar days, and other commenters suggested a 14 or 15 calendar day
window. However, one commenter thought that the seven day window was
reasonable.
Response: We proposed that a request for reconsideration must be
received by CMS within seven calendar days from the date identified on
the revisit user fee assessment notice. CMS has considered the
commenters' suggestions for extending the timeframe for submitting a
reconsideration request and we have agreed to expand the timeframe for
reconsideration requests to 14 calendar days from the date identified
on the revisit user fee assessment notice. We will, therefore, change
the timeframe for submitting a reconsideration request to 14 calendar
days in the final rule. The time trigger date is the date when the
assessment notice is prepared and sent. The revisit survey must have
occurred prior to our assessment of a revisit user fee.
Comment: Several commenters suggested that, where a reconsideration
determines that a revisit user fee was charged in error, any payments
made should be refunded immediately, instead of applying the payment to
future assessments of fees. One commenter suggested that refunds should
be made within 30 days, whereas another commenter suggested 60 calendar
days of approval of a reconsideration request. Commenters thought that
actions related to fees should remain pending until the outcome of the
reconsideration, and that a fee should not be paid until a facility
exhausts its appeals; upon successful reconsideration, a provider would
receive written confirmation that a fee is null and void.
Response: We believe that given the proposed timeframe for
submitting a reconsideration request and the regulatory obligation of
payment (within 30 calendar days), there would be a limited possibility
that payment would be sent without CMS providing a response to the
reconsideration. We, however, believe that regulatory clarification is
warranted based on the type of comments received. We have modified the
proposed text to include separate subparagraphs Sec. 488.30(e)(1)(i)
and (ii), (e)(2), and (e)(3). The modified language of Sec. 488.30(e)
will read as follows:
(e) Reconsideration process for revisit user fees.
(1) CMS will review a request for reconsideration of an assessed
revisit user fee--
(i) If a provider or supplier believes an error of fact has been
made in the application of the revisit user fee, such as clerical
errors, billing for a fee already paid, or assessment of a fee when
there was no revisit conducted, and
(ii) If the request for reconsideration is received by CMS
within 14 calendar days from the date identified on the revisit user
fee assessment notice.
(2) CMS will issue a credit toward any future revisit surveys
conducted, if the provider or supplier has remitted an assessed
revisit user fee and for which a reconsideration request is found in
favor of the provider or supplier. If in the event that CMS judges
that a significant amount of time has elapsed before such a credit
is used, CMS will refund the assessed revisit user fee amount paid
to the provider or supplier.
(3) CMS will not reconsider the assessment of revisit user fees
that request reconsideration of the survey findings or deficiency
citations that may have given rise to the revisit, the revisit
findings, the need for the revisit itself, or other similarly
identified basis for the assessment of the revisit user fee.
We believe that the potential that a provider or supplier would be
assessed a revisit user fee due to clerical error would be rare, when
this is viewed through the overall survey process and checks and
balances inherent in the survey and certification process. We believe
that in the rare case that this assessment should occur, we have
provided providers and suppliers with an opportunity to request a
reconsideration. We, indicated, however, in Sec. 488.30(e)(3) that
``we will not reconsider the assessment of revisit user fees that
request reconsideration of the survey findings or deficiency citations
that may have given rise to the revisit, the revisit findings, the need
for the revisit itself, or other similarly identified basis for the
assessment of the revisit user fee.'' We also, based on comments
received, have provided providers and suppliers a greater window for
submission of requests for reconsideration from 7 calendar days to 14
calendar days. We are including additional language in Sec.
488.30(e)(2) that identifies that we will issue a credit toward any
future revisit surveys conducted if a provider or supplier has remitted
an assessed revisit user fee and for which a reconsideration request is
found in favor of the provider or supplier as we discussed in the
preamble text of the Proposed Rule. We further clarify that we ``in the
event that CMS judges that a significant amount of time has elapsed
before such a credit is used, CMS will refund the assessed revisit user
fee amount paid to the provider or supplier.'' In regards to the
commenters' specific suggestion that refunds should be made within 30
calendar days, or commenters that suggested 60 calendar days, CMS will
make a concerted effort to respond to requests for reconsideration
within a timely manner and notify providers or suppliers that the
reconsideration was determined in their favor, as applicable prior to
the time frame for which they must remit payment. However, in those
cases where remittance has occurred and the provider or supplier has
not experienced an additional revisit survey and is then due a refund,
CMS is committed to developing a system that would ensure efficient
refund of any monies collected in error. CMS' present bill pay system
would require more than 30 to 60 calendar day processes. We estimate
that this cause for a refund may occur in less than 5% of all overall
cases. At this time, CMS does not have the requisite data in which to
provide specific amounts of provider or suppliers falling into this
category, however we believe it will be an even lower percentage
provided all the inherent checks and balances in our current survey and
certification process.
Comment: Several commenters requested that CMS clarify the time
frame for when a reconsideration decision will be made, and one
commenter requested that CMS include a deadline in the regulation for
responding to reconsideration requests. One commenter proposed that
reconsiderations be resolved within 30 days of a reconsideration
request.
Response: CMS is cognizant of the providers' 30 calendar day time
frame for submitting payment and will ensure that reconsiderations are
resolved in a timely manner. CMS will make a concerted effort to
respond to request for reconsideration within a timely manner and
notify provider or suppliers that the reconsideration was determined in
their favor, prior to the time frame for which they must remit payment.
We appreciate comments received on time frames, refund methodology,
and notification. As a result of suggestions, we have modified Sec.
488.30(e) to include
[[Page 53641]]
within 14 calendar days for requests for reconsideration. Section
488.30(e) will read in final as discussed above.
Section 488.30(f)--Enforcement
We proposed in Sec. 488.30(f) that if the full revisit user fee
payment is not received within 30 calendar days or a request for
reconsideration is not received within seven calendar days from the
date the provider or supplier receives written notice of assessment,
CMS may terminate the facility's provider agreement and enrollment in
the Medicare program or the supplier's enrollment and participation in
the Medicare program, and the provider or supplier may not seek
Medicare payment, nor be considered a Medicare participating provider
or supplier. We have changed the seven calendar day time period for
filing of a reconsideration request to fourteen calendar days.
Otherwise, CMS will adhere to the termination process as identified in
Sec. 489, subpart E, of this chapter.
Comment: Some commenters connected the discussion of revocation of
billing and the termination for nonpayment as proposed in Sec.
488.30(f) and Sec. 489.53(a)(16). One commenter felt that termination
for nonpayment within 30 days is power disproportionate to the offense
and is unrelated to quality of care and safety issues. Another
commenter felt that this provision is reason not to participate in
Medicare, or to care for Medicare patients.
Response: While we proposed that a provider or supplier may also be
determined not to be in compliance if a revisit user fee payment has
not been received within 30 calendar days from the date identified on
the assessment notice, we also state at Sec. 424.535(a)(1) that all
providers and suppliers are granted an opportunity to correct the
deficient payment compliance before a final determination is made to
revoke billing and enrollment privileges. We further note that a
payment-due notice from CMS is preceded by a survey or complaint
investigation that has found deficiencies, a correction period afforded
to the provider or supplier, a revisit to confirm compliance, then a
later issuance of the payment-due notice, followed by the formal 30-day
advance notice to the provider. As soon as a revisit occurs, each
provider or supplier will know that a revisit user fee will follow at a
later date, will know the amount of the fee due from the fee schedule
published in this rule, and will know that the payment will be due
within 30 calendar days. While the rule specifies that enforcement
action may occur if the bill has not been paid within 30 calendar days,
the total amount of planning time available to the provider or supplier
will have totaled much more than the 30-calendar day period before any
enforcement action may occur. Finally, the revocation of billing and
enrollment privileges is not an immediate action upon the failure of a
provider or supplier to remit the assessed revisit user fee. In this
final rule we therefore retain the time-frames for which action will
occur regarding this process and retain the amended language to Sec.
424.535(a)(1) as final.
Comment: A commenter indicated that the definition of revisit
survey should be revised to limit it to those revisits in which the
cited deficiency includes and is subject to an enforcement action under
Subpart B of Part 489.
Response: We have not included the commenter's suggestion to revise
the term revisit survey to include ``is subject to an enforcement
action under subpart B of Part 489.'' Subpart B of part 489 governs
provider agreements, not enforcement actions. However, we do agree with
the premise of the commenter's suggestion and thus have modified
language in Sec. 488.30(f) to include cross references to the
appropriate subpart and subsection of part 489 (governing termination)
and to a subsection of part 424 (governing revocation of enrollment and
billing privileges).
Section 488.30(f) will be modified to read as applicable components
``pursuant to Sec. 489.53(a)(16) of this chapter'' and ``pursuant to
Sec. 424.535(a)(1) of this chapter.'' We retain the remainder of the
proposed language in Sec. 488.30(f) as final.
Part 489--Provider Agreements and Supplier Approval
Subpart B--Essentials of Provider Agreements
Section 489.20 Basic Commitments
Section 489.20(u)
We proposed to add to Sec. 489.20 an additional paragraph that
would require a provider to agree to pay revisit user fees when and if
assessed.
We did not receive comments regarding this additional paragraph.
However, due to technical changes, paragraph (u) is designated as
paragraph (w) and we will retain the proposed language as final.
Subpart E--Termination of Agreement and Reinstatement After Termination
Section 489.53 Termination by CMS
Section 489.53(a)(16)
We proposed to add a new paragraph (16) to Sec. 489.53(a) that
would create an additional basis for termination if a provider has
failed to pay a revisit user fee when and if assessed.
We did not receive comments regarding this additional paragraph and
thus we retain the proposed language in Sec. 489.53(a)(16) as final.
III. Provisions of the Final Rule
In this final rule we are adopting the provisions as set forth in
the June 29, 2007 proposed rule with the following revisions:
All additional language proposed in Sec. 424.535, Revocation of
enrollment and billing privileges in the Medicare Program will be
retained as final.
All proposed definitions in Sec. 488.30(a) are adopted as final,
except for an addition to the definition of ``provider of services,
provider or supplier.'' The final definition now includes religious
nonmedical health care institutions.
All proposed language in Sec. 488.30(b)(1) and (b)(2) criteria for
determining the fee is adopted as final.
Language proposed in Sec. 488.30(c) Fee schedule is modified by
removing term ``will'' and inserting the term ``must'' where
applicable, we also removed ``adopts this schedule'' and added
``assesses revisit user fees'' for clarification. In addition we
include that the clarifying language ``which criteria will be used and
how, as well as * * *,'' the remainder of the language is adopted as
final.
The last sentence of the language proposed in Sec. 488.30(d)(1)
has been modified for clarification to state that ``CMS may consider
any method allowed by law, including: Credit care; electronic fund
transfer; check; money order; and offset collections from claims
submitted, the remainder of this paragraph is retained as final. All
proposed language in Sec. 488.30(d)(2)-- the prohibition of inclusion
of the revisit user fee on a provider cost report--is adopted as final.
We have added a new subparagraph and new language as a result of
various comments regarding the time frame for when we may collect fees,
and the concerns regarding the schedule of these fees, Sec.
488.30(d)(3) will read: ``Fees for revisit surveys will be due for any
revisit surveys conducted during the time period for which authority to
levy a revisit user fee exists.''
[[Page 53642]]
Language proposed in Sec. 488.30(e) reconsideration process for
revisit user fees will be modified by changing the formatting of the
paragraph to include paragraphs (e)(1)(i), (e)(1)(ii), (e)(2), and
(e)(3). Language in paragraph (e)(1)(i) previously proposed as first
sentence in paragraph (e) is retained as final. We have modified
paragraph (e)(1)(ii) by changing that a request for reconsideration
must be received by CMS within 14 calendar days instead of the 7
calendar days as proposed. We have added a new paragraph (e)(2) that
identifies when CMS will issue a credit or a refund of an assessed
revisit user fee in the rare case of a provider or supplier remitting
payment and ultimately a reconsideration is decided within their favor.
We have added a new paragraph (e)(3) that identifies that a request for
reconsideration of the revisit user fee may not include reconsideration
of the survey findings or deficiency citations that may have given rise
to the revisit, the revisit findings, or the need for the revisit
itself.
All proposed language in Sec. 488.30(f) Enforcement is adopted as
final with the addition of language identifying the interconnection of
changes made to both Sec. Sec. 424.535(a)(1) and 489.53(a)(16). The
language will read in final: ``If the full revisit user fee payment is
not received within 30 calendar days from the date identified on the
revisit user fee assessment notice, CMS may terminate the facility's
provider agreement (pursuant to Sec. 489.53(a)(16) of this chapter)
and enrollment in the Medicare program or the supplier's enrollment and
participation in the Medicare program (pursuant to Sec. 424.535(a)(1)
of this chapter).
All proposed new paragraphs to Sec. 489.20 and Sec. 489.53 are
adopted as final.
Waiver of 30-Day Delay in the Effective Date
We ordinarily provide a 30-day delay in the effective date of the
provisions of a rule in accordance with the Administrative Procedure
Act (APA) 5 U.S.C. 553(d). However, the delay in the effective date may
be waived as, in pertinent part, ``provided by the agency for good
cause found and published with the rule'' 5 U.S.C. 553(d)(3). The
Secretary finds that good cause exists to make effective the revisit
user fee and the corresponding fee schedule immediately upon display
and publication in the Federal Register.
The good cause exception to the 30 day effective date delay
provision of section 553(d) of the APA is read to be broader than the
good cause exception to the notice and comment provision of section
553(b) of the APA.
The legislative history of the APA indicates that the purpose for
deferring the effectiveness of a rule under section 553(d) was to
``afford persons affected a reasonable time to prepare for the
effective date of a rule or rules or to take other action which the
issuance may prompt.'' S. Rep. No. 752, 79th Cong., 1st Sess. 15
(1946); H.R. Rep. No. 1980, 79th Cong., 2d Sess. 25 (1946). In this
case, affected parties do not need time to adjust their behavior before
this rule takes effect. With or without a revisit fee, a provider or
supplier must be found to have corrected significant deficiencies in
order to avoid termination. Additionally, the application of a fee for
the revisit does not place appreciable administrative burdens on the
affected providers or suppliers. We do not expect appreciable cost to
State survey agencies because CMS is undertaking the billing and
collection of the revisit user fee.
CMS identified in the proposed rule the immediacy of this revisit
user fee program and the limited nature of the Continuing Resolution.
Specifically, the Continuing Resolution requires CMS to implement the
revisit fee program in fiscal year 2007. Accordingly, providers and
suppliers have been on notice for some time that these fees would be
imposed, and do not need additional time to be prepared to comply with
the requirements of this regulation. We believe that given the short
time frame that CMS has to collect fees before the authority of the
Continuing Resolution expires, there is good cause to waive the 30 day
effective date.
IV. Collection of Information Requirements
This document does not impose information collection and
recordkeeping requirements. Consequently, it need not be reviewed by
the Office of Management and Budget under the authority of the
Paperwork Reduction Act of 1995.
V. Regulatory Impact Analysis
A. Overall Impact
We have examined the impacts of this rule as required by Executive
Order 12866 (September 1993, Regulatory Planning and Review), the
Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96-354),
section 1102(b) of the Social Security Act, the Unfunded Mandates
Reform Act of 1995 (Pub. L. 104-4), and Executive Order 13132.
Executive Order 12866 (as amended by Executive Order 13258, which
merely reassigns responsibility of duties) directs agencies to assess
all costs and benefits of available regulatory alternatives and, if
regulation is necessary, to select regulatory approaches that maximize
net benefits (including potential economic, environmental, public
health and safety effects, distributive impacts, and equity). A
regulatory impact analysis (RIA) must be prepared for major rules with
economically significant effects ($100 million or more in any 1 year).
This final rule is not a major rule. The aggregate costs will total
approximately $37.3 million in any 1 year.
The RFA requires agencies to analyze options for regulatory relief
of small businesses. For purposes of the RFA, small entities include
small businesses, nonprofit organizations, and small governmental
jurisdictions. Individuals and States are not included in the
definition of a small entity. Small businesses are small entities,
either by nonprofit status or by having revenues of $6.5 million to
$31.9 million or less in any 1 year for purposes of the RFA. In the
June 29, 2007 Federal Register, CMS issued a proposed rule identifying
its limited information to separate and identify specific providers and
suppliers that may be subject to a revisit user fee by the requirements
described for purposes of the RFA. CMS also identified its limited
information on the total revenues collected by provider or supplier
type. CMS does collect information regarding Medicare and Medicaid
claims submitted, however this would not provide the requisite
requirements for the RFA regarding total revenues. CMS also identified
that it does collect National level information which includes personal
health care expenditures and payments. Personal health care as we
discussed in the proposed rule includes hospital care, professional
services, nursing and home health care, all of which cover those
services provided by the provider and suppliers who may be assessed a
revisit user fee.
Based on the information provided within the proposed rule a few
commenters felt that the user fee would add what they consider
financial strains on an already strained nursing home industry,
especially to stand alone, not-for-profits. Additionally, two
commenters stated that the economic implication must be considered,
including the potential impact on wages for employees within healthcare
facilities. Another commenter requested that CMS in this section take
into account State differences, citing their State's increased costs
for all their home health and hospice providers, who are subject to
increased fees in general and
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felt this user fee would disproportionately impact these providers in
their State. Another commenter felt that Home Health Agencies have been
adversely impacted by stagnant and declining reimbursement from both
Medicare and Medicaid in the past years.
CMS specified in the proposed rule that the providers and suppliers
that may be assessed a revisit user fee fall into the category of
revenues collected under personal health care funds. As such CMS
calculated that the overall impact of the estimated $37.3 million that
will be assessed for revisit user fees would only amount to 2.3 percent
of the $1,560.2 million personal health care revenues collected and
only 1.9 percent of all national health care expenditures of which
personal health care expenditures are included.
Although we do not deny that the revisit user fee would require a
payment from a provider or supplier who is assessed a fee due to the
need for a revisit survey, we do not believe it will have such an
economic impact that it would create additional financial strains on
providers and suppliers. We believe that many providers and suppliers
will pay no fees because they consistently provide high quality care,
have no deficiencies identified through the survey process, and
therefore will require no revisits. Thus, this rule will have minimal
financial impact on those providers and suppliers. In addition, we
appreciate the commenters' concern regarding their specific State's
financial situation.
For the immediate future, we have calculated the user fee by
provider type and by average number of hours required for a revisit
survey. It is our intent that we will consider other criteria as
identified in Sec. 488.30(b), which includes regional differences when
proposing and finalizing future fee schedules. Based on our information
gathered, we have determined, and the Secretary certifies, that this
rule will not have a significant impact on small entities based on the
overall effect on revenues.
Section 1102(b) of the Act requires us to prepare a regulatory
impact analysis if a rule may have a significant impact on the
operations of a substantial number of small rural hospitals. This
analysis must conform to the provisions of section 604 of the RFA. For
purposes of section 1102(b) of the Act, we define a small rural
hospital as a hospital that is located outside of a Metropolitan
statistical Area (superseded by Core Based Statistical Areas) and has
fewer than 100 beds. This final rule affects those small rural
hospitals that have been cited for a deficiency based on noncompliance
with required conditions of participation and for which a revisit is
needed to make sure that the deficiency has been corrected.
Based on the information provided as a requirement for Section
1102(b) of the Act, some commenters raised concerns that these fees
will be very expensive for various rural providers or suppliers, not
just rural hospitals, but also small rural Home Health Agencies and
long-term care facilities in rural communities, and that CMS could be
affecting the availability of care in rural areas. One commenter asked
why hospitals should be exempt from the fee just because the fee may
have a significant impact on them; while another commenter raised what
they identified as unfairness in the frequency of surveys conducted
annually for long-term care facilities versus 3 years for hospitals.
Hospitals are not exempt from the revisit user fees. While
hospitals are surveyed less frequently than nursing homes, hospitals
are subject to CMS complaint investigations similar to nursing home
complaint investigations as well as other providers and suppliers. CMS
is statutorily obligated to conduct a regulatory impact analysis for
small rural hospitals as part of its rule making process. As such, we
have reviewed data affecting these rural hospitals, and upon that
review have determined that of all hospitals identified, 285 revisits
or 3.9 percent were conducted in rural hospitals to ensure that
deficiencies identified were corrected. Based on the effective time
period of this proposed rule, less than 3 percent of all hospitals may
in fact be assessed a revisit user fee in this current fiscal year (FY
2007), we estimate that less than 1 percent of rural hospitals will be
impacted by this rule.
The statutory analysis that is required does not indicate that
small rural hospitals would be exempt from regulatory requirements.
Rather, it requires only that the rule making agency must determine the
overall financial impact on small rural hospitals. We do not make a
distinction on the quality-of-care provided to residents or patients by
either urban or rural location. Federal regulations call for all
residents and patients to receive adequate care. The revisit user fee
will only be assessed as a result of deficiencies cited with respect to
providers or suppliers not fully complying with Federal requirements.
With regard to the survey frequency, nursing homes are mandated by
statute to be certified annually, whereas CMS policy calls for
hospitals (both accredited and non-accredited) to be certified or
deemed certified on a 3 year cycle.
In addition, we appreciate the commenters' concern regarding the
potential impact on various rural communities. For the immediate
future, we have calculated the user fee by provider type and by average
number of hours required for a revisit survey. It is our intent that we
will consider other criteria as identified in Sec. 488.30(b), which
includes regional differences and facility size when proposing and
finalizing future fee schedules. Based on our information gathered, we
have determined, and the Secretary certifies, that this rule will not
have a significant impact on small rural hospitals.
Section 202 of the Unfunded Mandates Reform Act of 1995 also
requires that agencies assess anticipated costs and benefits before
issuing any rule whose mandates require spending in any 1 year of $100
million in 1995 dollars, updated annually for inflation. That threshold
level is currently approximately $120 million. This rule will have no
mandated effect on State, local, or tribal governments and the impact
on the private sector is estimated to be less than $120 million and
will only effect those Medicare providers or suppliers for which a
revisit user fee is assessed based on the need to conduct a revisit
survey to ensure deficient practices that were cited have been
corrected.
Executive Order 13132 establishes certain requirements that an
agency must meet when it promulgates a proposed rule (and subsequent
final rule) that imposes substantial direct requirement costs on State
and local governments, preempts State law, or otherwise has Federalism
implications. This final rule will not substantially affect State or
local governments. This final rule establishes user fees for providers
and suppliers for which CMS has identified deficient practices and
requires a revisit to assure that corrections have been made. Therefore
we have determined that this final rule will not have a significant
affect on the rights, roles, and responsibilities of State or local
governments.
B. Impact on Providers/Suppliers
The source of the data used to estimate the number and cost of
revisit surveys is CMS's Online Survey, Certification and Reporting
(OSCAR) database. OSCAR is the repository of information about CMS and
State survey agency survey actions. Data collected include the dates of
surveys, survey findings, and the length of time that surveyors spent
conducting the survey. State survey agencies record survey time
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on the CMS-670 form. Data from the CMS-670 form are entered into OSCAR
by the State survey agency. CMS analyzed average survey time length
using actual data from FY 2006.
Based on information entered into OSCAR, we proposed user fees in
accordance with the type of revisit survey (onsite vs. offsite); the
type of provider or supplier; the average number of hours that a
revisit survey requires; and the average per hour cost of a revisit
survey.
Overall Effect on Providers and Suppliers
We estimate that there are potentially 47,804 providers and
suppliers affected by the revisit user fee, although we expect only
some of those providers will be charged a revisit user fee in any one
particular year. We based this estimate on FY 2006 actual data. Table B
below presents the key information. Of those providers and suppliers,
34.8 percent required and received a revisit survey in FY 2006,
including both onsite and offsite revisits. As identified in the
proposed rule, providers and suppliers that required a revisit survey
ranged widely across facility types from 87.9 percent for skilled
nursing facilities (``SNFs'')/nursing facilities (``NFs'') to 2.8
percent for ambulatory surgical centers. We did not include transplant
centers in FY 2006 and 2007 calculations due to lack of available cost
and revisit data at this time. Transplant centers will be newly
surveyed providers starting in FY 2008, and will be subject to revisit
fees at the hospital rate.
Table B.--Percentage of Providers/Suppliers That Had a Revisit Survey FY 2006
----------------------------------------------------------------------------------------------------------------
Number of Percent of
providers/ provider/
Total Total revisit suppliers that suppliers that
providers/ survey for FY required required
suppliers\1\ 2006 (onsite & revisit survey revisit survey
offsite) (onsite & (onsite &
offsite) offsite)
----------------------------------------------------------------------------------------------------------------
SNF/NF \2\...................................... 15,172 29,426 13,350 87.9
Hospitals\3\.................................... 7,139 853 594 8.3
HHAs............................................ 8,901 1,585 1,320 14.8
Hospices........................................ 3,077 307 246 7.9
ASC............................................. 4,735 188 133 2.8
RHC............................................. 3,828 216 204 5.3
ESRD............................................ 4,952 929 781 15.7
---------------------------------------------------------------
Total....................................... 47,804 33,504 16,662 34.8
----------------------------------------------------------------------------------------------------------------
\1\ Online Survey, Certification and Reporting (OSCAR) database (via PDQ, Provider Summary Table), includes
providers considered active at any time in the fiscal year.
\2\ Total number does not include Medicaid-only Nursing Facilities.
\3\ Total includes accredited and non-accredited hospitals, as well as psychiatric hospitals, and critical
access hospitals.
Comments: One commenter observed that, in CMS' impact analysis and
fee proposals, CMS chose to include critical access hospitals in a
single grouping with all other hospitals, even though section 1861(e)
of the Social Security Act states that the term hospital does not
include, unless the context otherwise requires, a critical access
hospital (as defined in section 1861(mm)(1)). The commenter stated that
because critical access hospitals are typically smaller and less
complex organizations than most other hospitals, the context clearly
does not require their inclusion with hospitals in this analysis and
that it would seem that the average length of an onsite revisit survey,
and the corresponding assessed fee, would be less than that of other
hospitals. CMS should at least present the relevant data on critical
access hospitals.
Response: We included critical access hospitals in our hospital
average fee due to their similar functions and surveying process. We
believe this issue raised by commenters has merit which will require
further analysis and we will consider looking at critical access
hospitals in future fee schedules as its own distinct entities. We
agree that revisit time may be affected by many factors in addition to
size of the facility. We have adopted a relatively straightforward
method of calculating the user fee. If the Congress renews or extends
the authority to collect the revisit user fee for any considerable time
period, we intend to build into the fee schedule a means to take into
account facility size and location to the extent that we find such
factors make a significant difference in the time and actual cost of
the revisits.
Frequency and Duration of Revisit Surveys
There are many differences across providers and suppliers in the
frequency and duration of revisit surveys. Skilled nursing facilities/
nursing facilities accounted for 83 percent of total onsite revisit
surveys conducted in FY 2006 following