SS 1215-0193 December 2006

SUPPORTING STATEMENT

CLAIM FOR MEDICAL REIMBURSEMENT FORM (OWCP-915)

OMB NO. 1215-0193

1. The Office of Workers’ Compensation Programs (OWCP) administers the Federal Employees’ Compensation Act (FECA), 5 U.S.C. 8101 et seq., the Black Lung Benefits Act (BLBA), 30 U.S.C. 901 et seq., and the Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA), 42 U.S.C. 7384 et seq. All three statutes require OWCP to pay for covered medical treatment that is provided to beneficiaries, and also to reimburse beneficiaries for any out-of-pocket covered medical expenses they have paid. Form OWCP-915, Claim for Medical Reimbursement Form, is used for this purpose and collects the necessary beneficiary and medical provider data in a standard format. Beneficiaries must also attach billing information prepared by the medical provider (Form OWCP-1500 for professional medical services, Form OWCP-92 for institutional providers and hospitals, or a paper bill for prescription drugs dispensed by a pharmacy) and proof of payment. The hour and cost burdens to collect the billing information from medical providers in the required attachments to Form OWCP-915 are accounted for in OMB Nos. 1215-0055, 1215-0176 and 1215-0194. This is the same billing information a medical provider reports when it bills OWCP directly. Regulations implementing the FECA, BLBA and EEOICPA programs require the collection of information that is needed to determine if reimbursement claims submitted by beneficiaries can be paid. (20 CFR 10.802, 30.702, 725.701 and 725.705).

2. All claims for reimbursement undergo automated scanning upon receipt at OWCP’s Central Mail Facility. Because Form OWCP-915 presents the required information in a standard format, scanning allows claims that meet payment criteria to be paid very quickly, ensuring timely reimbursement payments to beneficiaries. When a beneficiary pays for services out of his or her own pocket, OWCP needs to collect basic information about the beneficiary and the amount paid, and also needs to process the actual bills that have been paid. To accomplish this, OWCP’s medical billing contractor evaluates the billing data elements that are approved in OMB Nos. 1215-0055, 1215-0176 and 1215-0194. If all the data requested on Form OWCP-915 is not collected, OWCP’s contractor cannot process the attached medical bills properly and either pay or deny the reimbursement claim in a timely manner.

3. The OWCP-915 is currently posted on the Internet at http://www.dol.gov/esa/regs/compliance/owcp/OWCP-915.pdf. This form will be replaced with the renewed OWCP-915 following approval by OMB. All reimbursement claims are received at one location, scanned, and undergo an automated review that utilizes a comprehensive set of tables to compare the services rendered with treatment suites for the medical condition(s) accepted by the pertinent program. OWCP is working to expand its ability to accept electronic bills, but because Form OWCP-915 requires attachments (bills prepared by the medical provider and proof of payment made by the beneficiary), submission of this information electronically is not feasible. However, use of a standard claim form keeps the paperwork burden on the public to a minimum by nearly eliminating the need to ask for required information that wasn’t submitted with the original reimbursement claim.

4. The information collected on this form is not duplicative of any information available elsewhere. The beneficiary is the only source of the information for these out-of-pocket expenditures.

5. This information collection has been streamlined to obtain the minimum information needed for OWCP’s bill processing system while imposing the minimum burden on respondents. The required attachments to Form OWCP-915 do not impose additional burdens on small businesses or other small entities since providing billing information to the beneficiary at the time payment is requested is part of a medical provider’s usual business practices.

6. Please refer to Nos. 1 and 2 on page 1. The information required from medical providers is the minimum needed to meet the bill processing needs of the three programs and is collected with widely recognized standard billing formats. Reimbursement claims for medical services provided to and paid for by beneficiaries cannot be processed by OWCP’s medical bill contractor without the information collected. Frequency of data collection is based on how often the beneficiary claims for reimbursement. Because Form OWCP-915 lends itself to multiple visits or services, the number of times a respondent files the form will vary with the number of times during any period that the respondent decides to submit a reimbursement claim. Less frequent collection of this data would result in delayed reimbursement payments to beneficiaries.

7. There are no special circumstances for the collection of this information.

8. A Federal Register notice inviting public comment on this information collection was published on August 15, 2006. No comments were received.

9. No gifts or other form of remuneration are made.

10. All medical reimbursement requests that are submitted are fully protected by the Privacy Act in the following systems of records: DOL/GOVT-1 (FECA); DOL/ESA-6 (BLBA); and DOL/ESA-49 (EEOICPA).

11. There are no questions of a sensitive nature on the Form OWCP-915.

12. The following burden estimates for the three programs have been derived from data compiled during the latest complete fiscal year—FY 2005:

FECA: Approximately 20,677 respondents submit a claim for reimbursement four times annually, for a total number of responses of 82,708 for the FECA program. It is estimated that each Form OWCP-915 claiming reimbursement takes about 10 minutes for the beneficiary to prepare, which results in an annual hour burden of 13,729.53 hours (82,708 responses x 0.166 = 13,729.53 hours).

BLBA: Approximately 120 respondents submit a reimbursement claim four times annually, for a total number of responses of 480 for the BLBA program. It is estimated that each Form OWCP-915 claiming reimbursement takes about 10 minutes for the beneficiary to prepare, which results in an annual hour burden of 79.68 hours (480 responses x 0.166 = 79.68 hours).

EEOICPA: About 599 respondents submit a reimbursement claim four times annually, for a total number of responses of 2,396 for the EEOICPA program. It is estimated that each Form OWCP-915 claiming reimbursement takes about 10 minutes for the beneficiary to prepare, for an annual hour burden of 397.74 hours (2,396 responses x 0.166 = 397.74).

Combining the burden hours for all three programs, Form OWCP-915 has a total respondent annual burden hour estimate of 14,207 hours (13,379.53 + 79.68 + 397.74 = 14,206.95 rounded to 14,207). The specific wage category of beneficiaries who provide this information is not documented in OWCP’s bill processing system. Therefore, using the current national average wage rate (based on Bureau of Labor Statistics data) of $17.18 per hour, the respondent annualized cost estimate for this collection is $244,076.26.

13. There are no recordkeeping or collection costs associated with the beneficiary information collected on Form OWCP-915. The only operation and maintenance cost is for postage. An estimated annual total of 85,584 mailed responses at $1.21 per response ($1.06 in postage for 4 ounces to accommodate attachments + $.15 for large size envelope) = annual operation and maintenance costs of $103,556.64.

14. The estimated costs to the Federal government for collecting the information on Form OWCP-915 are set out below:

Printing costs: OWCP estimates that it will print 100,000 OWCP-915 forms yearly at a cost of $2,400.00 per each fifty thousand forms. Therefore, printing costs for the OWCP-915 will amount to $4,800 per year.

Mailing/Developmental costs: Beneficiaries seeking reimbursement for out-of-pocket medical expenses under FECA, BLBA and EEOICPA may download copies of Form OWCP-915 from the Internet. The form is also included in the packet of materials that OWCP mails to a beneficiary when it accepts the beneficiary’s claim under one of the programs and for that reason, no additional mailing costs for the form are normally incurred. There are also no developmental costs associated with this collection of information.

Processing/Reviewing Costs:

FECA: Under OWCP’s contractor medical bill processing system, the contractor cost to process one Form OWCP-915 is $7.56. Therefore, the contractor cost to process 82,708 forms for the FECA program will be $625,272.48 (82,708 forms x $7.56/form = $625,272.48).

Reimbursement claims that suspend out of the new contractor medical bill processing system and require manual review are examined by 79.68 bill resolution clerks and coding specialists employed by the FECA program at the GS-5 level, and by 12 at the GS-9 level; approximately 5% of their time is required for this function. Thus, the cost to provide this review function is $150,873.04 (79.68 x $31,185/year (GS 5, step 4 using Salary Table 2006-RUS) x 5% = $124,241.04; 12 x $44,387/year (GS 9, step 2 using Salary Table 2006-RUS) x 5% = $26,632; $124,241.04 + $26,632= $150,873.24).

Total FECA Processing/Reviewing costs: $776,145.72.

BLBA: OWCP’s contractor medical bill processing system will perform all processing and manual review functions for the BLBA program, at the same contractor cost of $7.56 per form. Therefore, the contractor cost to process and review 480 forms for the BLBA program will be $3,629 (480 forms x $7.56/form = $3,628.80).

EEOICPA: As it does for FECA, OWCP’s contractor medical bill processing system will process Forms OWCP-915 for the EEOICPA program at a cost of $7.56 per form. Therefore, the contractor cost to process the 2,396 forms submitted for the EEOICPA program will be $18,113.76 (2,396 forms x $7.56/form = $18,113.76).

Two Federal employees in Washington, DC review all claims for reimbursement under the EEOICPA program that suspend out of the contractor bill processing system: a payment systems manager (GS-14, step 3 using Salary Table 2006-DCB) at $97,500 yearly and an assistant payment systems manager (GS-13, step 7 using Salary Table 2006-DCB) at $92,820 yearly. About 5% of their time is attributable to this reviewing function, for a cost of $951,600 ($97,500 + $92,820 = $190,320 x 5% = $9,516).

Total EEOICPA Processing/Reviewing costs: $27,629.76.

$4,800 (printing costs) + $776,145.72 (FECA processing and reviewing costs) + $3,629 (BLBA processing and reviewing costs) + $27,629.76 (EEOICPA processing and reviewing costs) = Total Federal Cost of $812,204.48.

15. Due to the continuing decline in the number of BLBA beneficiaries currently in the program, and the increase in medical providers billing OWCP directly for medical services rather than billing their patients, who then would have to seek reimbursement from OWCP using Form OWCP-915, Form OMB 83-I shows an adjustment change of -8,372 burden hours and -$60,444 operational and maintenance costs.

16. There are no plans to publish data collected by Form OWCP-915.

17. This information collection request does not seek a waiver from the requirement to display the expiration date.

18. There are no exceptions to the certification statement.

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