SUPPORTING STATEMENT
HEALTH INSURANCE CLAIM FORM – OWCP-1500
OMB NO. 1215-0055
Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collections. Attach a copy of the appropriate section of each statute and of each regulation mandating or authorizing the collection of information
1. The Office of Workers’ Compensation Programs (OWCP) is the agency responsible for administration of 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 of these statutes require that OWCP pay for medical treatment of beneficiaries; BLBA also requires that OWCP pay for medical examinations and related diagnostic services to determine eligibility for benefits under that statute. In order to determine whether billed amounts are appropriate, OWCP needs to identify the patient, the injury or illness that was treated or diagnosed, the specific services that were rendered and their relationship to the work-related injury or illness. The regulations implementing these statutes require the use of Form OWCP-1500 for medical bills submitted by certain physicians and other providers (20 CFR 10.801, 30.701, 725.405, 725.406, 725.701 and 725.704).
2. Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.
2. Form OWCP-1500 is used by OWCP and contractor bill payment staff to process bills for medical services provided by medical professionals other than medical services provided by hospitals, pharmacies and certain other medical providers. To consider the appropriateness of the requested payment in a timely fashion, it is essential that provider bills be submitted on a standard form that will capture the critical data elements needed to evaluate the bill, such as procedure and diagnosis codes. Form OWCP-1500 therefore includes the standard billing form (Form CMS-1500) for medical professionals used by Centers for Medicare and Medicaid Services (CMS), Civilian Health and Medical Program for Uniform Services (CHAMPUS), Department of Veteran Affairs (DVA) and most private health insurance carriers. However, since OWCP only needs some of the information requested by the CMS-1500 to process bills submitted in the three programs, it does not require providers to respond fully to the CMS-1500 (see instructions for completing Form OWCP-1500).
For diagnostic services needed to determine claimant eligibility under the BLBA, OWCP staff complete the data elements relevant to claimant identification, and pre-code the medical procedures on the OWCP-1500 forms that are sent to the medical professionals who provide specific authorized services related to the benefit determination process. Information collected by these forms that relates to the actual services provided, the dates of services, fees, required medical reports and signatures is submitted by the medical provider.
The Internal Revenue Service requires the reporting of payments to specific providers in excess of $600 in any one year, making it necessary to obtain the provider’s tax identification number for each bill. If the provider’s tax identification number and social security number (SSN) are the same, OWCP is required to obtain the SSN to meet IRS reporting requirements.
3.Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also, describe any consideration of using information technology to reduce burden.
In accordance with the Government Paperwork Elimination Act,
the current Form OWCP-1500 is electronically interactive and is posted on the Internet at http://www.dol.gov/libraryforms/go-us-dol-form.asp?FormNumber=385 A provider may complete the form online, print out a paper copy and mail it to OWCP’s medical billing contractor. Once the renewal of No. 1215-0055 is approved, the currently posted version of this form will be replaced with a revised version.
4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.
4. The information requested through the Form OWCP-1500 is not duplicative of any information available elsewhere. The medical providers who use Form OWCP-1500 to bill the programs for their services are the only sources of the required information.
5. If the collection information impacts small businesses or other small entities (Item 5 of OMB Form 83-1), describe any methods used to minimize burden
5. This information collection has been streamlined to obtain the necessary information for OWCP’s bill processing system while imposing the minimum burden on respondents. Form OWCP-1500 does not impose additional burdens on small businesses or other small entities because providing billing information in this format is part of a medical provider’s usual business practices.
Describe the consequence of Federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.
6. Please refer to Nos. 1 and 2 on page 1. The information required is the minimum needed to meet the bill processing needs of the three programs and is in a widely recognized standard format. Appropriate payment for the medical services provided by law to eligible claimants cannot be made by OWCP and contractor bill payment staff without the information collected. Frequency of data collection is based on how often the provider requests payment for covered services it has rendered. Because Form OWCP-1500 lends itself to multiple visits or services, the number of times the form is filed with OWCP varies with the number of times during any period that the provider decides to submit billing. Less frequent collection of data would result in delayed payment to providers.
Explain any special circumstances.
7. There are no special circumstances for the collection of this information.
If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the agency's notice, required by 5 CFR 1320.8 (d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments.
8. OWCP was represented on the National Uniform Claim Committee responsible for the current version of Form CMS-1500 that is part of Form OWCP-1500. The design is intended to ease the burden of completion by medical providers, to reduce reimbursement delays through standardized data entry, standardized nomenclature code use and standardized locator code use, to facilitate quality/cost control measures, and to be a useful instrument to third party payers (including both government and private sector users) for other purposes such as the analyses of commonly provided health care services.
A Federal Register Notice inviting public comment was published on March 12, 2009. No comments were received.
9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees
There are no gifts to respondents. Payments are only for medical services provided under the various acts.
Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulations, or agency policy.
10. All bill payment requests submitted on Form OWCP-1500 are fully protected under the Privacy Act in the following systems of records: DOL/GOVT-1 (for FECA); DOL/ESA-6 (for BLBA); DOL/ESA-49 (for EEOICPA).
Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary; the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.
11. There are no questions of a sensitive nature.
Provide estimates of the hour burden of the collection of information. The statement should:
Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. Unless directed to do so, agencies should not make special surveys to obtain information on which to base burden estimates. Consultation with a sample of potential respondents is desirable. If the burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated burden and explain the reason for the variance. Generally, estimates should not include burden hours for customary and usual business practices. If the request for approval is for more than one form, provide separate burden estimates for each form and aggregate the hour burdens in Item 13 of OMB Form 83-1.
Provide estimates of annualized cost to respondents for the hour burdens for collections of information, identifying and using appropriate wage rate categories. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14.
12. The following burden estimates for the three programs were derived from data compiled during the latest complete fiscal year—FY 2009: FECA: an estimated 700,000 respondents submit the OWCP-1500 four times a year; BLBA: an estimated 35,500 respondents submit the OWCP-1500 four times a year, and EEOICPA: an estimated 13,604 respondents submit the OWCP-1500 four times a year, which is an average of number of times respondents will submit in a year, making the total number of respondents 749,104.
FECA: An estimated 700,000 respondents submit the OWCP-1500 four times yearly, for an estimated total number of responses under that program of 2,800,000. It is estimated that each of these responses will take approximately seven minutes to complete, for an annual hour burden of 336,000 hours. (2,800,000 x .12 = 336,000 hours)
BLBA: An estimated 35,500 respondents submit the OWCP-1500 four times yearly, for an estimated total number of responses under that program of 142,000. Of these responses, about 5,720 will be for benefit determination-related services authorized by the BLBA. Because the forms for these particular responses are pre-coded by OWCP, it is estimated that these responses will take approximately five minutes, for an annual hour burden of 475 hours (5,720 x 0.083 = 475.00 hours (rounded to 475 hours). It is estimated that the remaining responses will take approximately seven minutes to complete, for an annual hour burden of 16,354 hours (136,280 x .12 = 16,354 hours). These two figures results in annual hour burden for all of BLBA of 16,829 hours.
EEOICPA: An estimated 13,604 respondents will submit Form OWCP-1500 four times yearly, for an estimated total number of responses under that program of 54,416. It is estimated that each of these responses will take approximately seven minutes to complete, for an annual hour burden of 6,530 hours. (54,416 x .12 = 6,530 hours)
Combining the burden hours for all three programs, Form OWCP-1500 has a total respondent burden hour estimate of 359,359. The mean wage rate for billing clerks (based on Bureau of Labor Statistics data) is estimated to be $14.94 per hour. Thus, the respondent cost estimate for this collection is $5,368,823.
13. Annual Costs to Respondents (capital/start-up & operation and maintenance).
13. The cost of completing and submitting bills using Form OWCP-1500 is included in the charges submitted by respondents for the services provided. Therefore, respondents experience no operation and maintenance costs.
14. Provide estimates of annualized cost to the Federal government
14. The estimated costs to the Federal government for collecting the information on Form OWCP-1500 are set out below:
Printing costs: OWCP estimates that it will print 50,000 OWCP-1500 forms yearly, to be available when respondents ask for them and this is just an estimate, at a cost of $2,400.00 per each fifty thousand forms. Therefore, printing costs for the OWCP-1500 will total $2,400.00 per year.
Mailing costs: Physicians and other providers seeking payment under FECA, BLBA and EEOICPA may obtain copies of Form OWCP-1500 from various sources on the Internet. The vast majority is now downloaded and computer-generated; for these forms, there are no distribution costs. For BLBA, if providers are testing claimants so the program can determine their eligibility for benefits, OWCP staff sends them pre-coded forms by mail; about 5,720 pre-coded forms x $0.47 ea. (includes cost of envelope) = $2,688.00 yearly.
Processing/Reviewing costs:
FECA: Under OWCP’s contractor medical bill processing system, the contractor cost to process one Form OWCP-1500 is $3.03. Therefore, the contractor cost to process 2,800,000 forms for the FECA program will be $8,484,000 (2,800,000 forms x $3.03/form = $8,484,000).
Bills that suspend out of the contractor medical bill processing system and require manual review are examined by 80 bill resolution clerks and coding specialists employed by the FECA program at the GS-5, step 4 level, and by 12 at the GS-9, step 2 level; approximately 5% of their time is required for this function. Thus, the cost to provide this review function is $164,303(80 x $33,849/year (GS 5, step 4 using Salary Table 2009-RUS) x 5% = $135,396; 12 x $48,179/year (GS 9, step 2 using Salary Table 2009-RUS) x 5% = $28,907; $135,396 + $28,907 = $164,303).
Total FECA processing/review costs: $8,648,303.
BLBA: Approximately 5,720 OWCP-1500 forms will be used to pay medical providers who perform disability determination procedures. These forms are pre-coded and reviewed by GS-5 clerks. This takes 5 minutes per form. The physician will complete the form by entering the charged amount. 5 minutes (.083) x 5,720 forms = 475 hours x GS-5, step 4 using Salary Table 2009-RUS at $21.16/hour = $10,051.
OWCP’s contractor medical bill processing system processes Forms OWCP-1500 for the BLBA program at a cost of $3.03 per form. Therefore, the contractor cost to process the estimated 136,280 forms submitted for the BLBA program will be $ (136,280 forms x $3.03/forms = $412,928).
Total BLBA processing/coding costs: $422,979.
EEOICPA: OWCP’s contractor medical bill processing system processes Forms OWCP-1500 for the EEOICPA program at a cost of $3.03 per form. Therefore, the contractor cost to process the estimated 54,414 forms submitted for the EEOICPA program will be $164,874 (54,414 forms x $3.03/forms = $164,874).
Two Federal employees in Washington, DC review all OWP-1500 forms under the EEOICPA program that suspend out of the bill processing system: a Payment Systems Manager (GS-14, step 5 using Salary Table 2009-DCB) at $116,419 yearly and an Assistant Payment Systems Manager (GS-13, step 4 using Salary Table 2009-DCB) at $95,620 yearly. About 40% of their time is attributable to this reviewing function, for a cost of $84,816 ($116,419 + $95,620 = $212,039 x 40% = $84,816).
Total EEOICPA Processing/Reviewing costs: $249,690.
$2,400 (printing costs) + $2,688 (mailing costs) + $ 8,648,303 (FECA processing and reviewing costs) + $ $422,979 (BLBA coding and processing costs) + $249,690 (EEOICPA processing and reviewing costs) = Total Federal Cost of $9,326,060.
15. Explain the reasons for any program changes or adjustments reported in Items 13 or 14 of the OMB
Form 83-I.
15. As use of the OWCP-1500 as the standard billing form for all three programs increases, the total number of bills submitted on the form also increases. Other factors also affect use of the OWCP-1500. For example, improved medical technology has resulted in an increase in outpatient services with a comparable decrease in inpatient services. This place of service change has resulted in an increase in the use of the OWCP-1500 because it is the most commonly used billing form for outpatient services. For these reasons, OMB Form 83-I shows a net adjustment increase of +16,451 hours.
16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection information, completion of report, publication dates, and other actions.
16. There are no plans to publish data collected on the form.
17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.
This information collection request does not seek a waiver from the requirement to display the expiration date.
Collections of Information Employing Statistical Methods:
Explain each exception to the certification statement identified in Item
"Certification for Paperwork Reduction Act Submissions," of OMB Form 83-I.
18. There are no exceptions to the certification statement.
| File Type | application/msword |
| File Title | OMB No |
| Author | Unknown |
| Last Modified By | US Department of Labor |
| File Modified | 2009-07-17 |
| File Created | 2009-07-17 |