SupportStatementOMBNO 12400037 OWCP957 5 11 10 (2)

SUPPORTING STATEMENT

MEDICAL TRAVEL REFUND REQUEST—FORM OWCP-957

OMB NO. 1240-0037 (Formerly 1215-0054)

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 reimburse beneficiaries for travel expenses for covered medical treatment. In order to determine whether amounts requested as travel expenses are appropriate, OWCP must receive certain data elements, including the signature of the physician for medical expenses claimed under the BLBA. Form OWCP-957 is the standard format for the collection of these data elements. The regulations implementing these three statutes allow for the collection of information needed to enable OWCP to determine if reimbursement requests for travel expenses should be paid. (20 CFR 10.315, 30.404, 725.406 and 725.701).

2. Form OWCP-957 is used by OWCP and contractor bill processing staff to process reimbursement requests for travel expenses. To enable OWCP and its contractor bill processing staff to consider the appropriateness of the request in a timely fashion, it is essential that request include all of the data elements needed to evaluate the request. If all the data elements required by OWCP are not collected, the contractor staff cannot process the request for reimbursement.

3. Use of a standard format for reimbursement requests enables OWCP’s contractor bill processing staff to scan in the data on the form and speed the payment process to the beneficiary. Form OWCP-957 has been posted on the Internet at multiple locations, such as:

http://www.dol.gov/owcp/energy/regs/compliance/claimsforms.htm

http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm

http://www.dol.gov/owcp/dcmwc/regs/compliance/blforms.htm

and may be filled in online and printed out by the beneficiary. However, since the form must be accompanied by a number of attachments (and must include a physician’s signature for BLBA respondents), electronic submission of Form OWCP-957 is not considered to be practicable.

4. The information collected on this form is not duplicative of any information available elsewhere. The respondent is the only source of the travel expenses data that is needed to process the request for reimbursement.

5. This information collection has been streamlined to obtain the minimum information needed for OWCP to process a request for reimbursement while imposing the minimum burden on respondents, and does not have a significant economic impact on a substantial number of small entities.

6. Please refer to Nos. 1 and 2 on page 1. The information collected from respondents is the minimum necessary to evaluate whether a reimbursement request meets the requirements in the FECA, BLBA and the EEOICPA. Reimbursement requests cannot be processed by OWCP without the information collected.

7. There are no special circumstances for conducting this information collection.

8. No outside consultations have been conducted concerning the use of Form OWCP-957. However, OWCP has been processing these reimbursement requests for approximately 25 years and therefore has had sufficient experience with Form OWCP-957 to maximize its utility.

A notice inviting public comment on this information collection (under the former OMB Control No. 1215-0054) was published in the Federal Register on February 18, 2010. No comments were received.

9. Respondents do not receive any gifts or payments to furnish the requested information.

10. All reimbursement requests that are submitted to OWCP 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 this form.

12. The following burden estimates for the three programs have been derived from data compiled during the latest complete fiscal year—FY 2009:

FECA: Approximately 166,656 respondents submit a request for reimbursement once annually, for a total number of responses of 166,656 for the FECA program. It is estimated that each Form OWCP-957 takes about 10 minutes for the beneficiary to prepare, which results in an annual hour burden of 27,665 hours (166,656 x 0.166 responses = 27,665 hours).

BLBA: Approximately 3,016 respondents submit a request for reimbursement once annually, for a total number of responses of 3,016 for the BLBA program. It is estimated that each Form OWCP-957 takes about 10 minutes for the beneficiary to prepare, which results in an annual hour burden of 501 hours(3,016 responses x 0.166 = 501 hours).

EEOICPA: Approximately 12,863 respondents submit a request for reimbursement once annually, for a total of 12,863 responses for the EEOICPA program. It is estimated that each Form OWCP-957 takes about 10 minutes to complete, for an annual hour burden of 2,135 hours (12,863 responses x 0.166 = 2,135 hours).

Combining the burden hours for all three programs, Form OWCP-957 has a total respondent annual burden hour estimate of 30,301 hours (27,665 + 501 + 2,135 = 30,301). A specific wage category for the beneficiaries who provide this information is not documented in OWCP’s contractor bill processing system. Using the current national hourly non-farm average wage rate (based on Bureau of Labor Statistics data) of $20.32, the respondent annualized cost estimate for this collection is $615,716.

13. There are no recordkeeping or collection costs associated with the beneficiary information collected on Form OWCP-957. The only operation and maintenance cost is for postage. An estimated annual total of 182,535 mailed responses at $0.47 per response ($0.44 in postage + $.03 for envelope) = annual operation and maintenance costs of $85,791.

14. The estimated costs to the Federal government for collecting the information on Form OWCP-957 are set out below:

Printing costs: OWCP estimates that it will print 50,000 OWCP-957 forms each year at a cost of $2,400.00. Therefore, printing costs for the OWCP-957 will amount to $2,400.00 per year.

Mailing/Developmental costs: Beneficiaries seeking reimbursement for out-of-pocket travel expenses under FECA, BLBA and EEOICPA may download copies of Form OWCP-957 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-957 is $4.33. Therefore, the contractor cost to process 166,656 forms for the FECA program will be $721,620 (166,656 forms x $4.33/form = $721,620).

Reimbursement requests 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 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 $167,502 (80 x $34,508/year (GS 5, step 4 using Salary Table 2010-RUS) x 5% = $138,032; 12 x $49,116/year (GS 9, step 2 using Salary Table 2010-RUS) x 5% = 29,470; $138,032 + $29,470 = $167,502).

Total FECA Processing/Reviewing costs: $889,122.

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 $4.33 per form. Therefore, the cost to process and review 3,016 forms for the BLBA program will be $13,059 (3,016 forms x $4.33/form = $13,059).

EEOICPA: As it does for FECA, OWCP’s contractor medical bill processing system will process Forms OWCP-957 for the EEOICPA program at a cost of $4.33 per form. Therefore, the contractor cost to process the 12,863 forms submitted for the EEOICPA program will be $55,697 (12,863 forms x $4.33/form = $55,697).

Two Federal employees in Washington, DC review all requests for reimbursement under the EEOICPA program that suspend out of the bill processing system: a Bill Pay Manager (GS-14, step 3 using Salary Table 2010-DCB) at $112,224 yearly and an Assistant Bill Pay Manager (GS-13, step 7 using Salary Table 2010-DCB) at $106,839 yearly. About 5% of their time is attributable to this reviewing function, for a cost of $10,694($112,224 + $106,839 = $219,063 x 5% = $10,953).

Total EEOICPA Processing/Reviewing costs: $66,650

$2,400 (printing costs) + $889,122 (FECA processing and reviewing costs) + $13,059 (BLBA processing and reviewing costs) + $66,650 (EEOICPA processing and reviewing costs) = Total Federal Cost of $971,231.

15. There has been a significant increase in the number of reimbursement requests filed for the FECA program and as a result there is an increase from 27,098 burden hours to 30,301 burden hours which is an adjustment increase of 3,203 burden hours. Also due to the decrease in mailed responses the operation and maintenance cost has increased from $68,559 to $85,791 which is an adjustment of $17,232.

16. There are no plans to publish data collected by Form OWCP-957.

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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