ss 1240-0007 (OWCP-915) 2012

SUPPORTING STATEMENT

CLAIM FOR MEDICAL REIMBURSEMENT

1240-0007, FORMERLY 1215-0193 (OWCP-915)

A. Justification

1. 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.

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, 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-04 for institutional providers and hospitals, or a paper bill for prescription drugs dispensed by a pharmacy) and proof of payment by the beneficiary. 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. 1240-0044, 1240-0019 and 1240-0050. 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. 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.

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. 1240-0044, 1240-0019 and 1240-0050. 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. 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.

Form OWCP-915 is currently posted on the Internet at http://

www.dol.gov/esa/owcp/dfec/regs/compliance/OWCP-915.pdf and 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 paper 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. 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.

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

5. If the collection information impacts small businesses or other small entities, describe any methods used to minimize burden.

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. 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.

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. Explain any special circumstances required in the conduct of this information collection.

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

8. 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.

A Federal Register notice inviting public comment on this information collection was published on September 17, 2012. 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 payments or gifts made to respondents.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulations, or agency policy.

All medical reimbursement requests that are submitted are fully protected by the Privacy Act in the following systems of records:

FECA’s System of Records Notice is DOL/Govt-1: http://www.dol.gov/sol/privacy/dol-govt-1.htm. Moreover, FECA case files are exempted from disclosure under the Freedom of Information Act (See U.S.D.C., D.C. Civil Action No. 78-1647, Plain Dealer Publishing Company, et. al. vs. U.S. Department of Labor). Black Lung System of Records Notices are DOL/ESA-6 http://www.dol.gov/sol/privacy/dol-esa-6.htm and DOL/ESA-30 http://www.dol.gov/sol/privacy/dol-esa-30.htm protects Black Lung recovery questionnaires. EEOICPA System of Records Notice is DOL/ESA-49 http://www.dol.gov/sol/privacy/dol-esa-49.htm protects EEOICPA questionnaires.

11. 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.

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

12. 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. Provide estimates of the hour burden of the collection of information.

The following burden estimates for the three programs have been derived from data compiled during the latest complete fiscal year—FY 2011:

FECA: Approximately 7,400 respondents submit a claim for reimbursement for a total number of responses of 22,551 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 3,743 hours (22,551 responses x 0.166 = 3,743 hours).

BLBA: Approximately 11 respondents submit a reimbursement claim, for a total number of responses of 13 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 2 hours (responses x 0.166 = 2 hours).

EEOICPA: About 898 respondents submit a reimbursement claim for a total number of responses of 3,308 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 549 hours (3,308 responses x 0.166 = 549).

Combining the burden hours for all three programs, Form OWCP-915 has a total respondent annual burden hour estimate of 4,294 hours (3,743 + 2 + 549 = 4,294). 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 $21.74 per hour, the respondent annualized cost estimate for this collection is $93,352.

13. Annual Costs to Respondents (capital/start-up & operation and maintenance).

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 25,872 mailed responses at $1.65 per response ($1.50 in postage for 4 ounces to accommodate attachments + $.15 for large size envelope) = annual operation and maintenance costs of $42,689.

14. Provide estimates of annualized cost to the Federal government.

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 50,000 OWCP-915 forms yearly at a cost of $2,400 per each fifty thousand forms. Therefore, printing costs for the OWCP-915 will amount to $2,400 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 $4.19. Therefore, the contractor cost to process 22,551 forms for the FECA program will be $94,489 (22,551 forms x $4.19/form = $94,489).

Reimbursement claims 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 $167,197 [(80 x $34,445 /year (GS 5, step 4 using Salary Table 2012-RUS) x 5% = $137,780; 12 x $49,029 /year (GS 9, step 2 using Salary Table 2012-RUS) x 5% =$29,417; $137,780 +$29,417 =$167,197)].

Total FECA Processing/Reviewing costs: $261,686 ($94,489 + $167,197).

BLBA: OWCP’s contractor medical bill processing system also performs all manual review functions for the BLBA program, at the same contractor cost of $4.19 per form. Therefore, the contractor cost to process and review 13 forms for the BLBA program will be $54 (13 forms x $4.19/form = $54).

EEOICPA: As it does for FECA, OWCP’s contractor medical bill processing system processes Forms OWCP-915 for the EEOICPA program at a cost of $4.19 per form. Therefore, the contractor cost to process the 3,308 forms submitted for the EEOICPA program will be $13,681 (3,308 forms x $4.19/form = $13,861).

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 2012-DCB) at $112,224 yearly and an assistant payment systems manager (GS-13, step 7 using Salary Table 2012-DCB) at $106,839 yearly. About 5% of their time is attributable to this reviewing function, for a cost of $10,953 ($112,224 + $106,839 = $219,063 x 5% = $10,953).

Total EEOICPA Processing/Reviewing costs: $24,814 ($13,861 + $10,953).

Total Federal Costs: $311,368 [$2,400 (printing costs) + $261,686 (FECA processing and reviewing costs) + $54 (BLBA processing costs) + $24,814 (EEOICPA processing and reviewing costs)].

15. Explain the reasons for any program changes or adjustments.

As use of the OWCP-915 form decreases, the total number submitted also decreases. For this reason there is a net Burden adjustment decrease of 6,877 hours.

While not expected to change respondent burden, this ICR has been characterized as a revision because the agency has reformatted elements of Form OWCP-915 (e.g., replaced an obsolete logo with the DOL Seal, OMB Control Number, additional notice on rights for persons with disabilities, and removed references to the no longer existent Employment Standards Administration). Upon OMB’s clearance of this request OWCP will update the form to show the new expiration date.

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.

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

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.

18. Explain each exception to the certification statement identified in ROCIS.

There are no exceptions to the certification statement.

B. Collections of Information Employing Statistical Methods

Statistical methods are not used in these collections of information.

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