(2900-0335)
1. Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.
VA Form 10-2570d, Dental Record Authorization and Invoice for Outpatient Services, is essential to the proper administration of VA outpatient fee dental program. The associated instructions make it possible to communicate with clarity the required procedures, peculiarities and precautions associated with VA authorizations for contracting with private dentists for the provision of dental treatment for eligible veteran beneficiaries. This form serves these multi-purposes:
a. VA authorization to the veteran to seek a private dentist for examination;
b. Fee dentist's record of examination findings;
c. Dentist's treatment plan and listing of services needed;
d. Listing of dentist’s usual and customary fees for specific services involved in treatment plan;
e. VA review, verification and authorization of treatment to the fee dentist;
f. Dentist's certification of services completed;
g. VA permanent record of treatment provided for veterans and statement of exhaustion of benefits (if indicated);
h. Eligibility’s approval of dental services and total fees for payment; and,
i. Fiscal approval and certification of payment and amount.
Various Public Laws provide for VA outpatient dental benefits for veterans. Their authorities and requirements are contained in Title 38, USC, Sections 1701 (4) (c) and 1712 (a) and (b). Since many of the veterans who are authorized fee dental care are geographically inaccessible to VA dental clinics, it necessary to request information as to the veteran’s oral condition, treatment needs and the usual and customary fees for these services from the private fee dentist whom the veteran has selected.
2. Indicate how, by whom, and for what purposes the information is to be used; indicate actual use the agency has made of the information received from current collection.
VA Form l0-2570d lists the dental treatment needs of the veteran patient, the cost to VA to provide such services, and serves as an invoice for payment. Without its submission, veterans' treatment needs could not be identified, fees for services could not be established, the veterans could not receive treatment and the fee dentists could not be reimbursed.
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 described any consideration of using information technology to reduce burden.
VA Form 10-2570d has now been made available in a electronic fillable format at http://vaww.va.gov/vaforms/.
In accordance with the Government Paperwork Reduction Act (GPEA), VA investigated the feasibility of electronic on-line submission of this data. There are several major issues to be resolved before this can be accomplished. Although our contractor identified this as a good candidate for re-engineering to support electronic submissions, mitigating circumstances currently exist.
This is a multi-purpose form, beginning as an authorization for fee-basis dental treatment and containing several signatures as well as several processing steps. At present, VA is not equipped to accept the electronic signatures for the multiple steps in the routing workflow this form represents. Most importantly, VA does not wish to permit veterans to presume authorization or their fee dentists to begin work for which they will not be compensated.
All Health Insurance Portability and Accountability (HIPAA) non-compliance issues are related to the electronic equivalent of the VA Form 10-2570d, not to the form itself. There is no HIPAA issue for paper claims, which are not covered by the HIPAA electronic standards. This prevents our immediate conversion to electronic fill and print.
The Health Administration Center (HAC) in Denver, in conjunction with the VACO Business Office, had plans in 2004 to re-engineer VistA Fee work processes and the accompanying tracking software. However, due to resource allocations, this project has been suspended with no immediate plans for renewal.
With increasing availability of computer resources, there exists the potential to utilize improved information technology to reduce VA workload burden. Use of improved information technology would allow dental fees for various treatment services to be continuously monitored against VA's maximum allowable fee schedule. Thus, VA schedules of maximum allowances can be maintained on a current and viable basis rather than falling behind, due to sporadic and spot surveys. Other areas for possible use could be to track applications, eligibility changes and payments, to mention a few possibilities. However, none of these will reduce the burden of information collection for the private dentist.
4. Describe effort 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.
An application for dental care requires VA review to verify the veteran's eligibility to receive dental benefits. VA Form 10-2570d provides authorization for X-rays, examination and treatment. The case is held open until the dental treatment has been completed or terminated. An application and authorization are required for each episode of care. There is no duplication of data requested.
5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.
Although small businesses and other small entities are impacted by this information collection, every effort has been made to minimize the burden. The data provided gives a record of the dental examination, the proposed treatment plan for the individual veteran patient, along with the fees proposed by the fee dentist. These needs vary from patient to patient, as do the fees of different dentists. In an effort to minimize the burden for the fee-basis dentist and VA, the form was designed with a minimum number of questions. Administration of the dental fee program does not involve obtaining information from State or local governments.
Fee-basis dentists perform the dental examination and list their usual and customary fees for the services listed on the exam form. Once completed and signed, the fee-basis dentist sends the examination findings and treatment plan to the VA dental fee jurisdiction facility that issued the authorization.
After VA review of the treatment plan for suitability, the dollar value is reviewed for compatibility with the maximum allowances for specific procedures. After any necessary adjustments, the case is approved and returned to the fee dentist for the initiation of dental treatment. If there is no response, the VA will not authorize treatment and payment of services; therefore, since pre-authorization is the protocol, compliance is universally high.
6. Describe the consequences to 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.
VA would not be responsive to the needs of the patient and to the legal requirement to provide for VA outpatient dental benefits for veterans if information was collected less frequently. If VA Form l0-2570d was not submitted, the dental care could not be authorized and eligible veteran patients would be denied the opportunity to receive treatment from fee dentists.
7. Explain any special circumstances that would cause an information collection to be conducted more often than quarterly or require respondents to prepare written responses to a collection of information in fewer than 30 days after receipt of it; submit more than an original and two copies of any document; retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years; in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study and require the use of a statistical data classification that has not been reviewed and approved by OMB.
There are no such special circumstances.
8. a. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the sponsor’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 sponsor in responses to these comments. Specifically address comments received on cost and hour burden.
The notice of Proposed Information Collection Activity was published in the Federal Register on November 11, 2012, Volume 77, No. 223, page 69550 -69551. VA received no comments in response to this notice.
b. Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, clarity of instructions and recordkeeping, disclosure or
reporting format, and on the data elements to be recorded, disclosed or reported. Explain any circumstances which preclude consultation every three years with representatives of those from whom information is to be obtained.
Outside consultation is conducted with the public through the 60- and 30-day Federal Register notices. No one else outside the Department has been consulted in designing the form used by VA. It is a standard record for the Department's use and has been used for many years. Respondents are quite familiar with reporting requirements. Efforts have been made to standardize data elements with the accepted ADA universal form.
9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.
No payment or gift is provided to respondents.
10. Describe any assurance of privacy to the extent permitted by law, provided to respondents and the basis for the assurance in statue, regulation, or agency policy.
The VA does not promise confidentiality. However, we do maintain the confidentiality of private dentists' fee charges since we do not maintain a listing or divulge individual provider's fees. Over the past several years we have found it easier to use an up-to-date commercial program that provides percentile listing of private sector dental procedure fees by zip code areas in the US. The information contained in the form is used for the sole purpose of administering the VA’s congressionally mandated dental fee program. An analysis of aggregate dental fees does not identify the individual reporting dentist by name. VA Form l0-2570d becomes a part of the Consolidated Health Record, filed by veteran’s name rather than that of the dentist. The Consolidated Health Record complies with the Privacy Act of 1974. These forms are part of the system of records identified as 24VA19 “Patient Medical Record – VA” as set forth in the 2003 Compilation of Privacy Act Issuances via online GPO access at http://www.access.gpo.gov/su_docs/aces/2003_pa.html.
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; include 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.
The information provided by the fee dentists would not be considered sensitive. In cases where a grave diagnosis is included with the information, the dentist involved has the professional responsibility to inform the veteran patient of the nature of the problem and properly refer the veteran to a specialist, dental or medical, for proper disposition of the problem. The VA, of course, shares that responsibility of proper referral for diagnosis and treatment.
12. Estimate of the hour burden of the collection of information:
a. There are an estimated 44,000 dental treatment cases authorized annually for fee dental treatment. It is estimated 25% of fee dentists will use this form, the remainder will use forms auto generated by their office automation software. Generally one report is made for each respondent. Experience has shown it takes the fee dentist office approximately 20 minutes to complete each form. Thus the annual burden on the public is 3,666 hours.
(44,000 x .25) 11,000 x 1 x 20 minutes divided by 60 = 3,666 hours
b. If this request for approval covers more than one form, provide separate hour burden estimates for each form and aggregate the hour burdens in Item 13 of OMB 83-I.
This request covers only one form.
c. Provide estimates of annual cost to respondents for the hour burdens for collections of information. 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.
Billing clerks at the office of the fee basis physician complete these forms. Therefore, the cost to the respondents for completing these forms is $65,988 (3,666 hours x $18 per hour). We do not require any additional recordkeeping.
13. Provide an estimate of the total annual cost burden to respondents or recordkeepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).
a. There is no capital, start-up, operation or maintenance costs.
b. Cost estimates are not expected to vary widely. The only cost is that for the time of the respondent.
c. There is no anticipated recordkeeping burden.
14. Provide estimates of annual cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operation expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 in a single table.
Existing VA staff dentists perform reviews of the private dentists' treatment plans for veterans authorized private sector dental care. The dentists are full-time employees who spent the majority of their time providing care for VA patients and perform this function as an additional duty.
The cost to the Federal Government for processing the form and reviewing the submission from a fee basis dentist for need for and quality of treatment is estimated to be $352,363. This is computed as follows:
Printing and Distribution |
|
|
|
|
|
= |
$ 1,500 |
||||||||
Mailing Costs |
$ 1.35 |
x |
11,000 |
|
|
= |
$ 14,850 |
||||||||
VA Administrative Staff (GS 5/5) |
$18.50/hr. |
x |
11,000 |
x |
20 min |
= |
$ 67,833 |
||||||||
VA Staff dentist (GS 15/8) |
$73.14/hr |
x |
11,000 |
x |
20 min |
= |
$268,180 |
||||||||
|
|
|
TOTAL |
|
|
= |
$352,363 |
|
|||||||
15. Explain the reason for any program changes or adjustments reported in Items 13 or 14 of OMB 83-I
The adjustments reported in item 14 are a result of hourly pay increases for VA staff members. The adjusted rates are based on the last scale for federal pay rates within the past 3 years.
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 of information, completion of report, publication dates, and other actions.
There are no plans to publish the results of the information collected. There is no reporting outside the Department except when required by Congress. The records maintained (aside from those retained in the individual veteran's medical record) are statistical, providing for recovery of the number of beneficiaries, categories of beneficiaries and total dollars expended for exams and treatment.
17. If seeking approval to omit the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.
VA seeks to minimize the cost to itself of collecting, processing and using the information by not displaying the expiration date. We seek an exemption that waives the displaying of the expiration date on this VA Form. The VA Form may be reproduced by the responding dentists and veterans service organizations from the Internet and then stocked. If we are required to display an expiration date, it would result in unnecessary waste of existing stock of the forms. Inclusion of the expiration date would place an unnecessary burden on the respondent (since they would find it necessary to obtain a newer version, while VA would have accepted the old one).
18. Explain each exception to the certification statement identified in Item 19, “Certification for Paperwork Reduction Act Submissions,” of OMB 83-I.
There are no exceptions.
Not applicable as no statistical methods are used in this data collection.
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | SUPPORTING STATEMENT FOR REQUESTS FOR 0MB APPROVAL UNDER |
| Author | Bickoff |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |