Medical Travel Refund Request Form
1240-0037 (OWCP-957)
December 2016
SUPPORTING STATEMENT
MEDICAL TRAVEL REFUND REQUEST FORM
1240-0037 (OWCP-957)
A. Justification
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) 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).
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.
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.
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.
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.
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 A.2 above.
The information collected on this form OWCP-957 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.
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 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.
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 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.
Explain any special circumstances required in the conduct of this information collection.
There are no special circumstances for conducting this information collection.
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.
No formal outside consultations have been conducted concerning the use of Form OWCP-957. However, OWCP has been processing these reimbursement requests for approximately 31 years and regular contact with respondents have not resulted in suggestions for improving this ICR.
A notice inviting public comment on this information collection was published in the Federal Register on October 24, 2016 [81FR73142]. No comments were received.
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.
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).
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 this form.
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 2015:
FECA: Approximately 306,125 respondents submit a request for reimbursement once annually, for a total number of responses of 306,125 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 50,817 hours (306,125 x 0.166 responses = 50,817 hours).
BLBA: Approximately 5,713 respondents submit a request for reimbursement once annually, for a total number of responses of 5,713 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 948 hours(5,713 responses x 0.166 = 948 hours).
EEOICPA: Approximately 30,624 respondents submit a request for reimbursement once annually, for a total of 30,624 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 5,084 hours (30,624 responses x 0.166 = 5,084 hours).
Combining the burden hours for all three programs, Form OWCP-957 has a total respondent annual burden hour estimate of 56,849 hours (50,817 + 948 + 5,084 = 56,849). 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 $25.61, the respondent annualized cost estimate for this collection is $1,455,903 (56,849 x 25.61) = $1,455,903.
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-957. The only operation and maintenance cost is for postage. An estimated annual total of 342,462 mailed responses at $0.50 per response ($0.47 in postage + $.03 for envelope) = annual operation and maintenance costs of $171,123.
Provide estimates of annualized cost to the Federal Government.
The estimated costs to the Federal government for collecting the information on Form OWCP-957 are set out below:
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 306,125 forms for the FECA program will be $1,325,521 (306,125 forms x $4.33/form = $1,325,521).
Reimbursement requests that suspend out of the contractor medical bill processing system and require manual review are examined by 12 Medical Coding Specialists employed by the FECA program at the 12 district offices who are GS-11s, with various steps as noted below:
1. GS-11/Step 2 (1)
2. GS-11/Step 6 (1)
3. GS-11/Step 7 (3)
4. GS-11/Step 8 (2)
5. GS-11/Step 9 (4)
6. GS-11/Step 10 (1)
The average salaries of the above is $72,246 ($61,221 X 1, $69,120 X 1, $71,095 X3, $73,070 X2, $75,044 X 4, and $77,019 X 1 = $866,961/12 = $72,247.
Approximately 5% of their time is required for this function. Thus, the cost to provide this review function is $43,348 (12 x $72,247 X 5%) (using Salary Table 2016-RUS, https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2016/RUS.pdf
Total FECA Processing/Reviewing costs: $1,352,521 + $43,348 = $1,395,869.
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 5,713 forms for the BLBA program will be $17,775 (5,713 forms x $4.33/form = $24,737).
Total BLBA Processing/Reviewing costs: $24,737
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 30,624 forms submitted for the EEOICPA program will be $55,697 (30,624 forms x $4.33/form = $132,602).
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 2016-DCB) at $116,146 yearly and an Assistant Bill Pay Manager (GS-13, step 7 using Salary Table 2016-DCB) at $110,578 yearly. About 5% of their time is attributable to this reviewing function, for a cost of $11,336 ($116,146 + $110,578 = $226,724 x 5% = $11,336).
Total EEOICPA Processing/Reviewing costs:
$132,602 + $11,336 = $143,938
Total Federal Processing/Reviewing costs Cost:
$1,368,869 (FECA processing and reviewing costs) + $24,737 (BLBA processing and reviewing costs) + $143,938 (EEOICPA processing and reviewing costs) = $1,537,544.
Explain the reasons for any program changes or adjustments.
There has been an increase in the number of reimbursement requests filed for the FECA, BLBA and EEOICPA programs and as a result there is an increase from 50,263 burden hours to 56,849 burden hours which is an adjustment increase of 6,586 burden hours. Also due to the increase in mailed responses the operation and maintenance cost has increased from $148,369 to $171,123 which is an adjustment of $22,754.
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 on the form.
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.
Explain each exception to the certification statement 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.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | OMB No |
| Author | Unknown |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |