Ss 1240-0021 (owcp-1168)

Provider Enrollment Form, OWCP-11168

1240-0021

January 2016

SUPPORTING STATEMENT

PROVIDER ENROLLMENT FORM (OWCP-1168)

1240-0021

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) 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. These statutes require OWCP to pay for appropriate medical and vocational rehabilitation services provided to beneficiaries. In order for OWCP’s billing contractor to pay providers of these services with its automated bill processing system, providers must enroll with one or more of the OWCP programs that administer the statutes by submitting certain profile information, including identifying information, tax I.D. information, and whether they possess specialty or sub-specialty training. Form OWCP‑1168 is used to obtain this information from each provider.

If this information is not obtained before the provider submits his or her first bill for payment, the bill payment process is substantially prolonged and increases the burden on providers. The regulations implementing the above statutes that OWCP administers permit the collection of information necessary to allow its billing contractor to process and pay bills submitted by providers of medical and vocational rehabilitation services. (20 CFR 10.801, 30.701, 725.704 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.

The information provided is used by all three programs to identify the providers of medical and vocational rehabilitation services, and to direct payments to these providers accurately and in a timely manner. The information obtained also provides data for OWCP’s billing contractor to carry out a wide range of automated bill edits, such as the identification of duplicate billings, the application of pertinent fee schedules, utilization review, and fraud and abuse detection. The profile information is also used to furnish detailed reports to providers on the status of previously submitted bills.

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-1168 is posted on the Internet so providers wishing to submit bills under one or more of the programs that OWCP administers can print it out, fill it in, and mail it in to OWCP’s billing contractor, (https://www.dol.gov/owcp/dfec/regs/compliance/OWCP-1168.pdf). OWCP’s billing contractor has made the collection of this information possible online through the billing contractor’s web portal.

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 A.2 above.

The information collected on this form is not duplicative of any information available elsewhere. The respondent is the only source of the information required to enroll the provider.

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 by OWCP’s billing contractor while imposing the minimum burden on respondents, and does not have a significant economic impact on a substantial number of small entities.

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.

Please refer to Nos. 1 and 2 on pages 1-2. The information requested from respondents is the minimum needed to meet the bill processing needs of the three programs and is only collected on an occasional basis (after the first response, the information is only collected if there is a change in the type of information that is needed). Bills for medical and vocational rehabilitation services provided to beneficiaries cannot be processed for payment by OWCP’s billing contractor without the information collected. Failure to collect this data would result in delayed manual payments to respondents.

7. Explain any special circumstances for conducting this information collection.

There are no special circumstances for conducting this information collection.

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.

No outside consultations have been conducted concerning the use of this form. However, the form has been in use for several years in the three programs and thousands of responses have been received providing ample time for comments and consultation. To our knowledge, no respondent has voiced a complaint regarding the use of this form.

A notice inviting public comment on this information collection was published in the Federal Register on July 7, 2015, in Vol. 80, No. 129, page 38749. No comments were received.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

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

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

All information submitted on Form OWCP-1168 is fully protected under the Privacy Act in the following systems of records: DOL/GOVT-1 (for FECA); DOL/ESA-6 (for BLBA); and DOL/ESA-49 (for EEOICPA). A Privacy Act Statement is included on the form.

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 (as described in paragraph 11 above) on this form.

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.

The following burden estimates for the three programs have been derived from data compiled during FY 2012 through FY 2014:

 

FECA:  Approximately 17,469 respondents submit a Form OWCP-1168 each year for the FECA program.  It is estimated that each Form OWCP-1168 takes about 8 minutes for the respondent to prepare, which results in an annual hour burden of 2,323 hours (17,469 responses x 0.133 = 2,323 hours).

 

BLBA:  Approximately 6,906 respondents submit a Form OWCP-1168 each year for the BLBA program.  It is estimated that each Form OWCP-1168 takes about 8 minutes for the respondent to prepare, which results in an annual hour burden of 918 hours (6,906 responses x 0.133 = 918 hours).

 

EEOICPA:  About 7,604 respondents submit a Form OWCP-1168 each year for the EEOICPA program.  It is estimated that each Form OWCP-1168 takes about 8 minutes for the respondent to prepare, for an annual hour burden of 1,011 hours (7,604 responses x 0.133 = 1,011 hours).

 

Combining the burden hours for these programs, Form OWCP-1168 has a total respondent annual burden hour estimate of 4,252 hours (2,323 + 918 + 1,011 = 4,252).  Using the current hourly wage reported for general clerical work in offices and clinics of medical doctors (based on Bureau of Labor Statistics data for May 2013 http://www.bls.gov/oes/current/naics4_622100.htm) of $27.79 per hour, the respondent annualized cost estimate for this collection is $118,163.

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

There are no startup costs for this information collection.  Operation and maintenance costs consist solely of mailing costs.  Using a cost of $ 0.52 per response ($0.49 for postage and $0.03 for an envelope), operation and maintenance costs are estimated to be $16,629 (31,979 responses x $0.52 = $16,629 rounded).

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

 

The estimated costs to the Federal government of collecting the information on Form OWCP-1168 are set out below:

 

Mailing/Developmental costs:  Providers seeking to enroll under one of OWCP’s benefit programs may print out a copy of Form OWCP-1168 from the Internet.  However, OWCP anticipates that approximately two-thirds of providers will request a paper form; there will be a mailing cost of $11,086 (21,319 x $.52 = $11,086 rounded) for these forms. There are no developmental costs associated with this collection of information.

 

Processing/Reviewing Costs:  OWCP pays its billing contractor $ 28.60 to process one Form OWCP-1168. Therefore, OWCP’s cost to have its contractor process 31,979 of these forms for the three programs is $914,599 31,979 forms x $ 28.60 = $914,599).

 

$11,086(mailing) + $914,599 (processing) = Total Estimated Federal Cost of $925,685.

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

There has been a decrease in the number of respondents seeking to provide medical or vocational services to beneficiaries. Accordingly, the burden hours decreased from 7,174 to 4,252, an adjustment of 2,922 hours and the operational and maintenance costs decreased from $25,888 to $16,629, an adjustment of $9,259. While not affecting burden estimates, we updated the form OWCP-1168 including: provider letter, privacy act statement, several items on the form and instructions.

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 data collected by Form OWCP-1168.

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 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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