ICR 1240-0019 - Supporting Statement A 2.25.22

Uniform Billing Form

OMB Control Number 1240-0019

OMB Expiration Date: June 30, 2022

SUPPORTING STATEMENT FOR

UNIFORM BILLING FORM

OMB CONTROL NO. 1240-0019

This ICR seeks to revise the currently approved ICR.

1. JUSTIFICATION

1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collection. Attach a copy of the appropriate section of each statute and 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, the Black Lung Benefits Act (BLBA), 30 U.S.C. 901, and the Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA), 42 U.S.C. 7384. All three of these statutes require that OWCP pay for medical treatment of beneficiaries; this medical treatment can include inpatient/outpatient hospital services, as well as services provided by nursing homes and skilled nursing facilities. In order to determine whether billed amounts are appropriate, OWCP needs to identify the patient, the specific services that were rendered and their relationship to the work-related injury or illness. The regulations implementing these statutes require the use of Form OWCP-04 or UB-04 for the submission of medical bills from institutional providers (20 CFR 10.801, 30.701, 725.405, 725.406, 725.701 and 725.715).

The Uniform Billing Form, also known as the paper UB-04, has been approved by the American Hospital Association. It is used by the Centers for Medicare and Medicaid Services (CMS), Tricare, the Department of Veterans Affairs (DVA), and the private sector to request payment to institutional providers for medical services. The paper UB-04 has been designed by the National Uniform Billing Committee and is neither a government-printed form nor distributed by OWCP; OWCP has, however, developed detailed instructions for institutional providers that use the UB-04 to ensure that they provide the information needed to evaluate their requests for payment. The paper UB-04 is an ideal billing instrument for the provider community that services FECA, BLBA and EEOICPA beneficiaries because of its familiarity, its common use, and its acceptance by both government and private health service payers.

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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.

Form OWCP-04 is used by OWCP and contractor bill payment staff to process bills for medical services provided by hospitals and other institutional medical providers. To ensure that OWCP is able to consider the appropriateness of the requested payment in a timely fashion, it is essential that bills be submitted on a standard form that will capture the critical data elements needed to evaluate the bill, such as procedure and diagnosis codes. To do this, Form OWCP-04 therefore includes the Uniform Billing Form (UB-04) used by CMS, Tricare, DVA and private health insurance carriers as its first page. However, since OWCP only needs some of the information requested by the UB-04 to process the medical bills submitted in the three programs, it does not require providers to respond fully to the UB-04 (see instructions for completing Form OWCP-04).

There are now standardized specifications for the electronic transmission of Form OWCP-04 data elements that are commonly used by the great majority of hospitals for billing other government programs such as Medicare and many private third-party payers.

The Internal Revenue Service requires the reporting of payments to specific providers in excess of $600 in any one year, making it necessary to obtain the provider’s tax identification number for each bill. If the provider’s tax identification number and social security number (SSN) are the same, we are required to obtain the SSN to meet IRS reporting requirements.

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 to adopt this means of collection. Also, describe any consideration of using information technology to reduce burden.

The instructions for Form OWCP-04 have been designed to be computer generated and take advantage of the commonly accepted Form UB-04. Use of this standard billing form keeps paperwork burden on the public at a minimum level since it lends itself to automation, provides information necessary to process payment of a bill, and is in a format that is acceptable to both government and private sector payers.

Form OWCP-04, which is fillable and printable, appears on the Internet for downloading at https://www.dol.gov/owcp/dfec/regs/compliance/OWCP-04.pdf and https://owcpmed.dol.gov/portal/formsAndLinks.do. OWCP now has the capability of accepting electronic transmission of Form OWCP-04 billings directly from certain hospitals and transmits all bills it receives electronically for inpatient services to another government facility for particular processing services through the use of a clearing house. Clearing houses act as the intermediary between providers and third-party payers for the electronic exchange of data.

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.

Form OWCP-04 is used by OWCP to obtain information necessary to appropriately process payments for medical services provided under each program. Duplicate information is not obtained since the three programs service distinct populations. Other Federal agencies request similar information but the populations serviced are not the same; therefore, no duplication of information is expected.

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

This information collection has been streamlined to obtain the necessary information for OWCP’s bill processing system while imposing the minimum burden on respondents. Form OWCP-04 does not impose additional burdens on small businesses or other small entities because providing billing information in this format is part of a medical provider’s usual business practices.

Efforts to minimize burden on providers include requiring the use of a standard billing form that is readily available and accepted by many users, that facilitates automated bill processing, and that uses standard coding language for identification of conditions treated and services provided. Additionally, the three programs provide detailed instructions for completion of the OWCP-04 in program provider manuals that are distributed to all providers enrolled in the programs, as well as opportunities for providers to attend workshops conducted by OWCP’s medical bill processing contractor. The National Uniform Billing Committee evaluates the use of paper Form UB-04 periodically and initiates changes when appropriate.

6. Describe the consequence 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.

The information required is the minimum needed to meet the bill processing needs of the three programs and is in a widely recognized standard format. Appropriate payment for the medical services provided by law to eligible claimants cannot be made by OWCP and contractor bill payment staff without the information collected. Frequency of data collection is based on how often the provider requests payment for covered services it has rendered. Because Form OWCP-04 is a summary billing form and lends itself to multiple visits or services, the actual number of times the form is filed with OWCP varies with the number of times during any period that the provider decides to submit billing. Less frequent collection of data would result in delayed payment to providers.

7. Explain any special circumstances that would cause an information collection to be conducted in a manner:

• requiring respondents to report information to the agency more often than quarterly;

• requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it;

• requiring respondents to submit more than an original and two copies of any document;

• requiring respondents to 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;

• requiring the use of statistical data classification that has not been reviewed and approved by OMB;

• that includes a pledge of confidentiality that is not supported by authority established in statute or regulation, that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

• requiring respondents to submit proprietary, trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.

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. Specifically address comments received on cost and hour burden.

Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, the clarity of instructions and recordkeeping, disclosure, or reporting format (if any), and on the data elements to be recorded, disclosed, or reported.

Consultation with representatives of those from whom information is to be obtained or those who must compile records should occur at least once every 3 years -- even if the collection-of-information activity is the same as in prior periods. There may be circumstances that may preclude consultation in a specific situation. These circumstances should be explained.

In accordance with the Paperwork Reduction Act of 1995, the public was given 60 days to comment on the Federal Register Notice published on 11/18/2021 (86 FR 64529). No comments were received.

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

The only payment OWCP makes to respondents is for medical services they have provided under the three programs; no gifts or other forms of remuneration are made.

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

All bill payment requests that are submitted on Form OWCP-04 are fully protected by the Privacy Act in the following systems of records: DOL/GOVT-1 (FECA); DOL/ESA-6 (BLBA); DOL/ESA-49 (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 on the 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 conduct special surveys to obtain information on which to base hour burden estimates. Consultation with a sample (fewer than 10) of potential respondents is desirable. If the hour burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated hour burden, and explain the reasons for the variance. Generally, estimates should not include burden hours for customary and usual business practices.¹

• If this request for approval covers more than one form, provide separate hour burden estimates for each form.

• Provide estimates of annualized cost to respondents for the hour burdens for collections of information, identifying and using appropriate wage rate categories. 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 13.

Estimated Annualized Respondent Cost and Hour Burden

Activity	No. of Respondents	No. of Responses per Respondent	Total Responses	Average Burden (Minutes per Hours)	Total Burden (Hours)	Hourly Wage Rate	Monetized Value of Respondent Time
OWCP-04	16,276	15.1330179	246,305	6/60 (rounded in this table)	24,684	$20.25	$4,426,132

The following burden estimates for the three programs have been derived by averaging data for FY2018 through FY2020; FECA: an estimated 5,445 respondents submit the OWCP-04; BLBA: an estimated 469 respondents submit the OWCP-04, and EEOICPA: an estimated 10,362 respondents submit the OWCP-04, making the total number of respondents 16,276. Note: all numbers may not add due to rounding.

FECA: An estimated 5,445 respondents submit the OWCP-04, for a total number of responses under that program of 195,357. Of these, approximately 15,991 responses are submitted electronically and 160,641responses are submitted manually. It is estimated that each of these responses will take approximately one minute to complete electronically and seven minutes to complete manually.

Total annual hour burden of 19,014 hours (267 + 18,747 = 19,014)

Electronic (15,991 x .0167 = 267 hours)

Manual (160,641 x .1167 = 18,747 hours)

BLBA: An estimated 469 respondents submit the OWCP-04, for a total number of responses under that program of 9,157. Of these, approximately 169 responses are submitted electronically and 8,988 responses are submitted manually. It is estimated that each of these responses will take approximately one minute to complete electronically and seven minutes to complete manually.

Total annual hour burden of 1,051 hours (2 + 1,049 = 1,051)

Electronic (169 x .0167 = 2 hours)

Manual (8,988 x .1167 = 1,049 hours)

EEOICPA: An estimated 942 respondents will submit Form OWCP-04, for a total number of responses under that program of 41,791. Of these, approximately 2,826 responses are submitted electronically and 38,950 responses are submitted manually. It is estimated that each of these responses will take approximately one minute to complete electronically and seven minutes to complete manually.

Total annual hour burden of 4,363 hours (47 + 4,545 = 4,592)

Electronic (2,826 x .0167 = 47 hours)

Manual (38,950 x .1167 = 4,545 hours)

Total Burden hours: 24,684 (19,041 + 1,051 + 4,592)

Combining the burden hours for all three programs, Form OWCP-04 has a total respondent burden hour estimate of 24,684 The current mean wage rate for billing clerks (based on Bureau of Labor Statistics data for May 2020, https://www.bls.gov/oes/current/oes433021.htm) is estimated to be $20.25 per hour. Thus, the respondent cost estimate for this collection is $544,826 (24,684 X $20.25 = $499,851).

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).

• The cost estimate should be split into two components: (a) a total capital

and start up cost component (annualized over its expected useful life); and (b) a

total operation and maintenance and purchase of service component.

The estimates should take into account costs associated with generating,

maintaining, and disclosing or providing the information. Include descriptions of

methods used to estimate major cost factors including system and technology acquisition, expected useful life of capital equipment, the discount rate(s), and the time period over which costs will be incurred. Capital and start-up costs include, among other items, preparations for collecting information such as purchasing computers and software; monitoring, sampling, drilling and testing equipment; and record storage facilities.

• If cost estimates are expected to vary widely, agencies should present ranges of cost burdens and explain the reasons for the variance. The cost of purchasing or contracting out information collection services should be a part of this cost burden estimate. In developing cost burden estimates, agencies may consult with a sample of respondents (fewer than 10), utilize the 60-day pre-OMB submission public comment process and use existing economic or regulatory impact analysis associated with the rulemaking containing the information collection, as appropriate.

• Generally, estimates should not include purchases of equipment or services, or portions thereof, made: (1) prior to October 1, 1995, (2) to achieve regulatory compliance with requirements not associated with the information collection, (3) for reasons other than to provide information or keep records for the government, or (4) as part of customary and usual business or private practices.

No operation and maintenance costs are experienced by respondents.

14. Provide estimates of the annualized cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operational expenses (such as equipment, overhead, printing, and support staff), 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 into a single table.

The estimated costs to the Federal government for collecting the information on Form OWCP-04 are set out below:

Printing/Mailing costs: There are no printing or mailing costs associated with Form OWCP-04. The instructions for filling out the portions of the form that is required for OWCP’s billing processes are included in the program provider manuals that are available to and/or disseminated by the servicing contractor to all providers in the programs. When needed, updates are issued in the form of bulletins to the programs’ provider community. Printing and mailing costs for provider manuals and bulletins are built into the contract that OWCP has with the contractor that provides billing support services to the three programs.

Processing/Reviewing costs:

FECA: Under OWCP’s contractor medical bill processing system, the average contractor cost to process one Form OWCP-04 is $8.45. Therefore, the contractor cost to process 195,357 forms for the FECA program will be $1,650,767 (195,357 forms x $8.45 forms = $1,650,767).

Bills 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, step 4 level, and by 12 at the GS-9, step 2 level; approximately 10% of their time is required for this function. Thus, the cost to provide this review function is $25,861 ((80 x $38,792/year) (GS 5, step 4 using (Salary Table 2021-RUS) x 10% = $258,613; (12 x $55,212/year) (GS 9, step 2 using Salary Table 2021-RUS) x 10% = $61,709; ($258,613+ 66,254 = $324,867).

Total FECA processing and reviewing costs: $1,975,634 ($1,650,767 + $324,867 =$1,975,634).

BLBA: OWCP’s contractor medical bill processing system also processes Forms OWCP-04 for the BLBA program at an average cost of $ 8.45 per form. Therefore, the contractor cost to process the estimated 9,157 forms submitted for the BLBA program will be $77,377(9,157 forms x 8.45/forms = $77,376).

Two Federal employees in Washington, DC review all OWCP-04 forms under the BLBA program that suspend out of the bill processing system: a Payment Systems Manager (GS-14, step 7 using Salary Table 2017-DCB) at $147,043 yearly, and an Assistant Payment System Manager (GS-13, step 9 using Salary Table 2021-DCB) at $131,141 yearly.

Approximately 2% of the Payment Systems Manager’s time is attributable to this reviewing function. Approximately 10% of the Assistant Payment System Manager’s time is attributable to this reviewing function. The total cost attributable to this reviewing function is $16,055 ($147,043 x 2% = $2,941) ($131,141 x 10% = $13,114)

Additionally, two Federal employees, one in Washington, DC and one in Tucson, Arizona, coordinate referral of bills that exceed $75,000 to a contracted consultant for determination of whether billed medical services were appropriate: an Assistant Payment System Manager (GS-13, step 9 using Salary Table 2020-DCB) at $131,341 yearly and a Claims Analyst (GS-13, step 4 using Salary Table 2020-TU) at $102,442 yearly.

The Assistant Payment System Manager spent approximately 1 hour on each of approximately 35 bills over $75,000 per year. (35 hours X $62.93 per hour = $2,202 attributable to this function.)

The Claims Analyst spent approximately 30 minutes on each of the 35 bills. (35 X 30 = 1,050 minutes/60 = 18 hours X $54.65 per hour = $984 attributable to this function.)

https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2021/DCB.pdf

https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2021/TU.pdf

Total BLBA processing and reviewing costs: $96,438 ($77,377 + $16,055 + $2,022 + $984 = $96,438).

EEOICPA: OWCP’s contractor medical bill processing system processes Forms OWCP-04 for EEOICPA program at an average cost of $8.45 per form. Therefore, the contractor cost to process the estimated 41,791 forms submitted for the EEOICPA program will be $ 353,134 (41,791 forms x $ 8.45/forms = $353,134).

Two Federal employees in Washington, DC review all OWCP-04 forms under the EEOICPA program that suspend out of the bill processing system: a Payment Systems Manager (GS-14, step 5 using Salary Table 2021-DCB) at $138,866yearly and an Assistant Payment Systems Manager (GS-13, step 4 using Salary Table 2021-DCB) at $114,059 yearly. About 10% of their time is attributable to this reviewing function, for a cost of $25,292 ($138,861 + $ 114,059 = $252,920 x 10% = $25,292).

Total EEOICPA Processing and Reviewing costs: $378,426 ($353,134 + $25,292 = $378,426).

$1,975,634 (FECA processing and reviewing costs), + $96,438 (BLBA processing cost), + $378,426 (EEOICPA processing and reviewing costs) = Total Federal Cost of $4,426,132

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

The previously approved number of respondents has increased from 6,315 to 16,276. However, the average number of forms submitted per respondent decreased as well as the average time per response as a result of more filers filing electronically. As a result, the burden hours requested decreased by 4,782.

The instruction for UB-04 Block 43 have been updated to include the following: “If billing an unlisted J-Code with RCC 0636, a valid NDC Code must be specified in this block and the drug quantity listed in Block 46.”

16. For collections of information whose results will be published, outline plans for tabulations, 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 on the OWCP-04.

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.

There are no exceptions to the certification statement.

B. COLLECTIONS OF INFORMATON EMPLOYING STATISTICAL METHODS.

Statistical methods are not used in these collections of information.

1 Indicate the retention period for any recordkeeping requirements that pertain to the ICR.

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