Medical travel Refund request Form
1240-0037
April 2021
SUPPORTING STATEMENT
MEDICAL TRAVEL REFUND REQUEST FORM
1240-0037 (OWCP-957)
This Information Collection Request extends the currently approved ICR.
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, 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 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(e), 725.701(d), 725.703(c) and 725.406.
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 is electronically interactive and is posted on the Internet at https://www.dol.gov/owcp/dfec/regs/compliance/OWCP-957.pdf. The beneficiary may complete the form online and print out a paper copy. 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.
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.
7. Explain any special circumstances required in the conduct of this information collection. 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 confidentially 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 confidentially to the extent permitted by law.
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. 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.
A Federal Register Notice inviting public comment was published on February 9, 2021 (86 FR 8805). No public 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), 81 FR 47418 (July. 21, 2016); = A Privacy Act Statement is included on the form.
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.
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. General, estimates should not include burden hours for customary and usual business practices.
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 14.
Activity |
No. of Respondents |
No. of Responses per Respondent |
Total Responses |
Average Burden (Hours) |
Total Burden (Hours) |
Hourly Wage Rate |
Total Burden Cost |
OWCP-957 |
34,703 |
9.610927 |
333,528 |
.166001 |
55,366 |
$30.01 |
$1,661,534 |
Totals |
34,703 |
|
333,528 |
|
55,366 |
|
$1,661,534 |
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 (2021 Table B-3 Private Service-Providing, Bureau of Labor Statistics data) of $30.01, the respondent annualized cost estimate for this collection is $1,661,534 (55,366 x 30.01) = $1,661,534 .
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.
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 333,528 mailed responses at $0.58 per response ($0.55in postage + $.03 for envelope) = annual operation and maintenance costs of $193,446 .
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-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 293,859 forms for the FECA program will be $1,272,409 (293,859 forms x $4.33/form = $1,272,409).
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) $66,143
2. GS-11/Step 6 (1) $74,676
3. GS-11/Step 7 (3) $76,810
4. GS-11/Step 8 (2) $78,943
5. GS-11/Step 9 (4) $81,077
6. GS-11/Step 10(1) $83,210
The average salaries of the aboveis $66,143 X 1, 74,676 X 1, 76,810 X 3, 78,943 X 2, 81,077 X 4, 83,210 X 1= 936,653 (using 2020 RUS, https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2020/rus.pdf .
Approximately 5% of their time is required for this function. Thus, the cost to provide this review function is $46,833 (12 x $83,210 X 5%).
Total FECA Processing/Reviewing costs: $1,272,409 + $46,833 = $1,319,242.
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 6,707 forms for the BLBA program will be $29,041 (6,707 forms x $4.33/form = $29,041).
Two Federal employees, one in Washington, DC and one in Columbus, Ohio review OWCP-957 forms under the BLBA program that suspend out of the bill processing system: an Assistant Payment System Manager (GS-13, step 9 using Salary Table 2020-DCB) at $131,341 yearly and a Claims Analysist (GS-13, step 10 using Salary Table 2020-COL) at $122,766 yearly. 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/2020/COL.pdf .
Approximately 5% of the Assistant Payment System Manager’s time is attributable to this reviewing function. Approximately 5% of the Claims Analysist’s time is attributable to this reviewing function. The total time attributable to this reviewing function is $6,567 (131,341 x 5% = $6,567) ($122,766 x 5% = $6,138 )
Total BLBA Processing/Reviewing costs: $29,041 + $12,705 = $41,746
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 32,962 forms submitted for the EEOICPA program will be $142,725 (32,962 forms x $4.33/form = $142,725).
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) at $130,698 yearly and an Assistant Bill Pay Manager (GS-13, step 7) at $124,428 yearly. About 5% of their time is attributable to this reviewing function, for a cost of $11,662 ($130,698 + $124,428 = $255,126 x 5% = $12,756). (Using https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2021/DCB.pdf.
Total EEOICPA Processing/Reviewing costs:
$142,725 + $12,756 = $155,481
Total Federal Processing/Reviewing costs:
$1,319,242 (FECA processing and reviewing costs) + $41,746 (BLBA processing and reviewing costs) + $155,481 (EEOICPA processing and reviewing costs) = $1,516,469.
15. Explain the reasons for any program changes or adjustments.
There are no changes to this collection. The increased cost burden is the result of increased postage prices.
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 on the form.
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.
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 | 2022-03-07 |