Supporting Statement 1240-0021 OWCP 1168 2020

Provider Enrollment Form

1240-0021 (OWCP-1168)

June 2020

SUPPORTING STATEMENT

PROVIDER ENROLLMENT FORM (OWCP-1168)

1240-0021

This Information Collection Request revises the currently approved ICR to incorporate regulatory updates implementing the Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA), 42 U.S.C. 7384 et seq.

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., the Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA), 42 U.S.C. 7384 et seq., and the Longshore and Harbor Workers’ Compensation Act, 33 U.S.C 901 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 for these services with its 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, 725.705 and 725.714).

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 four 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.

In accordance with the Government Paperwork Elimination Act, the current Form OWCP-1168 is electronically interactive and is posted on the Internet at https://www.dol.gov/owcp/dfec/regs/compliance/OWCP-1168.pdf and https://owcpmed.dol.gov/ . OWCP’s billing contractor has allowed the submission of this information to be made online through the billing contractor’s web portal. The online information collection and submission process allows more expedited collection of the required information by using best practices in information technology. A provider may also print out a paper copy and mail it to OWCP’s billing contractor. A provider may also complete the form online, print out a paper copy and mail it to OWCP’s medical billing contractor.

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 responses. The information requested from respondents is the minimum needed to meet the bill processing needs of the four 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 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 a 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 secrets, 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 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.

A Federal Register Notification inviting public comment was published on February 26, 2020 [85 FR 11119]. Commenters were not 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), 81 FR 25776 (Apr. 29, 2016); DOL/OWCP-4 (for LHWCA), 81 FR 25860 (Apr. 29, 2016); DOL/OWCP-9 (for BLBA), 81 FR 25866 (Apr. 29, 2016); and DOL/OWCP-11 (for EEOICPA), 81 FR 25868 (Apr. 29, 2016). 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 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.

* If this request for approval covers more than one form, provide separate hour burden estimates for each form and aggregate the hour burdens.

* 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 under “Annual Cost to Federal Government.”

The following burden estimates for the three programs have been derived by averaging data compiled from FY2015 through 2017:

 

FECA:  Approximately 35,347 respondents submit a Form OWCP-1168 each year for the FECA program.  It is estimated that each Form OWCP-1168 takes up to 30 minutes for the respondent to prepare, which results in an annual hour burden of 17,673.5 hours (35,347 responses x 0.5 = 17,673.5 hours).

 

BLBA:  Approximately 14,081 respondents submit a Form OWCP-1168 each year for the BLBA program.  It is estimated that each Form OWCP-1168 takes up to 30 minutes for the respondent to prepare, which results in an annual hour burden of 7,040.5 hours (14,081 responses x 0.5 = 7,040.5 hours).

 

EEOICPA:  About 14,897 respondents submit a Form OWCP-1168 each year for the EEOICPA program.  It is estimated that each Form OWCP-1168 takes up to 30 minutes for the respondent to prepare, for an annual hour burden of 7,448.5 hours (14,897 responses x 0.5 = 7,448.5 hours).

LHWCA: The LHWCA program did not process providers with the OWCP-1168 form. The program will be using the 1168 and OWCP’s billing contractor with the information collection updates submitted therein. An average of two providers per year, if any, are enrolled annually. This program was not included in the burden hours because it has a minimal impact to the estimate below.

 

Combining the burden hours for these programs, Form OWCP-1168 has a total respondent annual burden hour estimate of 32,162.5 hours (17,673.5 + 7,040.5 + 7,448.5 = 32,162.5).  Using the 2018 hourly wage reported for general clerical work in offices and clinics of medical doctors (based on Bureau of Labor Statistics data for May 2018 https://www.bls.gov/oes/current/oes439199.htm) of $18.02 per hour, the respondent annualized cost estimate for this collection is $579,568.25 (32,162.5 X 18.02 = $579,568.25).

The OWCP-1168 was recently reformatted to allow appropriate selection of information by use of checkbox as opposed to field entries and to reflect clear and correct section and field headings, as well as renumbering of fields throughout the document to accommodate added fields and field elaborations to capture pertinent provider enrollment information. The form changes consist of adding a new check box for re-validate provides allows providers to indicate if the enrollment is being presented to validate their provider information submitted previously; a checkbox to reflect if the enrollment is for LongShore new providers; a section was added to capture information for SSN based enrollment when new providers are using an SSN as opposed to a TIN for verification purposes; added County and Country fields to the Physical and Mailing address sections; new ownership section has been added to collect information to support validations/verifications of organization owners of the enrolling providers; license/certification and taxonomy section was revised in order to capture additional information that confirms license type and expiration dates and specialty; type of media that the provider would use to submit bills (e.g. EDI, web, batch) to include all the electronic submission details and contact information for data exchange as well as clearinghouse and third party billing agents that bill on behalf of the enrolling provider.

13. Provide an estimate for the total annual cost burden to respondents or record keepers resulting from the collection of information. (Do not include the cost of any hour burden already reflected on the burden worksheet).

* 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 services 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 collections 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 startup costs for this information collection.  Operation and maintenance costs consist solely of mailing costs.  Using a cost of $ 0.58 per response ($0.55 for postage and $0.03 for an envelope), operation and maintenance costs are estimated to be $37,309 (64,325 responses x $0.58 = $37,309 rounded).

14. Provide estimates of annualized costs 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), and any other expense that would not have been incurred without this collection of information. Agencies may also aggregate cost estimates from Items 12, 13, and 14 in a single table.

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 $24,997 (43,098 x $.58 = $24,997) 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 64,325 of these forms for the three programs is $1,839,695 (64,325 forms x $ 28.60 = $1,839,695).

 

$24,997(mailing) + $1,839,695 (processing) = Total Estimated Federal Cost of $1,864,692.

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

There are no program changes nor any changes in burden estimates.

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.

Data collected with this form will not be published

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.

The OMB Number and expiration date will be displayed.

18. Explain each exception to the certification statement in ROCIS.

There are no exceptions to certification.

B. Collections of Information Employing Statistical Methods

Statistical methods are not used in these collections of information.

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