1240-0037 Supporting Statement_FINAL

Medical Travel Refund Request Form

OMB Control Number: 1240-0037

OMB Expiration Date: 06/30/2024

SUPPORTING STATEMENT FOR

MEDICAL TRAVEL REFUND REQUEST FORM

OMB CONTROL NO. 1240-0037

This Information Collection Request seeks to revise the current OWCP-957 into two forms, OWCP-957 Part A and OWCP-957 Part B, and to revise the currently approved ICR.

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, 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, including the signature of the physician for medical expenses claimed under the BLBA.¹ Form OWCP-957, Medical Travel Refund Request, is the standard form for the collection of these data. The implementing regulations for each statute allow for the collection of information that OWCP needs to determine if reimbursement requests for medical travel expenses should be paid. (20 CFR 10.315, 30.404, 725.406(e), 725.701(d), 725.703(c) and 725.406.

¹BLBA requires a physician signature to process reimbursements; EEOICPA and FECA do not require a physician signature.

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.

Current Form OWCP-957 is used by OWCP and contractor bill processing staff to process reimbursement requests for all covered medical travel expenses, including mileage. Moving forward, Form 957 Part A would be used only for mileage-reimbursement requests and Form 957 Part B would be used to request reimbursement for all other covered medical 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 requests include all data elements needed to evaluate the request. If the data elements required by OWCP are not collected, the contractor staff cannot process the request for reimbursement.

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.

Use of a standard form for reimbursement requests enables OWCP’s contractor bill processing staff to scan in the data on the form and expedite the processing of payments to the beneficiary. The current form OWCP-957 is electronically interactive and available on the Internet at https://owcpmed.dol.gov/portal/sites/default/files/inline-files/OWCP-957.pdf. The beneficiary may complete the form online and print out a paper copy.

For FECA, the beneficiary is required to print out a paper copy and mail the form for processing.

For EEOICPA, the beneficiary, through an online portal that includes identity proofing, may complete, digitally sign and submit the form. All supporting documentation can be submitted through the same portal concurrent with the form submission.

Since the current OWCP-957 form must include a physician’s signature for BLBA respondents, electronic submission of Form OWCP-957 is considered not practicable for the BLBA program.

The revised form OWCP-957 Part A removes all fields specific to Black Lung. As a mileage-only request, there would be no circumstance that would require claimants to attach receipts or evidence of payment. The revised OWCP-957 Part A also permits a respondent to claim more trips per form when compared to the existing OWCP-957 form that limits reimbursements request to three trips.

Form OWCP-957 Part B – Travel Expense Reimbursement Request. This form is designed to reimburse claimants for expenses separate from mileage reimbursement such as train or bus tickets, parking, tolls, lodging, meals, etc. This form retains the Black Lung specific fields but can also be used by other programs to process more complex medical travel expense reimbursement requests. The Black Lung program has decided it will use this form exclusively due to program specific processing protocols.

The updated OWCP-957 Part A and Part B will both be made available through an online portal including identity proofing for digital completion, signature and submission for EEOICPA claimants.

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 forms OWCP-957 Part A and OWCP-957 Part B is not duplicative of any information available elsewhere. The respondent is the only source of the medical travel expenses data that is needed to process the request for reimbursement.

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 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.

6. 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 publications 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 June 1, 2023 (88 FR 35932). No comments were received. OWCP has not consulted with the public for this specific ICR. We are in the process of reviewing all our ICR requirements and implementing procedures to comply with M-22-10. We anticipate this process to be implemented by FY2024.

9. 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.

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

The information collected by these forms is maintained in OWCP claim files which are fully protected under the Privacy Act. The applicable Privacy Act System of Records are:

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 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.

• 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 A	35,646	10	342,600	.15	51,390	$33.60	$1,726,704
OWCP-957 B	1,486	9	14,275	.15	2,141	$33.60	$71,937.60
Totals	37,132	9.6109	356,875	.15	53,531		$1,798,642 (rounded)

The burden was estimated using data prior to 2020 with a growth rate from the last analysis. Data from pre-pandemic was used to forecast future numbers. Beginning 2020 to present, data was severely skewed due to the COVID-19 pandemic and closures. A consultation with a sample 9 respondents was conducted to estimate burden hours. Each form took an average of 9 minutes (0.15 hour) to complete. 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 for June 2023(2023 Table B-3 Private Service-Providing, Bureau of Labor Statistics data) of $33.60, the respondent annualized cost estimate for this collection is $1,798,642 (53,531 x 33.60 = $1,798,641.60 or $1,798,642 rounded).

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.

There are no recordkeeping or collection costs associated with the beneficiary information collected on forms OWCP-957 Part A and OWCP-957 Part B. The only operation and maintenance cost is for postage. The response cost is $ 0.70 per response ($0.66 for postage and $0.04 for an envelope. However, electronically uploaded responses using EEOICPA’s online portal is 33% of EEOICPA’s total responses entail no response cost. The total cost for the 343,795 forms mailed is calculated at $240,656, as noted in the chart below.

[$0.66 (postage) + $0.04 (envelopes)] x 356,875 (forms) = $249,812.50, rounded up to $249,813.

Total Cost for mailed response = [$0.66 (postage) + $0.04 (envelopes)] x [ 311,267 (FECA) + 7,137 (BLBA) + (38,471 x .66 (EEOICPA mailed in responses)] = $240,656.40, rounded down to $240,656.

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 Forms OWCP-957 Part A and OWCP-957 Part B are set out below:

FECA:  Under OWCP’s contractor medical bill processing system, the contractor cost to process one Form OWCP-957 is $4.63. The contractor cost to process 304,914 (Part A) and 6,353 (Part B) forms for the FECA program will be $1,469,913 (311,267 forms x $4.63/form = $1,441,166.21 or $1,441,166 rounded). All reimbursement requests for the FECA program are processed by the medical bill processing contractor.

Total FECA Processing cost = $1,441,166

BLBA: Under OWCP’s contractor medical bill processing system, the contractor cost to process one Form OWCP-957 for BLBA is at the same contractor cost of $4.63. The cost to process 7,137 (Part B) forms for the BLBA program will be $33,044 (7,137 forms x $4.63/form = $33,044.31 or $33,044 rounded).

Two Federal employees, one in Washington, DC and one in Columbus, Ohio manually review OWCP-957 forms under the BLBA program that the bill processing system is unable to process: an Assistant Payment System Manager (GS-13, step 10 using Salary Table 2023-DCB:https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2023/DCB.pdf ) at $145,617 yearly and a Claims Analysist (GS-13, step 10 using Salary Table 2023-COL: www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2023/COL.pdf ) at $133,285 yearly.

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 $13,945 = (145,617 x 5% = $7,280.85, or $7,281 rounded) + ($133,285 x 5% = $6,664.25 or $6,664 rounded).

Total BLBA Processing and Reviewing costs: $33,044+ $13,945 = $46,989

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 $4.63 per form. The contractor cost to process the 37,686 (Part A) and 785 (Part B) forms submitted for the EEOICPA program will be $178,120 (38,471 forms x $4.63/form = $178,120.73 or $178,121 rounded).

Under the EEOICPA program, OWCP-957 reimbursement requests that suspend out of the contractor medical bill processing system and require manual review are examined by one of 40 Medical Benefits Examiners employed by the EEOICPA program throughout the country, with various salaries as noted below:

1. GS-12 (31) $95,255

2. GS-9 (5) $65,684

3. GS-7 (4) $53,700 (rounded)

Specific salary grade and step of all 40 examiners was not available. An average of the range for each grade was utilized to calculate the average salaries of the above: (($95,255 X 31) X ($65,684 X 5) X ($53,699 X 4))/40 = $87,403.03 or $87,403 rounded using 2023 RUS, https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2023/rus.pdf.

Approximately 1% of their time is required for this function. Thus, the cost to provide this review function is $34,961 (40 X $87,403 X 1% = $34,961.20 or $34,961 rounded).

Total EEOICPA Processing and Reviewing costs: $178,121 + $34,961 = $213,082.

Total Federal Processing and Reviewing costs:

$1,441,166 (FECA processing costs) + $46,989 (BLBA processing and reviewing costs) + $213,082 (EEOICPA processing and reviewing costs) = $1,701,237

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

The increased cost burden is the result of increased postage prices, inflation of envelopes and cost of living adjustment for salaries. Since OWCP entered a new medical bill processing contract in 2020, the per-bill cost calculation was adjusted by calculating projected billing volumes with operations cost for the current year. The new contract encompasses a combination of services and there is not a cost breakdown for this specific form.

In March 2022, DEEOIC conducted Customer Experience (CX) survey related to medical travel reimbursement. Claimants expressed that paperwork, and the travel reimbursement form were among the top concerns. Problems identified with the existing form include:

• Claimants could only enter three trips per page and were required to enter all names, addresses, and claim number information on each page.

• The form was cumbersome requiring Claimants to make a separate entry for each trip, even if it was to the same medical provider (ex: physical therapy)

• The form itself was confusing.

• A large portion of Form 957 was used for Black Lung only and within Black Lung was only used by approximately two percent of claimants seeking reimbursement of medical travel expenses in addition to or instead of medical mileage reimbursement.

• During investigation on the use of Form 957, it was discovered that on an annual basis 93% of the medical reimbursement requests in 2022 were for mileage only.

Based on this information, this request seeks to revise the current OWCP-957 into two forms, OWCP-957 Part A for medical mileage-only reimbursement requests and OWCP-957 Part B for all medical travel expenses, and also extend the currently approved ICR.

The new Form OWCP-957 Part A – Medical Travel Refund Request – Mileage form provides the following benefits:

• The form is visually simplified and easier to understand.

• The reading level decreased from Flesch Kinkaid Read Level of 10.5 on the existing form to 9.2 on the proposed form¹

• The space to enter an origination/destination address, originally 2” W x .66” H, was increased from to 2.25” W x 1” H.

• A claimant can submit up to six trips to a single provider without re-entering the origin/destination addresses.

• A claimant can submit up to 30 trips on one page.

• This form will not require the submission of separate documentation to validate the accuracy of claimed mileage.

The new Form OWCP-957 Part B – Medical Travel Expense Reimbursement Request provides the following benefits:

• The form is visually simplified but retains all data fields on the original Form 957, other than the mileage that is captured on 957 Part A.

• The form has Black Lung specific fields needed for diagnosis and treatment of black lung conditions but can still be used by the other programs.

• The space to enter an origination/destination address, originally 2” W x .66” H, was increased from to 3” W x .66” H.

• This form will alert program staff that additional evidence of expenses such as receipts will likely be attached to the form and, if not, will likely require additional requests for information from the claimant.

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.

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.

1 This comparison excluded a summary of the statutory citations, the Public Burden notice, and the Privacy Act Statement for both the original and proposed forms.