Supporting Statement 1240-0021 OWCP 1168 2023 _20230927_FINAL

Provider Enrollment Form

OMB Control Number: 1240-0021

OMB Expiration Date: December 31, 2023

SUPPORTING STATEMENT FOR

Provider Enrollment Form

OMB CONTROL NO. 1240-0021

This ICR seeks to revise a currently approved collection.

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 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. Also, OWCP’s billing contractor has allowed the submission of this information to be made online through the billing contractor’s web portal at: https://owcpmed.dol.gov/. 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 fax or mail it to OWCP’s billing contractor. A provider may also complete the form online, print out a paper copy and fax or 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 of information impacts small businesses or other small entities, describe any methods used to minimize burden.

This information collection was streamlined to obtain the information OWCP’s billing contractor needs while imposing the minimum burden on respondents. It does not have a significant economic impact on a substantial number of small entities.

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 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 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 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 comments on this collection of information was published in the Federal Register on June 29, 2023, at 88 FR 42104. Public comments were not 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 payments or gifts 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, regulation, or agency policy.

The information collected by this form is maintained in OWCP claim files which are fully protected under the Privacy Act. The applicable Privacy Act System of Records are (FECA) DOL/GOVT-1, (Longshore) DOL/OWCP-3 and DOL/OWCP-4, (FECA) DOL/GOVT-1, DOL/OWCP-2 (Black Lung) and DOL/OWCP-11 (Energy).

Reference: https://www.dol.gov/agencies/sol/privacy

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.

• 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.

Estimated Annualized Respondent Cost and Hour Burden

Activity	No. of Respondents	No. of Responses per Respondent	Total Responses	Average Burden (Hours)	Total Burden (Hours)	Hourly Wage Rate	Total Burden Cost
OWCP-1168	23,318	1	23,318	0.4167 (25 minutes)	9,717	$20.75	$201, 628

The following burden estimates for the three programs are derived by averaging data compiled from May 2021 – April 2023. Data from May 2020 – April 2021 was omitted since OWCP acquired a new medical bill processing contractor in April 2020. During the transition, current providers were rolled over into the new contractor’s system and a new enrollment form 1168 was not required. This change reduced the number of respondents significantly.

FECA: Approximately 11,063 respondents submit a Form OWCP-1168 each year for new enrollment to the FECA program. It is estimated that each Form OWCP-1168 takes up to 25 minutes for the respondent to prepare, which results in an annual hour burden of 4,609.5 hours (11,063 responses x 25 minutes = 276,575/60 minutes = 4,609.5 hours or 4610 rounded).

FECA = 4,610 hours

BLBA: Approximately 6,049 respondents submit a Form OWCP-1168 each year for new enrollment to the BLBA program. It is estimated that each Form OWCP-1168 takes up to 25 minutes for the respondent to prepare, which results in an annual hour burden of 2,520.5 hours (6,049 responses x 25 minutes = 151,225/60 minutes = 2,520.5 hours or 2521 rounded).

BLBA = 2,521hours

EEOICPA: Approximately 6,207 respondents submit a Form OWCP-1168 each year for new enrollment to the EEOICPA program. It is estimated that each Form OWCP-1168 takes up to 25 minutes for the respondent to prepare, which results in an annual hour burden of 2,586.25 hours (6,207 responses x 25 minutes = 155,175/60 minutes = 2,586.25 hours or 2, 586 rounded).

EEOICPA = 2,586 hours

LHWCA: The LHWCA program did not process providers with the OWCP-1168 form. The program is not using the 1168 and OWCP’s billing contractor with the information collection updates submitted therein. Moreover, LHWCA and FECA merged into Division of Federal Employees', Longshore and Harbor Workers' Compensation (DFELHWC). This program was not singled out for inclusion in the burden hours because it has a minimal impact to the estimate below.

Combining the number of respondents and burden hours for these programs, Form OWCP-1168 has a total of 23,318 respondents (11,063 + 6,049 + 6,207 = 23,318), and therefore a total of 23,318 responses and a respondent annual burden of 9,717 hours (4,610 + 2,521 + 2,586 = 9,717).

Using the 2022 hourly wage reported for general clerical work in offices and clinics of medical doctors (based on Bureau of Labor Statistics current data for May 2022 (https://www.bls.gov/oes/current/oes439199.htm) of $20.75 per hour, the respondent annualized cost estimate for this collection is $201,628 1 (9,717 x 20.75).

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 startup costs for this information collection. Operation and maintenance costs consist of solely mailing costs. The response cost is $ 0.70 per response ($0.66 for postage and $0.03 for an envelope). However, electronically uploaded responses using OWCP’s billing contractor’s web portal is approximately 95%. The total cost for the 5% mailed, is calculated as $816.00 as noted below.

Total electronic responses = 23,318 x 95% = 22,152.10 or 22,152 rounded

Total mailed responses = 23,318 x 5% = 1165.9 or 1,166 rounded

Total cost for mailed response = $816.20 or $816 rounded (1,166 mailed responses x $0.70 = $816.20.)

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 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, based on enrollment data from May 2021 – April 2023, OWCP anticipates that approximately 5% of providers will request a paper form; there will be a mailing cost of $816.20 or $816 (rounded) (1,166 x $0.70) for these forms. There are no developmental costs associated with this collection of information.

Processing/Reviewing Costs: OWCP pays its billing contractor $18.40 to process one Form OWCP-1168.¹ Therefore, OWCP’s cost to have its contractor process 23,318 of these forms for the three programs is $429,051 (23,318 forms x $18.40 = $429,051.20 or 429,051 rounded).

$816 (mailing) + $429,051(processing) = Total Estimated Federal Cost of $429,867.

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

The changes to the form 1168 only pertain to the instruction’s pages (Pages 13-22). We made a minor change to the form 1168, by decreasing the length of the instruction pages to provide clear and concise instructions for the provider completing the form. Limiting the instructions reduces the time to fill out the form since there are less pages for referring to when completing certain fields. The burden is reduced by 5 minutes and with this revision, it takes 25 minutes to complete the form.

The decreased cost of burden is the result of OWCP acquiring a new medical bill processing contractor in April 2020. During this transition, current providers were rolled over into the new contractor’s system and a new enrollment form 1168 was not required. This change reduced the number of respondents significantly – it was reduced from 64,325 to 23,318, a decrease of 41,007. This resulted in an equivalent decrease in number of responses and attendant decreases to the total respondent burden hours and cost to the federal government. The previously approved number for burden hours was 32,162.5 and the requested number now is 9,717, a decrease of 22,445.5 hours. The previous cost to the federal government was $579,568 and is now $429,867, a decrease of $149,701. Additionally, since enrollment processing time is reduced when providers opt to complete the form online, very few new providers print and mail form 1168, which resulted in reduced cost to respondents. The previous approved annual cost to respondents was $24,997, and the cost requested now is $816, a decrease of $24,181.

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.

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.

There are no exceptions to certification.

B. COLLECTIONS OF INFORMATION EMPLOYING STATISTICAL METHODS.

Statistical methods are not used in these collections of information.

1 OWCP entered a new medical bill processing contract in 2020. This current contract encompasses a combination of services that includes mailroom and call center subcontracting costs, and there is not a specific itemized cost associated with processing OWCP-1168. Therefore, the per-form cost calculation was determined by calculating the enrollment portion of the option year price and then dividing this portion by a projected number of enrollments for the full option year.

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