1240-0007 Supporting Statement_2024__05232024_MN clean

Claim for Medical Reimbursement

OMB Control Number 1240-0007 (OWCP-915)

OMB Expiration Date: May 31, 2024

SUPPORTING STATEMENT FOR

CLAIM FOR MEDICAL REIMBURSEMENT

OMBCONTROL NO. 1240-0007

This Information Collection Request seeks a three-year extension of an existing 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) administers 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., and the Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA), 42 U.S.C. 7384 et seq. All three statutes require OWCP to pay for covered medical treatment provided to beneficiaries, and to reimburse beneficiaries for any out-of-pocket covered medical expenses that they paid. FECA, BLBA and EEOICPA implementing regulations require the collection of information needed to determine whether a beneficiary’s claim for medical reimbursement can be paid. (20 CFR 10.802, 30.702, 725.701 and 725.716). Form OWCP-915, Claim for Medical Reimbursement, is used for this purpose and collects the necessary beneficiary and medical provider data in a standard format. Beneficiaries must also attach billing information prepared by the medical provider (Form OWCP-1500 for professional medical services, Form OWCP-04 for institutional providers and hospitals, or a paper bill for medications dispensed in the physician’s office).¹ This is the same billing information a medical provider reports when it bills OWCP directly.

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.

All claims for reimbursement undergo automated scanning upon receipt at OWCP’s Central Mail Facility. Because Form OWCP-915 presents the required information in a standard format, scanning allows claims that meet payment criteria to be paid very quickly, ensuring timely reimbursement payments to beneficiaries. When a beneficiary pays for services out of his or her own pocket, OWCP must collect basic information about the beneficiary and the amount they paid for services. OWCP will process the bills for services rendered and will reimburse beneficiaries based on the calculations set forth in the OWCP Fee Schedule for the services rendered. If the data requested on Form OWCP-915 were not collected, OWCP’s would be unable to process the medical bills and reimbursement claim in a timely manner.

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.

Form OWCP-915 is currently posted on the Internet at https://owcpmed.dol.gov/. All reimbursement claims are received at one location, scanned, and undergo an automated review that utilizes a comprehensive set of treatment suites to compare the services rendered for a covered condition with medically acceptable, allowable treatments for that condition. OWCP is working to expand its ability to accept electronic bills, but because Form OWCP-915 requires attachments (bills prepared by the medical provider and paper proof of payment made by the beneficiary), submission of this information electronically is not feasible. However, use of a standard claim form keeps the paperwork burden on the public to a minimum by nearly eliminating the need to ask for required information that wasn’t submitted with the original reimbursement claim.

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 beneficiary is the only source of the information that he or she paid for these out-of-pocket expenditures.

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 minimum information needed for OWCP’s bill processing system while imposing the minimum burden on respondents. The required attachments to Form OWCP-915 do not impose additional burdens on small businesses or other small entities since providing billing information to the beneficiary at the time payment is requested is part of a medical provider’s usual business practices.

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.

Please refer to Nos. 1 and 2 on page 1. Beneficiaries must complete a Form OWCP-915 when seeking reimbursement for out-of-pocket monies they paid for covered medical expenses. Although beneficiaries must submit a separate reimbursement claim for each medical provider, Form OWCP-915 allows beneficiaries to claim reimbursement for multiple visits or services with a provider. The information collected is the minimum needed to process the claims for medical reimbursement submitted by beneficiaries. If the information was not collected or was collected less frequently, OWCP would be unable to timely reimburse claimants’ out-of-pocket payments for covered medical expenses.

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 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.

During this review period, OWCP reached out to both internal and external stakeholders with experience using the form to obtain their views. One of our internal stakeholders recommended updates to the “Personal Information” Additionally, it was recommended that the current reference to the “FOR DOL USE”, be moved to the signature area.

No other recommendations were made.

Contact	Organization	Email	Phone
Myra XXXX	Department of Labor Payment Systems Specialist	XXX	XXX
Marcela XXXX	Claims Examiner/Analyst, Branch of Policy Analysis and Program Standards	XXX	XXX
Bill XXXX	Claimant	XXX	XXX

A Federal Register Notice inviting public comment was published on 02/12/2024 (89 FR 9869). Comments were not received.

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

There is no gift or payment to respondents other than remuneration to contractors for services and expenses.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulation, 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 25776 (Apr. 29, 2016); DOL/OWCP-2 (BLBA), 81 FR 25858 (Apr. 29, 2016); and DOL/OWCP-11 (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 on the Form OWCP-915.

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.

In FY-2023, OWCP received a total of 54,067 OWCP-915 forms.

The FECA program received approximately 38,951 OWCP-915 forms.

The BLBA program received approximately 60 OWCP-915 forms.

The EEOICPA program received approximately 15,056 OWCP-915 forms.

38,951 _FECA + 60 _BLBA + 15,056 _EEOICPA = 54,067 OWCP-915 forms.

It is estimated that each Form OWCP-915 claiming reimbursement takes about 10 minutes (0.167 hour) for the beneficiary to prepare. Thus, we estimate 9,029 total burden hours annually (54,067 forms x 0.167 hour = 9,029.18 or 9,029 (hours rounded).

The specific wage category of beneficiaries who provide this information is not documented in OWCP’s bill processing system. Therefore, using the current national average wage rate (based on Bureau of Labor Statistics data https://www.bls.gov/news.release/ocwage.t01.htm) of $36.43 per hour, the respondent annualized cost estimate for this collection is $328,926.47 (3,010 x $36.43 = $328,926.47.

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	Monetized Value of Respondent Time
OWCP-915	54,067	1	54,067	0.167	9,029	$36.43	$328,926.47

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 Form OWCP-915. Operation and Maintenance costs consist solely of mailing cost, the price of postage and envelope to return the form.

It is estimated that 97% of the claimants will submit their response electronically; consequently, for these respondents, there is no cost. For approximately 3% of the respondents who will mail their form, the only operation and maintenance cost is for postage and envelopes.

Respondent Cost

$0.68 (postage as of July 1, 2024) + $0.05 (envelopes) = $ 0.73.

3% of 54,067 responses = 1622.01 or 1622 responses (rounded)

Total Cost is $0.73 x 1622 = $1,184.06 or $1,184 rounded

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-915 are set out below:

Printing costs: OWCP estimates that it will print 100,000 OWCP-915 forms yearly at a cost of $2,400 per each fifty thousand forms. Therefore, printing costs for the OWCP-915 will amount to $4,800 per year.

Mailing/Developmental costs: Beneficiaries seeking reimbursement for out-of-pocket medical expenses under FECA, BLBA and EEOICPA may download copies of Form OWCP-915 from the Internet. The form is also included in the packet of materials that OWCP mails to a beneficiary when it accepts the beneficiary’s claim under one of the programs and for that reason, no additional mailing costs for the form are normally incurred. There are also no developmental costs associated with this collection of information.

FECA: Under OWCP’s contractor medical bill processing system, the contractor cost to process one Form OWCP-915 is $5.32. Therefore, the contractor cost to process 38,951 forms for the FECA program will be $207,219.32 (38,951 forms x $5.32/form = $207,219.32).

Reimbursement claims 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 level, and by 12 at the GS-9 level; approximately 5% of their time is required for this function. Thus, the cost to provide this review function is

$204,986 [(80 x $43,533 /year (GS 5, step 4 using Salary Table 2024-RUS) x 5% = $174,132.

12 x $61,965/year (GS 9, step 2 using Salary Table 2024-RUS) x 5% = $37,179; $174,132 + $37,179 = $211,311].

Total FECA Processing/Reviewing costs: $280,386 ($69,074.88 + $211,311 = $280,385.88).

BLBA: OWCP’s contractor medical bill processing system also performs all manual review functions for the BLBA program, at the same contractor cost of $5.32 per form. Therefore, the contractor cost to process and review 60 forms for the BLBA program will be $319.20 (60 forms x $5.32/form = $319.20).

EEOICPA: As it does for FECA, OWCP’s contractor medical bill processing system processes Forms OWCP-915 for the EEOICPA program at a cost of $5.32 per form. Therefore, the contractor cost to process the 15,056 forms submitted for the EEOICPA program will be $80,097.92 (15,056 forms x $5.32/form = $80,097.92).

Two Federal employees in Washington, DC review all claims for reimbursement under the EEOICPA program that suspend out of the contractor bill processing system: a payment systems manager (GS-14, step 3 using Salary Table 2024-DCB) at $148,689 yearly and an assistant payment systems manager (GS-13, step 7 using Salary Table 2021-DCB) at $141,557 yearly. About 5% of their time is attributable to this reviewing function, for a cost of $14,512 ($148,689 + $141,557 = $290,246 x 5% = $14,512.30).

Total EEOICPA Processing/Reviewing costs: $42,213 ($27,701 + $14,512).

Total Federal Costs: $327,505 [$4,800 (printing costs) + $280,386 (FECA processing and reviewing costs) + $106 (BLBA processing costs) + $42,213 (EEOICPA processing and reviewing costs) = $327,505].

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

Burden hours have increased from 5,738 to 9,029 due to the increase in claim submissions.

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 by Form OWCP-915.

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.

This collection does not employ statistical methods.

1 The hour and cost burdens to collect the billing information from medical providers in the required attachments to Form OWCP-915 are accounted for in OMB Nos. 1240-0019, 1240-0044, and 1240-0050.

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