SS 1215-0137 June 2006

SUPPORTING STATEMENT

PROVIDER ENROLLMENT FORM – FORM OWCP-1168

OMB NO. 1215-0137

1. 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 (LHWCA), 33 U.S.C. 901 et seq. These statutes require OWCP to pay for medical and vocational rehabilitation services provided to beneficiaries. In order for OWCP’s billing contractor to pay providers of these services with its automated 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, the bill payment process is prolonged and increases the burden on providers. The regulations implementing the four 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, 702.503, 725.704 and 725.705).

2. 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 the 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. Form OWCP-1168 is posted on the Internet for downloading by providers wishing to submit bills under one of the programs that OWCP administers (http://owcp.dol.acs-inc.com/portal/main.do). Since Form OWCP-1168 is submitted only once when a provider first enrolls with OWCP’s billing contractor, providing for the submission of this information electronically is not considered to be practicable due to the increased burden on the respondent for electronic submission. However, using a standard enrollment form keeps the burden on the public to a minimum by eliminating the need to ask for required profile information not previously submitted.

4. 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. This information collection has been streamlined to obtain the minimum information needed by OWCP’s medical bill processing contractor while imposing the minimum burden on respondents, and does not have a significant economic impact on a substantial number of small entities.

6. Please refer to Nos. 1 and 2 on page 1. The information required from providers is the minimum needed to meet the bill processing needs of the four programs and is only collected one time. Bills for medical and vocational rehabilitation services provided to beneficiaries cannot be processed by OWCP’s medical bill contractor without the information collected. Failure to collect this data would result in delayed payments to providers.

7. There are no special circumstances for conducting this information collection.

8. No outside consultations have been conducted concerning the use of this form. However, the form has been in use for several years in the Black Lung and EEOICPA programs and thousands of responses have been received providing ample time for comments and consultation. To our knowledge, no respondent has voiced a complaint regarding the use of this form.

A notice inviting public comment on this information collection was published in the Federal Register on July 18, 2006. No comments were received.

9. Respondents do not receive any gifts or payments to furnish the requested information.

10. All information submitted on Form OWCP-1168 is protected under the Privacy Act in the following four systems of records: DOL/GOVT-1 (for FECA); DOL/ESA-6 (for BLBA); DOL/ESA-15 (for LHWCA); and DOL/ESA-49 (for EEOICPA).

11. There are no questions of a sensitive nature on this form.

12.  The following burden estimates for the four programs have been derived from data compiled during FY 2006:

 

FECA:  Approximately 42,768 respondents submit a Form OWCP-1168 each year for the FECA program.  It is estimated that each Form OWCP-1168 takes about 8 minutes for the provider to prepare, which results in an annual hour burden of 5,688  hours (42,768 responses x 0.133 = 5,688 hours).

 

BLBA:  Approximately 3,182 respondents submit a Form OWCP-1168 each year for the BLBA program.  It is estimated that each Form OWCP-1168 takes about 8 minutes for the provider to prepare, which results in an annual hour burden of 423 hours (3,182 responses x 0.133 = 423 hours).

 

EEOICPA:  About 2,192 respondents submit a Form OWCP-1168 each year for the EEOICPA program.  It is estimated that each Form OWCP-1168 takes about 8 minutes for the provider to prepare, for an annual hour burden of 292 hours (2,192 responses x 0.133 = 292 hours).

 

LHWCA:  Approximately 100 respondents submit a Form OWCP-1168 each year for the LHWCA program.  It is estimated that each Form OWCP-1168 takes about 8 minutes for the provider to prepare, which results in an annual hour burden of 13 hours (100 responses x 0.133 = 13.3 hours).

 

Combining the burden hours for all programs, Form OWCP-1168 has a total respondent annual burden hour estimate of 6,416 hours (5,688 + 423 + 292 + 13 = 6,417).  Using the current hourly wage reported for general clerical work in offices and clinics of medical doctors (based on Bureau of Labor Statistics data for July 2006) of $21.46 per hour, the respondent annualized cost estimate for this collection is $137,687.

 

13.  There are no startup costs for this information collection.  Operation and maintenance costs consist solely of mailing costs.  Using a cost of $0.42 per response ($0.39 for postage and $0.03 for an envelope), operation and maintenance costs are estimated to be $20,262 (48,242 responses x $0.42 = $20,262).

 

14.  The estimated costs to the Federal government of collecting the information on Form OWCP-1168 are set out below:

 

Printing costs:  OWCP estimates that it will print 25,000 OWCP-1168 forms yearly at a cost of $1,200.00.

 

Mailing/Developmental costs:  Providers seeking to enroll under one of OWCP’s benefit programs may download Form OWCP-1168 from the Internet.  However, OWCP anticipates that approximately 75% of providers will request a paper form; there will be a mailing cost of $15,196 (36,181 x $0.42 = $15,196) for these forms.  There are no developmental costs associated with this collection of information.

 

Processing/Reviewing Costs:  Under OWCP’s new contractor medical bill processing system, the contractor cost to process one Form OWCP-1168 is $26.12.  Therefore, the contractor cost to process 48,242 forms for the four OWCP programs will be $1,260,081 (48,242 forms x $26.12/form = $1,260,081).

 

$1,200 (printing) + $15,196 (mailing) + $1,260,081 (processing) = Total Estimated Federal Cost of $1,276,477.

 

15.  Since the bulk of providers enrolled in the four programs were required to re-enroll with current information, Form OMB 83-I shows an adjustment of +4608 burden hours and +$15,262 operational and maintenance costs.

 

 16. There are no plans to publish data collected by Form OWCP-1168.

17. This information collection request does not seek a waiver from the requirement to display the expiration date.

18. There are no exceptions to the certification statement.

5