1. Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.
38 U.S.C. Chapter 17 authorizes VA to provide hospital care, medical services, domiciliary care and nursing home care to eligible veterans. Public Law 106-117 "The Veterans Millennium Health Care and Benefits Act" amended 38 U.S.C. by adding § 1725 establishing reimbursement authority for an individual who is an active Department health-care participant who is personally liable for emergency treatment furnished in a non-Department facility provided that the veteran is (1) enrolled in the VA health care system as established under § 1705 (a) of this title and (2) the veteran is personally liable for emergency treatment furnished the veteran in a non-Department facility and has no entitlement to care of services under a health-plan contract without regard to any requirement or limitation relating to eligibility for care services from any department or agency of the United States and (3) the veteran has no other contractual or legal recourse against a third party that would, in whole or in part, extinguish such liability to the provider and (4) is not eligible for reimbursement for medical care or services under § 1728 of this title. Further, PL 106-117 directs VA to delineate the circumstances under which such payments may be made, to include such requirements on requesting reimbursement as the Secretary shall establish. Subject to this, the Secretary may only provide reimbursement after the veteran or the provider of emergency treatment has exhausted without success all claims and remedies reasonably available to the veteran or provider against a third party for payment of such treatment.
A consequence of this law is that many veterans who are not covered by 38 U.S.C. §1728 may request that non-Departmental emergency services be reimbursed. This includes veterans for whom: (1) such care or services were rendered in a medical emergency of such nature that delay would have been hazardous to life or health and (2) such care or services were rendered to a veteran in need thereof (A) for an adjudicated service-connected disability, (B) associated with and held to be aggravating a service-connected disability, (C) for any disability of a veteran who has a total disability permanent in nature from a service-connected disability, or (D) for any illness, injury, or dental condition in the case of a veteran who (I) is a participant in a vocational rehabilitation program and (3) Department of other Federal facilities were not feasibly available, and an attempt to use them beforehand would not have been reasonable, sound, wise, or practical.
2. Indicate how, by whom, and for what purposes the information is to be used; indicate actual use the agency has made of the information received from current collection.
Although this information may be submitted in any format, the form CMS 1500 (OMB approval 0938-0999) and form UB 04 are generally used to bill the U.S. Government for services rendered. The form CMS 1500, Health Insurance Claim Form, is used by non-institutional providers and suppliers to bill Medicare, Part B covered services. It is also used for billing some Medicaid covered services. The form UB 04, Medicare Uniform Institutional Provider Bill, is used by institutional and other selected providers to complete a Medicare, Part A paper claim for submission to Medicare Fiscal Intermediaries. The forms UB 04 and form CMS 1500 are not government printed forms nor distributed by The National Uniform Billing Committee (NUBC). The NUBC is responsible for the design of the form.
These forms are completed by the health care provider of emergency treatment that was furnished to the veteran in a non-VA hospital that qualifies to receive payment for emergency services from the Medicare Program under the provisions of 42 C.F.R. Part 424. The form can either be mailed, faxed, or hand carried to the VA. The claimant will be required to certify that 1) the reimbursement of payment for the initial evaluation and treatment is for a condition of such a nature that a prudent layperson would have reasonably expected that delay in seeking immediate medical attention would have been hazardous to life or health; and under the circumstances a VA or other Federal facility was not feasibly available and an attempt to use them before hand would not have been reasonable and 2) the reimbursement or payment for any medical care beyond the initial emergency evaluation and treatment is for continued medical emergency of such a nature that the veteran could not have been safely transferred to a VA or other Federal facility and 3) the veteran has no coverage under a health-plan contract for reimbursement or payment, in whole or in part, for the emergency treatment and 4) the veteran is financially liable to the provider of emergency treatment for that treatment.
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 described any consideration of using information technology to reduce burden.
Under the provisions of the Government Paperwork Elimination Act (GPEA), we examined the cost and risk involved with fully automating this procedure. There is no standardization of automation among private medical facilities, and little opportunity for automated data exchange exists at this time. Additionally, the issues of automated signature and attachments have not been resolved. Therefore, use of automated collection techniques beyond faxing would not decrease the respondent burden. Based on the submitted information, VA electronically inputs the requested data and resulting treatment codes into its internal data base to compute reimbursement rates.
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 2 above.
Public Law 106-117 imposes statutory requirements for the provision of additional non-VA emergent certification reimbursement requirements for certain eligible veterans. This information is not available elsewhere.
5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.
Data collected has been kept to an absolute minimum. The data provided by medical facilities and other medical providers is considered a standard business practice data exchange.
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.
VA's failure to collect this information would:
a. Not allow for timely reimbursement of veteran's non-VA emergency treatment.
b. Restrict VA's ability to determine certain veteran's eligibility for VA health care benefits when the determination is based on non-VA emergent treatment.
c. Prevent VA from recovering the cost of care from veteran's third party health insurer when it is found that the veteran had coverage.
7. Explain any special circumstances that would cause an information collection to be conducted more often than quarterly or require respondents to prepare written responses to a collection of information in fewer than 30 days after receipt of it; submit more than an original and two copies of any document; 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 and require the use of a statistical data classification that has not been reviewed and approved by OMB.
There are no such special circumstances.
8. a. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the sponsor’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 sponsor in responses to these comments. Specifically address comments received on cost and hour burden.
The notice of Proposed Information Collection Activity was published in the Federal Register on October 14, 2014 (Volume 79, Pages 61690). We received no comments in response to this notice.
b. Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, clarity of instructions and recordkeeping, disclosure or reporting format, and on the data elements to be recorded, disclosed or reported. Explain any circumstances which preclude consultation every three years with representatives of those from whom information is to be obtained.
Outside consultation is conducted with the public through the 60- and 30-day Federal Register notices.
9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.
No payment or gift is provided to respondents.
10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statue, regulation, or agency policy.
Assurances of confidentiality are contained in 38 U.S.C. 5701 and 7332. Respondents are informed that the information collected will become part of the Consolidated Health Record which complies with the Privacy Act of 1974. This is part of the system of records identified as 24VA136 “Patient Medical Record – VA” as set forth in the 2005 Compilation of Privacy Act Issuances via online GPO access at http://www.gpoaccess.gov/privacyact/search.html.
11. Provide additional justification for any questions of a sensitive nature (Information that, with a reasonable degree of medical certainty, is likely to have a serious adverse effect on an individual's mental or physical health if revealed to him or her), such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private; include 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.
This regulation asks for the submission for copies of all records and correspondence regarding the emergency treatment for which the claim for reimbursement is made (including, but not limited to, medical records, patient admission forms, and other documents related to that treatment, such as, explanation of benefits or other documents from insurance companies, and correspondence from attorneys) which may be of a sensitive nature. This information is necessary for VA to properly evaluate treatment rendered in order to provide reimbursement.
12. Estimate of the hour burden of the collection of information:
CMS Form 1500 and UB 04 or any similar forms are to be filled out by health care providers providing emergency treatment in a non-VA hospital seeking reimbursement of such treatment. Information used to populate the forms is captured by health care provider billing software and billing forms are auto-generated; therefore impact of filling out forms is minimal. The number of respondents is estimated at 461,188 annually. The time estimate to complete the form is 15 minutes. The annual hour burden is estimated at 115,298 hours.
461,118 x 1 x 15 minutes to complete form /60 = 115,298 hours
b. If this request for approval covers more than one form, provide separate hour burden estimates for each form and aggregate the hour burdens in Item 13 of OMB 83-I.
This information may be submitted on a private invoice, CMS Form 1500 or UB04. The means of submission is irrelevant as the respondent burden remains constant.
c. Provide estimates of annual cost to respondents for the hour burdens for collections of information. 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 of the OMB 83-I.
The cost to the respondents for completing these forms is estimated at $2,767,152 (115,298 hours x $24 per hour). We do not require any additional recordkeeping.
(Source: Department of Labor)
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).
a. There are no capital, start-up, operation or maintenance costs.
b. Cost estimates are not expected to vary widely. The only cost is that for the time of the respondent.
c. There are no anticipated capital start-up cost components or requests to provide information.
14. Provide estimates of annual cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operation 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 also may aggregate cost estimates from Items 12, 13, and 14 in a single table.
The cost to the Federal Government is estimated at $10,474,731.
Administrative review |
GS5/5 @ $17.18/hr x 30 min x 461,188 forms / 60 |
$3,961,604 |
Clinical review |
$56/hour x 15 minutes x 461,188 forms / 60 |
$6,456,632 |
Return Postage-incomplete claims |
461,188 forms / 4 x $0.49 |
$ 56,495 |
|
TOTAL |
$10,474,731 |
15. Explain the reason for any burden hour changes since the last submission.
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.
There are no plans to publish the results of the information collected.
17. If seeking approval to omit the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.
There is no such request as the forms submitted by providers are not VA Forms.
18. Explain each exception to the certification statement identified in Item 19, “Certification for Paperwork Reduction Act Submissions,” of OMB 83-I.
There are no exceptions.
No statistical methods are used in this data collection.
Page
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT FOR VA FORM 10-2065, FUNERAL ARRANGEMENTS; VA FORM 10-10, APPLICATION FOR MEDICAL BENEFITS; VA FORM 10-10I, |
| Author | Preferred Customer |
| Last Modified By | Department of Veterans Affairs |
| File Modified | 2015-07-08 |
| File Created | 2015-07-08 |