Audit 18245

Finding 2022-001 Identification of the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.461, COVID-19 Testing for the Uninsured Program Criteria or specific requirement (including statutory, regulatory or other citation): 2 CFR Section 200.303 of the Uniform Guidance states the following regarding internal control: ?The Non-Federal entity must: a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: Management did not perform sufficient procedures to ensure that patients did not have health care coverage at the time the services were rendered. Refunds required to be made to the COVID-19 Testing for the Uninsured Program were not identified timely. Management represented that it inquired of the patients for insurance coverage, if any, prior to providing the services. However, documentation was not retained to support these inquiries. In addition, there were no procedures performed to support that a reasonable effort beyond inquiry was performed by management to verify the uninsured status of the patients. Further, Management did not maintain sufficient documentation to support the effectiveness of internal controls in place to ensure balance billing was not performed. Cause: Management did not have sufficient internal controls in place to retain documentation of inquiries and other procedures performed to verify that patients were uninsured at the time services were provided. Internal controls over balance billing were not suitably designed to maintain supporting documentation to test the operating effectiveness of the internal controls. Internal controls were not suitably designed to identify refunds in a timely manner. Effect or potential effect: A patient may not be uninsured, and, therefore, the related encounter may be ineligible for reimbursement under the COVID-19 Testing for the Uninsured Program. Credit balances may not be resolved timely, and refunds to the COVID-19 Testing for the Uninsured Program may not be identified or completed in a timely manner. Questioned costs: None Context: Management performed an analysis of payments received from HRSA related to services provided from FY 2020 through the end of the program in March 2022 and identified approximately $2.3 million of claims that should not have been billed to HRSA. The $2.3 million was refunded to HRSA in 2023. Total HRSA payments on patient claims for FY 2022 was $9,837,735. The amounts on the schedule of expenditures of federal awards is adjusted by $205,839 which represents the amounts reflected on the SEFA pertaining to the refunds made towards the COVID-19 Testing for the Uninsured Program Identification as a repeat finding, if applicable: 2021-002 Recommendation: The COVID-19 Testing for the Uninsured Program ended in the second quarter of 2022 and therefore development of internal controls is not required. However, if the program were to continue, we recommend Management should enhance its internal controls to ensure that reasonable procedures are performed to verify the uninsured status of the patients and that it documents the inquiries and retains support for other procedures performed. In addition, Management should enhance its internal controls to ensure that any refunds to HRSA, are timely remitted. Finally, Management should also ensure supporting documentation is retained to support the operating effectiveness of internal controls over balance billing. Views of responsible officials: Management agrees with the finding. Our standard procedure is to verify insurance coverage for all patients. We believe in instances where documentation was not maintained to evidence that additional insurance verification procedures were performed in addition to the standard patient inquiry, such instances were a documentation error and not a process issue. Since the federal program has ended, no further action will be taken. Management has noted that in certain instances, patients identify themselves as uninsured but following their date of service, AdventHealth identified that the patient either had insurance coverage or was eligible for Medicaid. AdventHealth was not aware that the patient had insurance coverage and requested reimbursement from HRSA, prior to AdventHealth identifying insurance coverage. AdventHealth has processed a refund to HRSA in instances where reimbursement was received from another payer or another payer was available to provide reimbursement. Documentation was established effective September 30, 2022, to evidence the operating effectiveness of internal controls in place over balance billing.

Finding 2022-001 Identification of the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.461, COVID-19 Testing for the Uninsured Program Criteria or specific requirement (including statutory, regulatory or other citation): 2 CFR Section 200.303 of the Uniform Guidance states the following regarding internal control: ?The Non-Federal entity must: a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: Management did not perform sufficient procedures to ensure that patients did not have health care coverage at the time the services were rendered. Refunds required to be made to the COVID-19 Testing for the Uninsured Program were not identified timely. Management represented that it inquired of the patients for insurance coverage, if any, prior to providing the services. However, documentation was not retained to support these inquiries. In addition, there were no procedures performed to support that a reasonable effort beyond inquiry was performed by management to verify the uninsured status of the patients. Further, Management did not maintain sufficient documentation to support the effectiveness of internal controls in place to ensure balance billing was not performed. Cause: Management did not have sufficient internal controls in place to retain documentation of inquiries and other procedures performed to verify that patients were uninsured at the time services were provided. Internal controls over balance billing were not suitably designed to maintain supporting documentation to test the operating effectiveness of the internal controls. Internal controls were not suitably designed to identify refunds in a timely manner. Effect or potential effect: A patient may not be uninsured, and, therefore, the related encounter may be ineligible for reimbursement under the COVID-19 Testing for the Uninsured Program. Credit balances may not be resolved timely, and refunds to the COVID-19 Testing for the Uninsured Program may not be identified or completed in a timely manner. Questioned costs: None Context: Management performed an analysis of payments received from HRSA related to services provided from FY 2020 through the end of the program in March 2022 and identified approximately $2.3 million of claims that should not have been billed to HRSA. The $2.3 million was refunded to HRSA in 2023. Total HRSA payments on patient claims for FY 2022 was $9,837,735. The amounts on the schedule of expenditures of federal awards is adjusted by $205,839 which represents the amounts reflected on the SEFA pertaining to the refunds made towards the COVID-19 Testing for the Uninsured Program Identification as a repeat finding, if applicable: 2021-002 Recommendation: The COVID-19 Testing for the Uninsured Program ended in the second quarter of 2022 and therefore development of internal controls is not required. However, if the program were to continue, we recommend Management should enhance its internal controls to ensure that reasonable procedures are performed to verify the uninsured status of the patients and that it documents the inquiries and retains support for other procedures performed. In addition, Management should enhance its internal controls to ensure that any refunds to HRSA, are timely remitted. Finally, Management should also ensure supporting documentation is retained to support the operating effectiveness of internal controls over balance billing. Views of responsible officials: Management agrees with the finding. Our standard procedure is to verify insurance coverage for all patients. We believe in instances where documentation was not maintained to evidence that additional insurance verification procedures were performed in addition to the standard patient inquiry, such instances were a documentation error and not a process issue. Since the federal program has ended, no further action will be taken. Management has noted that in certain instances, patients identify themselves as uninsured but following their date of service, AdventHealth identified that the patient either had insurance coverage or was eligible for Medicaid. AdventHealth was not aware that the patient had insurance coverage and requested reimbursement from HRSA, prior to AdventHealth identifying insurance coverage. AdventHealth has processed a refund to HRSA in instances where reimbursement was received from another payer or another payer was available to provide reimbursement. Documentation was established effective September 30, 2022, to evidence the operating effectiveness of internal controls in place over balance billing.