Finding 2022-002 ? A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, L. Reporting Identification of the federal program: Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing: 93.948 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period: January 1, 2020 through December 31, 2021 Criteria or specific requirement (including statutory, regulatory or other citation): Section 200.303 of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (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).? The terms and conditions of the award require the following: ? The recipient certified that the payment will only be used to prevent, prepare for, and respond to coronavirus, and that the payment shall reimburse the recipient only for health care related expenses or lost revenues that are attributable to coronavirus. ? The recipient certifies that it will not use the payment to reimburse expenses or losses that have been reimbursed from other sources or that other sources are obligated to reimburse. ? The recipient shall submit reports as the secretary of Health and Human Services (HHS) determines are needed to ensure compliance with conditions that are imposed on the payment, and such reports shall be in such form, with such content, as specified by the secretary of HHS in future program instructions directed to all recipients. The Provider Relief Programs: Provider Relief Fund and ARP Rural Payments Frequently Asked Questions states the following: ? Duplication of expenses and lost revenues is not permitted. ? Expenses and lost revenues may not be duplicated: payments may not be applied to the same expenses and lost revenues that were reported on in prior reporting periods. Condition: UC Health?s internal controls over the review and approval of use of the funds (i.e., to prevent, prepare for, and respond to COVID-19) and related Portal reporting were not suitably designed, and thus were not operating effectively. During our testing over reporting, we observed management did not have effective internal controls in place to ensure expenses and lost revenues reported in the Portal were not duplicated. This resulted in the overstatements of expenses and lost revenues reported in the Portal. Cause: UC Health did not retain supporting documentation over its internal review and approval processes to evidence compliance with the Provider Relief Fund (PRF) T&Cs. Management did not design or have internal controls in place to ensure the expenses and lost revenues attributable to COVID-19 reported in the Portal were not duplicated across their multiple Portal submissions. Multiple submissions were required due to multiple program reporting periods, as well as the targeted distributions received across the company ? as each entity receiving a PRF targeted distribution is required to submit independent Portal submissions (while a consolidated submission is permissible for PRF general distributions). Effect or potential effect: A lack of formalized documentation prepared and retained to evidence the performance of internal controls could result in non-compliance with PRF T&Cs. A portion of expenses and lost revenue attributable to COVID-19 were duplicated and, therefore, reported incorrectly in the Portal. Questioned costs: $23,179,592 of duplicated expenses included in Period 2 UC Healthcare System Portal filing, as these expenses were also reported in Period 1 and / or other Period 2 Portal filings submitted by various UC Health entities. Context: We inquired of management, who noted internal controls over the allowability principles were not effectively designed, and thus were not operating effectively. As part of our testing procedures each of UC Health?s three Period 2 Portal filings were reviewed, with reported COVID-19 expenses and lost revenues reconciled to underlying files. We observed during the reconciliation process that the University of Cincinnati Medical Center (UCMC) expense balance included $18,716,595 of expenses incurred between January 1, 2020 and June 30, 2021 that had also been submitted as part of UC Healthcare System?s general distribution Period 1 Portal filing. Further, the UC Healthcare System Period 2 expense total was an aggregation of expenses incurred across various UC Health entities, including UCMC. As a result, $4,462,997 of UCMC expenses incurred between July 1, 2021 and December 31, 2021 were duplicated across the UCMC and UC Healthcare System Period 2 Portal filings. We also observed that the lost revenue reported in the Period 2 UC Healthcare System Portal filing was consistent with the lost revenue balance reported by that same entity in Period 1. However, this balance included the lost revenue of the UCMC, which did not have a Period 1 filing but did include report lost revenue in its Period 2 filing. As such, the UCMC lost revenue balance ($59,704,396) is included in both the UCMC and UC Healthcare System submissions is considered duplicative. Total federal expenditures for Assistance Listing 93.498 totaled $47,584,291 for the year ended June 30, 2022. All related Period 2 Portal submissions were reviewed as part our testing, with no Period 3 Portal submissions required to be filed as no funds were received in the related period. Identification as a repeat finding, if applicable: The nature and cause of this finding are consistent with the 2021-002 finding included in the June 30, 2021 Single Audit Report. Recommendation: Management should design and implement internal controls to document its review and compliance with the Provider Relief Fund?s T&C?s, as well as formalize retention policies pertaining to this documentation. This will prevent duplication of expenses and lost revenues in future Portal reporting periods. Views of responsible officials: Management agrees with this finding and will update policies and work procedures to ensure compliance with the Provider Relief Fund. In addition, management will also implement additional internal controls over Portal submissions to prevent the duplication of expenses and lost revenue in future reporting periods. Management believes more than sufficient lost revenues have been incurred (excluding any duplications) to support retention of all Provider Relief Funds reported to date.
Finding 2022-001 ? A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, E. Eligibility, N. Special Tests and Provisions Identification of the federal program: Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing: 93.461, HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (COVID-19 Uninsured Program) Award Period: July 1, 2021 through June 30, 2022 Criteria or specific requirement (including statutory, regulatory or other citation): Section 200.303 of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (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).? Health and Human Services (HHS) ? Health Resources and Services and Administrative (HRSA) issued Terms and Conditions for Participation in the HRSA COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Program (T&Cs) outlining requirements that recipients of funding from the HRSA COVID-19 Uninsured Program must comply with including the following sections: Testing Services, Treatment Services and Vaccine Administration, and General Provisions in FY2022 Consolidated Appropriations. Condition: UC Health did not timely execute or retain supporting documentation for all internal controls pertaining to compliance with the HRSA COVID-19 Uninsured Program T&Cs. While management has processes in place to review claims for potential insurance coverage before initial billing, evidence of insurance reviews and subsequent verification of lack of coverage was not retained. Refunds required to be made to the HRSA COVID-19 Uninsured Program were not identified timely. Cause: UC Health did not design or appropriately document internal controls to monitor the T&Cs and underlying HRSA COVID-19 Uninsured Program regulations during the COVID-19 pandemic. Additionally, UC Health did not have internal controls in place to formally document its compliance with the HRSA COVID-19 Uninsured Program?s allowability and eligibility requirements. Standard policies, procedures, and internal controls over the review for patient insurance coverage and review of credit balances used in the federal program were not suitability designed to address the unique aspects of the HRSA COVID-19 Uninsured Program. Effect or potential effect: UC Health could be in noncompliance with the HRSA COVID-19 Uninsured Program T&Cs. A patient may not be uninsured and therefore the related encounter may be ineligible for reimbursement under the HRSA COVID-19 Uninsured Program. Credit balances may not be resolved timely and refunds to the HRSA COVID-19 Uninsured Program may not be identified or completed in a timely manner. Questioned costs: None. Context: We inquired of management, who indicated internal controls over the determination of the eligibility of certain patient encounters were not effectively designed or were not operating effectively. For these patient encounters, documentation pertaining to the execution of internal controls was not adequately retained. Further, internal controls were not appropriately designed to evidence retroactive approval of alternative insurance or credit balance review of accounts billed to HRSA. Identification as a repeat finding, if applicable: This finding is a repeat of the internal control portion of the 2021-001 finding included in the June 30, 2021, Single Audit Report. Recommendation: Management should implement document retention policies in order to subsequently support the design and implementation of internal controls over its review and compliance with the HRSA COVID-19 Uninsured Program T&C?s. Management should design and implement sufficiently precise internal controls to review changes to the HRSA COVID-19 Uninsured Program to ensure it is administering the program in compliance with the HRSA COVID-19 Uninsured Program regulations. In addition, internal controls should be designed and implemented to ensure claims submitted to the HRSA COVID-19 Uninsured Program meet the allowability criteria established by the HRSA COVID-19 Uninsured Program regulations before claims are submitted to HRSA for reimbursement. Standard policies, procedures, and internal controls over the review for retroactively applied alternative patient insurance coverage should be updated to address the unique aspects of the HRSA COVID-19 Uninsured Program. Evidence of insurance discovery to verify third-party insurance searches are completed with no other insurance identified should be maintained. Views of responsible officials: Management agrees with this finding and the need to update documentation policies and work procedures to ensure compliance with HRSA COVID-19 Uninsured Program regulations. However, management acknowledges that the HRSA COVID-19 Uninsured Program stopped accepting new claims in March 2022, and thus remaining work pertaining to the program is limited to resolution of existing claims. This minimizes the amount of policy and work procedure updates deemed necessary.
Finding 2022-002 ? A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, L. Reporting Identification of the federal program: Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing: 93.948 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period: January 1, 2020 through December 31, 2021 Criteria or specific requirement (including statutory, regulatory or other citation): Section 200.303 of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (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).? The terms and conditions of the award require the following: ? The recipient certified that the payment will only be used to prevent, prepare for, and respond to coronavirus, and that the payment shall reimburse the recipient only for health care related expenses or lost revenues that are attributable to coronavirus. ? The recipient certifies that it will not use the payment to reimburse expenses or losses that have been reimbursed from other sources or that other sources are obligated to reimburse. ? The recipient shall submit reports as the secretary of Health and Human Services (HHS) determines are needed to ensure compliance with conditions that are imposed on the payment, and such reports shall be in such form, with such content, as specified by the secretary of HHS in future program instructions directed to all recipients. The Provider Relief Programs: Provider Relief Fund and ARP Rural Payments Frequently Asked Questions states the following: ? Duplication of expenses and lost revenues is not permitted. ? Expenses and lost revenues may not be duplicated: payments may not be applied to the same expenses and lost revenues that were reported on in prior reporting periods. Condition: UC Health?s internal controls over the review and approval of use of the funds (i.e., to prevent, prepare for, and respond to COVID-19) and related Portal reporting were not suitably designed, and thus were not operating effectively. During our testing over reporting, we observed management did not have effective internal controls in place to ensure expenses and lost revenues reported in the Portal were not duplicated. This resulted in the overstatements of expenses and lost revenues reported in the Portal. Cause: UC Health did not retain supporting documentation over its internal review and approval processes to evidence compliance with the Provider Relief Fund (PRF) T&Cs. Management did not design or have internal controls in place to ensure the expenses and lost revenues attributable to COVID-19 reported in the Portal were not duplicated across their multiple Portal submissions. Multiple submissions were required due to multiple program reporting periods, as well as the targeted distributions received across the company ? as each entity receiving a PRF targeted distribution is required to submit independent Portal submissions (while a consolidated submission is permissible for PRF general distributions). Effect or potential effect: A lack of formalized documentation prepared and retained to evidence the performance of internal controls could result in non-compliance with PRF T&Cs. A portion of expenses and lost revenue attributable to COVID-19 were duplicated and, therefore, reported incorrectly in the Portal. Questioned costs: $23,179,592 of duplicated expenses included in Period 2 UC Healthcare System Portal filing, as these expenses were also reported in Period 1 and / or other Period 2 Portal filings submitted by various UC Health entities. Context: We inquired of management, who noted internal controls over the allowability principles were not effectively designed, and thus were not operating effectively. As part of our testing procedures each of UC Health?s three Period 2 Portal filings were reviewed, with reported COVID-19 expenses and lost revenues reconciled to underlying files. We observed during the reconciliation process that the University of Cincinnati Medical Center (UCMC) expense balance included $18,716,595 of expenses incurred between January 1, 2020 and June 30, 2021 that had also been submitted as part of UC Healthcare System?s general distribution Period 1 Portal filing. Further, the UC Healthcare System Period 2 expense total was an aggregation of expenses incurred across various UC Health entities, including UCMC. As a result, $4,462,997 of UCMC expenses incurred between July 1, 2021 and December 31, 2021 were duplicated across the UCMC and UC Healthcare System Period 2 Portal filings. We also observed that the lost revenue reported in the Period 2 UC Healthcare System Portal filing was consistent with the lost revenue balance reported by that same entity in Period 1. However, this balance included the lost revenue of the UCMC, which did not have a Period 1 filing but did include report lost revenue in its Period 2 filing. As such, the UCMC lost revenue balance ($59,704,396) is included in both the UCMC and UC Healthcare System submissions is considered duplicative. Total federal expenditures for Assistance Listing 93.498 totaled $47,584,291 for the year ended June 30, 2022. All related Period 2 Portal submissions were reviewed as part our testing, with no Period 3 Portal submissions required to be filed as no funds were received in the related period. Identification as a repeat finding, if applicable: The nature and cause of this finding are consistent with the 2021-002 finding included in the June 30, 2021 Single Audit Report. Recommendation: Management should design and implement internal controls to document its review and compliance with the Provider Relief Fund?s T&C?s, as well as formalize retention policies pertaining to this documentation. This will prevent duplication of expenses and lost revenues in future Portal reporting periods. Views of responsible officials: Management agrees with this finding and will update policies and work procedures to ensure compliance with the Provider Relief Fund. In addition, management will also implement additional internal controls over Portal submissions to prevent the duplication of expenses and lost revenue in future reporting periods. Management believes more than sufficient lost revenues have been incurred (excluding any duplications) to support retention of all Provider Relief Funds reported to date.
Finding 2022-001 ? A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, E. Eligibility, N. Special Tests and Provisions Identification of the federal program: Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing: 93.461, HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (COVID-19 Uninsured Program) Award Period: July 1, 2021 through June 30, 2022 Criteria or specific requirement (including statutory, regulatory or other citation): Section 200.303 of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (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).? Health and Human Services (HHS) ? Health Resources and Services and Administrative (HRSA) issued Terms and Conditions for Participation in the HRSA COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Program (T&Cs) outlining requirements that recipients of funding from the HRSA COVID-19 Uninsured Program must comply with including the following sections: Testing Services, Treatment Services and Vaccine Administration, and General Provisions in FY2022 Consolidated Appropriations. Condition: UC Health did not timely execute or retain supporting documentation for all internal controls pertaining to compliance with the HRSA COVID-19 Uninsured Program T&Cs. While management has processes in place to review claims for potential insurance coverage before initial billing, evidence of insurance reviews and subsequent verification of lack of coverage was not retained. Refunds required to be made to the HRSA COVID-19 Uninsured Program were not identified timely. Cause: UC Health did not design or appropriately document internal controls to monitor the T&Cs and underlying HRSA COVID-19 Uninsured Program regulations during the COVID-19 pandemic. Additionally, UC Health did not have internal controls in place to formally document its compliance with the HRSA COVID-19 Uninsured Program?s allowability and eligibility requirements. Standard policies, procedures, and internal controls over the review for patient insurance coverage and review of credit balances used in the federal program were not suitability designed to address the unique aspects of the HRSA COVID-19 Uninsured Program. Effect or potential effect: UC Health could be in noncompliance with the HRSA COVID-19 Uninsured Program T&Cs. A patient may not be uninsured and therefore the related encounter may be ineligible for reimbursement under the HRSA COVID-19 Uninsured Program. Credit balances may not be resolved timely and refunds to the HRSA COVID-19 Uninsured Program may not be identified or completed in a timely manner. Questioned costs: None. Context: We inquired of management, who indicated internal controls over the determination of the eligibility of certain patient encounters were not effectively designed or were not operating effectively. For these patient encounters, documentation pertaining to the execution of internal controls was not adequately retained. Further, internal controls were not appropriately designed to evidence retroactive approval of alternative insurance or credit balance review of accounts billed to HRSA. Identification as a repeat finding, if applicable: This finding is a repeat of the internal control portion of the 2021-001 finding included in the June 30, 2021, Single Audit Report. Recommendation: Management should implement document retention policies in order to subsequently support the design and implementation of internal controls over its review and compliance with the HRSA COVID-19 Uninsured Program T&C?s. Management should design and implement sufficiently precise internal controls to review changes to the HRSA COVID-19 Uninsured Program to ensure it is administering the program in compliance with the HRSA COVID-19 Uninsured Program regulations. In addition, internal controls should be designed and implemented to ensure claims submitted to the HRSA COVID-19 Uninsured Program meet the allowability criteria established by the HRSA COVID-19 Uninsured Program regulations before claims are submitted to HRSA for reimbursement. Standard policies, procedures, and internal controls over the review for retroactively applied alternative patient insurance coverage should be updated to address the unique aspects of the HRSA COVID-19 Uninsured Program. Evidence of insurance discovery to verify third-party insurance searches are completed with no other insurance identified should be maintained. Views of responsible officials: Management agrees with this finding and the need to update documentation policies and work procedures to ensure compliance with HRSA COVID-19 Uninsured Program regulations. However, management acknowledges that the HRSA COVID-19 Uninsured Program stopped accepting new claims in March 2022, and thus remaining work pertaining to the program is limited to resolution of existing claims. This minimizes the amount of policy and work procedure updates deemed necessary.