Finding 2022-001: Management followed the HRSA uninsured patient reimbursement program guidelines and frequently asked questions (FAQs) related to diagnostic testing and testing-related visits eligible for reimbursement, which were published from time to time after the introduction of this program....
Finding 2022-001: Management followed the HRSA uninsured patient reimbursement program guidelines and frequently asked questions (FAQs) related to diagnostic testing and testing-related visits eligible for reimbursement, which were published from time to time after the introduction of this program. One such FAQ that management referred to and followed is shown below. We did not separate out and only submit specific COVID-19 diagnoses codes but we sent the entire charges relating to the patient to Health Resource & Services Administration (HRSA) if it had testing or treatment services provided related to COVID-19. Management?s understanding was that HRSA would determine what charges would be eligible for reimbursement so long as the claims that were submitted included treatment or testing services for uninsured patients related to COVID-19. These payments were approved and paid for by HRSA as they included the eligible diagnosis codes and hence management deemed this to be appropriate. However, management does agree with the finding that the questioned costs were incorrectly paid by HRSA. Management has submitted a refund for the portion of these claims payments that were unrelated to COVID?19 treatments. Prime Healthcare Foundation, Inc. hospitals perform eligibility checks and input insurance coverage details as a mandatory information gathering requirement during the admission of a patient. Prime Hospitals performed these eligibility checks for all patients by examining online insurance portals, interviewing patients and obtaining self-declaration of insurance status from patient upon patient admission. However, there were instances when hospitals did not retain insurance eligibility documentations although it was performed, for reasons such as emergency and urgency of patient care. Although this documentation was not in the file for these patients, all audit samples selected were ultimately shown to not have insurance coverage at the time services were rendered. Management agrees with the finding on lack of documentation retention for patient eligibility checks and will implement this as a facility control. Contact person: Kenneth Wheeler, Regional Vice President, Sowkya Ponnavolu, Corporate Director of Data Engineering & Analytics and Merhawy Worede, Corporate Executive Director of Accounting and Financial Reporting. Expected completion date: Management has submitted the questioned costs for refund to HRSA. Regarding the eligibility checks, according to HRSA COVID-19 Uninsured Programs Claims Submission Deadline FAQs published in April 2022, the COVID-19 Uninsured program stopped accepting claims and funding on April 5, 2022 and thus there are no changes required related to this particular program. However, if this program begins accepting claims again, management will implement a control requiring retention in the patient files supporting that the required eligibility checks have been performed.