Finding 31046 (2022-001)

Significant Deficiency
Requirement
AB
Questioned Costs
$1
Year
2022
Accepted
2023-01-30

AI Summary

  • Core Issue: Federal funds may have been used for unallowable expenses due to reimbursements for outpatient visits where COVID-19 was not the primary diagnosis.
  • Impacted Requirements: Compliance with HRSA guidelines and 2 CFR 200.303 regarding effective internal controls and allowable costs.
  • Recommended Follow-Up: Enhance documentation processes for reviewing potential overpayments and ensure staff are trained to accurately notate all communications and actions related to HRSA claims.

Finding Text

Finding No: 2022 001 Activities Allowed or Unallowed/Allowable Costs Federal Agency: U.S. Department of Health and Human Services Pass Through Entities: N/A Assistance Listing Number: 93.461 Program: HRSA COVID 19 Claims Reimbursement for the Uninsured Program and the COVID 19 Coverage Assistance Fund Award Year: February 4, 2020 through April 5, 2022 (a) Criteria or Requirement The HRSA COVID 19 Claims Reimbursement for the Uninsured Program and the COVID 19 Coverage Assistance Fund reimburses health care related expenses attributable to COVID 19 testing for the uninsured and treatment of uninsured individuals with COVID 19. Reimbursement includes COVID 19 testing and testing related items, COVID 19 treatment and COVID 19 vaccine administration fees. The HRSA FAQ document dated May 2020 specified that for inpatients COVID 19 must be the primary reason for treatment or for vaccine administration. Per 2 CFR 200.303, the non Federal entity must 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. (b) Condition Found, Including Perspective During our test work, we selected a sample of 50 reimbursements received from HRSA for COVID 19 uninsured claims during the fiscal year. We noted one outpatient instance in which the reimbursement received may have covered the entire patient visit not only the COVID 19 test. (c) Possible Cause When identifying patient activities under the program for the audit period of July 1, 2021 to April 5, 2022 (end of program), total charges for uninsured patients with a COVID 19 diagnosis code, were included in the outpatient submissions for reimbursement. Additionally, HRSA?s reimbursement formulary was never published. (d) Questioned Cost Known questioned costs $5,601 and likely questioned costs $258,764, which represents total outpatient reimbursements for claims without COVID 19 as a primary diagnosis for which reimbursement exceeded $416.78. (e) Effect Federal funds were possibly expended for unallowable purposes as the expenditures were for a diagnosis other than COVID 19 as a primary diagnosis. (f) Statistical Validity The sample was not intended to be, and was not, a statistically valid sample. (g) Repeat Finding in the Prior Year Not a repeat finding. (h) Recommendation We recommend that the System enhance the processes in place to document its review of potential overpayments. (i) View of Responsible Officials FMOL took every precaution to ensure the correct process was implemented for HRSA billing and payment. We followed the program guidelines for screening self pay patients that received COVID services. Once the patient was approved by HRSA, they supplied a patient ID through their provision portal. Those qualifying visits were further modified to bill claims for the approved patients with COVID services and diagnoses. There were instances in which we questioned HRSA to supply further specific details regarding billing and payment, but we were told the information was proprietary. In addition, we questioned SSI (the selected clearinghouse) to query HRSA for additional billing criteria details to be proactive. However, the same response was provided. Therefore, we continued to follow the original program guidelines of identifying, screening and claims submissions for patients receiving COVID services and diagnosis. HRSA would determine the eligible charges upon submission for consideration. In accordance with HRSA guidelines, any overpayment identified by the System is refunded to the program. Any other overpayments identified by HRSA are also refunded accordingly. Additional communication will be provided to team members regarding account documentation with special attention to the HRSA program. We will have the trainer and department managers remind staff members to notate all accounts with any communication and actions taken including those accounts identified for review and repayments as applicable.

Corrective Action Plan

Corrective Action Plan Additional processes will be implemented to audit billings to the HRSA uninsured program. The System is not aware of claims incorrectly reimbursed by HRSA but will implement an audit of claims without COVID as the primary diagnosis and will review these claims with HRSA if any do not appear to be in compliance with Federal guidelines. Any claims HRSA has already identified as overpayment based on their formulary have already been refunded at their request. Anticipated Completion Date June 30, 2023 Name of Contact Person for Corrective Action Ramona Fryer, VP Revenue Cycle

Categories

Questioned Costs Allowable Costs / Cost Principles Cash Management

Other Findings in this Audit

  • 31045 2022-003
    Material Weakness
  • 31047 2022-002
    Material Weakness
  • 607487 2022-003
    Material Weakness
  • 607488 2022-001
    Significant Deficiency
  • 607489 2022-002
    Material Weakness

Programs in Audit

ALN Program Name Expenditures
93.498 Covid-19 Provider Relief Fund and American Rescue Plan (arp) Rural Distribution* $103.51M
84.268 Federal Direct Student Loans (direct Loan) $17.01M
93.461 Covid-19 Hrsa Claims Reimbursement for the Uninsured Program and the Covid-19 Coverage Assistance Fund * $5.92M
97.036 Covid-19 Public Assistance Covid-19 Care Policy $1.44M
84.063 Federal Pell Grant Program (pell) $1.26M
84.425 Covid-19 Emergency Financial Aid Grants to Students Under the Coronavirus Aid, Relief, and Economic Security (cares)* $1.23M
93.301 Small Hospital Improvement Program (ship) Rural Grant $510,392
84.425 Covid-19 Higher Education Emergency Relief Fund (heerf) Institutional Portion* $423,264
93.914 Hiv Emergency Relief (ryan White Part A) $379,327
93.918 Our Lady of the Lake Early Intervention (ryan White Part C) $340,819
93.153 Coordinated Services and Access to Research for Women, Infants, Children, and Youth (ryan White Part D) $291,459
97.036 Covid-19 Disaster Grants-Public Assistance $220,206
14.241 Housing Opportunities for Persons with Aids $216,444
93.153 Ryan White Part D Affected Family Members Aids Healthcare $138,935
94.016 Senior Companion Program (scp) $134,050
93.889 National Bioterrorism Hospital Preparedness Program $127,722
90.201 Dra Air Handler Grant- St. Francis for Ahu Project $89,241
84.007 Federal Supplemental Education Opportunity Grant (fseog) $78,434
84.033 Federal Work-Study (fws) $48,399
93.918 Covid-19 Ryan White Part C $39,387
93.124 Nurse Anesthetist Traineeships $35,993
93.866 Impact Minds $33,826
93.914 Covid-19 Ryan White Part A $29,340
84.335 Child Care Access Mean Parents in School Purposeful Parent Support $28,560
93.686 Ryan White Ending the Hiv Epidemic $18,754
93.310 Echo $16,605
93.153 Covid-19 Ryan White Part D $8,278
84.116 Office of Postsecondary Education Open Textbooks Pilot Program $4,000
84.425 Governors Emergency Education Relief Fund $1,200