Finding Text
Finding 2022-001 Activities Allowed or Unallowed and Eligibility Information on the federal program: Federal Grantor: United States Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.461, COVID-19 HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (HRSA COVID-19 Uninsured Program) Award Period of Performance: 07/01/2021?06/30/2022 Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): 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: Mercy Health did not retain supporting documentation over the HRSA COVID-19 Uninsured Program report query logic (the Report) that was developed to identify patients that meet the allowability and eligibility requirements of the HRSA COVID-19 Uninsured Program. In addition, supporting documentation was not retained to validate who had access to modify and run the script, what changes were made to the script, and how any changes to the script were tested and implemented during the fiscal year based on changes to Health Resources and Services Administration (HRSA) guidance. Further, management did not maintain supporting documentation to demonstrate how it validated the completeness and accuracy of the data extracted by the script. In addition, Mercy Health did not retain supporting documentation over its approval of HRSA COVID-19 Uninsured Program claims, determination of a patient?s uninsured/self-pay status, and review of credit balances. While management had a process to identify and review claims for allowability under the HRSA COVID-19 Uninsured Program, determine a patient?s uninsured/self-pay status through third-party insurance discovery, and review of credit balances, sufficient supporting documentation was not retained to support internal controls over the process. Cause: Development of the Report occurred outside of the Information Technology (IT) department that would require a formal process for the development of IT reports, access and program changes; the report resided in the Revenue Cycle department. The Revenue Cycle department did not develop internal control over report writing, program changes and user access. In addition, while management represented that the Report?s logic and subsequent changes to the Report?s logic were reviewed, no audit evidence was retained to support internal controls over that process. Management represented it performed a review of claims charged to the HRSA COVID-19 Uninsured Program for allowability; however, supporting documentation to evidence that the internal controls were sufficiently designed and operating effectively was not maintained. 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: The Report used to identify eligible federal program participants could be inaccurate or incomplete. Unallowable services may be submitted for reimbursement to the HRSA COVID-19 Uninsured Program. 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: Total federal expenditures for Assistance Listing 93.461 totaled $14,281,788 for the year ended June 30, 2022. Identification as a repeat finding, if applicable: The finding is a repeat of finding 2021-001 from the prior year. Recommendation: The HRSA COVID-19 Uninsured Program ended in the first quarter of 2022. Therefore, no further changes are required to the current internal controls over this program or the related documentation of the operation of internal controls. If the program were to be reinstated, Mercy Health should 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 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. Management should retain documentation of the operation of controls responsive to risks related to the data stored in its IT systems as evidence of control activities. Credit balances should be resolved on a timely basis to ensure the HRSA COVID-19 Uninsured Program is refunded timely if third-party insurance is subsequently identified. Views of Responsible Officials: In March 2022, HRSA announced that the HRSA COVID-19 Uninsured Program was ending. Therefore, remediation of internal controls is no longer applicable. If this program is reinstated, Mercy Health will take the necessary steps to ensure proper documentation is retained to provide evidence of our internal control processes.