Finding 49532 (2022-001)

Material Weakness
Requirement
L
Questioned Costs
-
Year
2022
Accepted
2023-09-27

AI Summary

  • Core Issue: Indiana University Health did not follow HRSA guidance for reporting lost revenue related to PRF and ARP funds.
  • Impacted Requirements: Internal controls were insufficient to ensure compliance with federal reporting standards, specifically regarding the use of budgeted versus actual patient care revenue.
  • Recommended Follow-Up: For Period 5 submissions, use Option iii for lost revenue calculations if no pre-March 27, 2020 budget exists, as HRSA does not allow amendments to past reports.

Finding Text

Finding 2022-01 ? Reporting Identification of the federal program: Assistance Listing No. 93.498 ? COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution 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).? Providers who received one or more PRF or ARP payments greater than $10,000 in the aggregate were required to report on the use of the funds to the Health Resources & Services Administration (HRSA) Reporting Portal. The U.S. Department of Health and Human Services (HHS) requires the nonfederal entity to report lost revenue in order to support that funding received has been appropriately earned. HHS provided specific guidance in the June 11, 2021 Post-Payment Notice on how to complete the required reporting of lost revenue in the HRSA Reporting Portal. Under this guidance, recipients may choose to apply PRF and ARP payments towards lost revenue using one of the following options: ? Option i ? Up to the amount of the difference between actual patient care revenue ? Option ii ? Up to the amount of the difference between budgeted and actual patient care revenue, if the budget was established and approved prior to March 27, 2020 ? Option iii ? Up to the amount calculated by any reasonable method of estimating revenue Condition: Indiana University Health?s reporting submissions did not follow the published HRSA guidance related to the reporting of lost revenue. Cause: While Indiana University Health had designed and implemented internal controls over the allowability of expenses and amounts submitted in the HRSA and ARP reports, these internal controls were not precise enough to identify the submissions were not compliant with HRSA reporting guidance. Effect or potential effect: Noncompliance with HRSA reporting guidance could result in the submission of ineligible lost revenue to the HRSA Reporting Portal. Questioned costs: None. Context: We inspected the reconciliations of lost revenue to the Period 3 and Period 4 reports, determining the lost revenue submitted under Period 3 and Period 4 was based on the difference between actual and budgeted patient care revenue based on the 2022 budget, which was not approved prior to March 27, 2020. Management indicated the selection of Option ii was based on discussions with HRSA during the spring of 2022. Total federal expenditures for Assistance Listing No. 93.498 totaled $79,209,671 for the year ended December 31, 2022, which included $19,428,311 in lost revenue. Identification as a repeat finding: This is not a repeat finding. Recommendation: HRSA does not allow reporting entities to amend a previously submitted report after the reporting period has passed. Indiana University Health should plan to complete the Period 5 submissions using Option iii for the calculation of lost revenue, if a budget approved prior to March 27, 2020 does not exist. Views of responsible officials: Indiana University Health believes it appropriately designed and implemented the appropriate policies, procedures, and internal controls over the PRF and ARP reporting requirements. However, Indiana University Health agrees that the 2022 budget was not approved prior to March 27, 2020, but management asserts the Period 3 and Period 4 reports were filed in accordance with guidance obtained directly from HRSA. Furthermore, management asserts the amount of lost revenue submitted for Period 3 and Period 4 would not change, regardless of the lost revenue option selected.

Corrective Action Plan

IU Health designed and implemented internal controls over the allowability of expenses and amounts submitted in the HRSA and ARP reports. These internal controls were precise enough to ensure that the submissions were compliant with HRSA reporting guidance. In fact, IU Health reached out directly to HRSA to confirm the appropriateness of its election. IU Health remained consistent in utilizing the annual budget as a basis for lost revenue past 2020. As inferred from the annual budget approval date threshold of March 27, 2020, our 2021 and 2022 budgets were prepared using prepandemic years as a baseline expectation. IU Health also conversed directly with HRSA wherein a representative confirmed our use of option 2 as appropriate for Period 3 and beyond, because, according to the representative, the intention of the written regulation did not literally mean budget approval for years past 2020 to have occurred prior to March 27, 2020. As our annual budgets were already naturally materially in line with our long-range plan that was approved in December of 2019, it seemed we were adhering to the spirit of the guidelines set forth. For future periods, IU Health will elect option 3 for lost revenue. Contact Person(s) Responsible for Corrective Action: David Burton Anticipated Completion Date: Effective for Period 5 deadline of September 30, 2023

Categories

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles Eligibility Reporting

Other Findings in this Audit

  • 625974 2022-001
    Material Weakness

Programs in Audit

ALN Program Name Expenditures
93.498 Provider Relief Fund $79.21M
10.557 Special Supplemental Nutrition Program for Women, Infants, and Children $1.95M
93.155 Rural Health Research Centers $1.33M
14.241 Housing Opportunities for Persons with Aids $908,988
93.767 Children's Health Insurance Program $811,678
93.253 Poison Center Support and Enhancement Grant $454,041
32.006 Covid-19 Telehealth Program $376,448
93.211 Telehealth Programs $294,062
93.243 Substance Abuse and Mental Health Services_projects of Regional and National Significance $289,625
14.267 Continuum of Care Program $273,706
93.697 Covid-19 Testing for Rural Health Clinics $200,000
93.914 Hiv Emergency Relief Project Grants $158,527
20.513 Enhanced Mobility of Seniors and Individuals with Disabilities $156,088
93.940 Hiv Prevention Activities_health Department Based $131,653
93.866 Aging Research $122,562
16.575 Crime Victim Assistance $114,153
93.945 Assistance Programs for Chronic Disease Prevention and Control $71,728
21.027 Coronavirus State and Local Fiscal Recovery Funds $66,784
93.461 Covid-19 Testing for the Uninsured $64,002
93.994 Maternal and Child Health Services Block Grant to the States $62,997
93.918 Grants to Provide Outpatient Early Intervention Services with Respect to Hiv Disease $57,730
93.838 Lung Diseases Research $52,079
93.959 Block Grants for Prevention and Treatment of Substance Abuse $43,779
93.270 Adult Viral Hepatitis Prevention and Control $41,791
93.912 Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement $34,330
93.665 Emergency Grants to Address Mental and Substance Use Disorders During Covid-19 $23,456
93.917 Hiv Care Formula Grants $16,128
93.837 Cardiovascular Diseases Research $8,554
93.977 Preventive Health Services_sexually Transmitted Diseases Control Grants $8,486
93.969 Pphf Geriatric Education Centers $2,964
16.560 National Institute of Justice Research, Evaluation, and Development Project Grants $2,238