Finding Text
Finding 2022-001: Internal Control Deficiency and Noncompliance over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Eligibility. Identification of the federal program: Assistance Listing Number 93.461: ? COVID-19 ? HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund ? U.S. Department of Health and Human Services ? Federal award identification number ? Not Applicable ? Federal award year ? February 4, 2020 and after Criteria or specific requirement (including statutory, regulatory or other citation): Title 2, Subtitle A, Chapter II, Part 200, Subpart D, 200.303 ? Internal controls. 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 requires the following: ? The recipient certifies that it, or its agents, provided the items and services on the recipient?s claim form to the uninsured individuals identified on the claim form; that the dates of services (or admittance if applicable) occurred on February 4, 2020, or later (for testing and treatment claims) and December 14, 2020, or later (for vaccine administration claims); and that all items and services for which payment is sought were medically necessary as a preventative vaccination for COVID-19, or for care or treatment of COVID 19 and/or its complications, and/or for COVID-19 testing and/or testing-related items and services. The recipient also certified that to the best of its knowledge, the patient identified on the claim form were uninsured individuals at the time the services were provided. ? Required health services as described in the terms and conditions for uninsured individuals: ? Reimbursement of payments for COVID-19 testing and testing-related items for individuals who do not have any health care coverage at the time the services were rendered; ? Reimbursement of payments for COVID-19 treatment as determined by the program for individuals who do not have any health care coverage at the time the services were rendered; ? Services must be for individuals, who at the time the services were provided, were uninsured as described in the terms and conditions. Condition: We observed management did not have effective internal controls in place to ensure that treatment and testing and testing related items unrelated to COVID-19 were not submitted for reimbursement to HRSA. In addition, we observed management did not have effective internal controls in place to ensure documentation was consistently retained to verify that patients did not have health care coverage. Cause: Management did not have effective internal controls in place throughout the period to ensure claims submitted for reimbursement solely included treatment and testing and testing related items related to COVID-19. In addition, management did not have effective internal controls in place throughout the period to ensure documentation was consistently retained showing patient eligibility (i.e., that patient was uninsured) checks were performed. Effect or potential effect: The Company could be reimbursed for claims submitted for reimbursement for treatment and testing and testing related items unrelated to COVID-19. In addition, documentation was not retained showing patient eligibility (i.e., that patient was uninsured) checks were performed. Questioned costs: $7,529 ? Assistance Listing Number 93.461. Questioned costs were computed by summing the total reimbursements for claims paid unrelated to COVID-19. Context: During our testing over claims submitted for reimbursement, we obtained a listing of 827 patient accounts and selected a sample of 60 patient accounts. The total value of the 60 patient accounts selected was $92,922 out of the total per the SEFA of $1,454,293. There were 16 ($7,529) out of 60 ($92,922) selections where management submitted for reimbursement treatment and testing and testing related items unrelated to COVID-19. Identification as a repeat finding, if applicable: Yes ? 2021-001. Recommendation: Management should develop and implement effective internal controls to ensure that claims submitted for reimbursement solely include treatment and testing and testing related items related to COVID-19 and to ensure that sufficient documentation is retained to support patient eligibility internal controls were performed. Management should also refund the questioned costs identified to HRSA. Views of responsible officials: 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. 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. Conclusion: Despite management?s response in the preceding section, we still conclude that a finding is warranted based on the items noted in our Condition and Context sections based on the Criteria or Specific Requirement section above.