Finding 588560 (2022-001)

Finding 2022-001 Identification of the federal program: Federal Grantor: United States Department of Health and Human Services, 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 Pass-Through 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).? Health and Human Services (HHS) ? Health Resources and Services and Administrative (HRSA) issued Terms and Conditions for Participation in the HRSA COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Program (T&Cs) outlining requirements that recipients of funding from the HRSA COVID-19 Uninsured Program must comply with, including the following sections: Testing Services, Treatment Services and Vaccine Administration, and General Provisions in FY2020 Consolidated Appropriations. Per the HRSA T&Cs and further clarified in the HRSA FAQs for COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration, the FAQ states the following: ?If a provider tests for COVID-19 as part of pre-operative or other medical treatment unrelated to COVID-19, is the test eligible for reimbursement? For the HRSA COVID-19 Uninsured Program, COVID-19 testing is eligible for reimbursement if one of the following diagnoses codes is included in any position on the claim: ? Z03.818 ? Encounter for observation for suspected exposure to other biological agents ruled out (possible exposure to COVID-19) ? Z11.59 ? Encounter for screening for other viral diseases (asymptomatic) ? Z20.828 ? Contact with and (suspected) exposure to other viral communicable (confirmed exposure to COVID-19) ? Z11.52 ? Encounter for screening for COVID-19 (asymptomatic) ? Z20.822 ? Contact with and (suspected) exposure to COVID-19 ? Z86.16 ? Personal history of COVID-19 Related treatment visits and services are not eligible for reimbursement given the primary reason for treatment is not COVID-19.? Condition: Vanderbilt University Medical Center (VUMC) did not retain audit evidence to support the report logic that was developed to extract patients from the patient billing systems that were identified as having an allowable COVID-19 testing and treatment diagnosis code and eligible for reimbursement under this federal 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 HRSA guidance, and how management validated the completeness and accuracy of the data extracted by the script. For certain emergency department, physician office visits, and inpatient claims that included COVID-19 testing, but COVID-19 was not the primary reason for the related treatment visit and services, VUMC erroneously billed the HRSA COVID-19 Uninsured Program for the entire encounter, which was not in compliance with the HRSA COVID-19 Uninsured Program regulations. Cause: Management did not develop and maintain effective internal control over report writing, program changes, and user access. VUMC did not have internal controls in place to ensure claims billed to the HRSA COVID-19 Uninsured Program were in accordance with HRSA Uninsured Program regulations. Effect or potential effect: The key report used to identify eligible federal program participants could be inaccurate or incomplete. VUMC did not have internal controls in place to formally document its compliance with the HRSA COVID 19 Uninsured Program?s allowability and eligibility requirements. Outpatient encounters that included a COVID-19 testing diagnosis code, where the primary treatment diagnosis code was not COVID-19 related, were not reviewed for allowability and eligibility prior to submission to HRSA to verify treatment costs were allowable under the HRSA COVID-19 Uninsured Program. Questioned costs: $336,536 Context: Management performed an analysis over claims submitted to HRSA related to services with dates of service from July 1, 2021 through June 30, 2022, indicating that 1,013 patient accounts totaling $336,536 related to certain claims where COVID-19 was not the primary diagnosis were inappropriately billed to HRSA. The $336,536 was refunded to HRSA in August 2022. Total federal expenditures for Assistance Listing 93.461 totaled $5,809,048 for the year ended June 30, 2022. Identification as a repeat finding, if applicable: 2021-001 Recommendation: The Uninsured Program ended in 2022; therefore, the development of internal controls is not required. However, if the program were to continue, VUMC 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. VUMC should retain evidence of internal controls related to access and change management over the report. Management should implement a quality review process of eligible claims identified on a monthly basis to ensure that patients identified meet the required eligibility requirements. Views of responsible officials: Management agrees with this finding and performed a review of claims submitted to the HRSA COVID-19 Uninsured Program identifying payments for ineligible services and refunded the entire overpayment amount. In March 2022, HRSA announced the discontinuance of the HRSA COVID-19 Uninsured Program, and therefore, remediation of internal controls is no longer applicable.