Finding 969385 (2023-007)

Condition and Context: There were 40 Purchased/Referred Care (PRC) claims tested, which total $64,479, out of approximately 2,400 total PRC claims incurred during fiscal year 2023 totaling $1,685,699. For one of 40 PRC claims tested, in the amount of $7,439, the patient was covered by alternate resources and was not eligible for PRC. For two of the 40 PRC claims tested, totaling $171, the Hospital was not able to provide sufficient documentation to evidence that the patient was eligible to receive PRC. For 14 out of the 40 PRC claims tested, eligibility was not verified until after the PRC claim was paid. It was noted that the pool of eligible healthcare expenditures for which this grant program is utilized for was well in excess of the amount of grant funds received. Criteria: To receive Purchased/Referred Care (PRC) an individual must meet the eligibility requirements as defined by Federal regulations published in Code of Federal Regulations (CFR), at Title 42, Section 136.21 through 136.25, and Indian Health Services, Part 2, Chapter 3, "Contract Health Services" dated January 5, 1998. Cause: Policies and procedures were not well defined or communicated to staff to ensure proper eligibility verification was performed and documented prior to payment of PRC claims. Effect: The Hospital does not have sufficient documentation to evidence that patients were eligible to receive PRC. Payment was made on an ineligible claim. Questioned Cost: None. Repeat Finding: This is a repeat finding. Recommendation: We recommend the Hospital provide additional training to ensure employees are aware of eligibility guidelines and that the eligibility determination process is being properly documented. Management’s Response: The Purchase Referred Care (PRC) team of the PRC Supervisor and PRC staff are responsible for implementing proper processes and procedures for ensuring proper eligibility verification and documentation prior to payment of PRC claims. PRC staff attended a PRC training regarding eligibility verification on August 2-3, 2023 conducted Indian Health Service. Since, staff have increased their knowledge of eligibility requirements.