The Mount Sinai Hospital

Finding 2020-001 Activities Allowed or Unallowed and Eligibility Identification of the Federal Program: Grantor: Department of Health and Human Services Program Name: COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Assistance Listing No.: 93.461 Criteria or Specific Requirement: A. Activities Allowed or Unallowed ? Activities allowed include required primary health services as described in the terms and conditions of the award for uninsured individuals, including reimbursement of payments for COVID-19 testing and testing-related items for individuals who do not have coverage through an individual or employer-sponsored plan, a federal healthcare program, or the Federal Employees Health Benefits Program at the time the services were rendered. E. Eligibility ? Services must be for individuals who at the time the services were provided were uninsured as described in the terms and conditions of the award. 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: Certain claims submitted to the Health Resources and Services Administration (HRSA) for reimbursement were not in compliance with the program?s terms and conditions for participation. Certain claims were submitted for insured individuals. Other claims were submitted for services unrelated to COVID-19 testing and/or testing-related services. The Hospital?s controls did not prevent or detect this noncompliance. Cause: A control was not in place to verify that claims submitted to HRSA were in full compliance with the program?s terms and conditions. Management did not prevent services rendered that were unrelated to COVID-19 testing and/or testing related services from being submitted to HRSA for reimbursement. A control was performed utilizing a third-party service provider to verify that patients were uninsured at the time services were provided, prior to the initial submission of a claim to HRSA. However, based upon review of insurance information retained in The Hospital?s billing system in conjunction with our audit procedures, it was identified that certain patients were insured at the date services were provided. Management?s controls did not detect the identified coverage that was present at the time services were rendered and did not prevent the associated claims from being submitted to HRSA. Effect or Potential Effect: The lack of an effective control over these compliance requirements resulted in noncompliance including questioned costs. Questioned Costs: Questioned costs of $33,608 were identified, representing payments received from HRSA on claims for which the terms and conditions of the program were not complied with. The total sample value tested was $61,463 and total program expenditures were approximately $4,101,046. Context: In a sample of 60 claims, 29 claims were found to be noncompliant with the program?s terms and conditions: 5 claims were submitted to, and reimbursed by, HRSA for services rendered that were not related to COVID-testing and/or testing related services; 24 claims were identified as having active insurance coverage identified subsequent to the claim being submitted to, and reimbursed by, HRSA. Recommendation: Management should review services rendered to ensure claims for reimbursement to HRSA are submitted for services rendered related to COVID-19. Management should also refine its controls to ensure that claims are being fully assessed for insurance coverage, utilizing insurance records on hand, prior to submitting claims to HRSA. Views of Responsible Officials: Management agrees with the finding described above. The Hospital is in the process of reviewing all amounts reimbursed by HRSA under the COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured program. Any amounts that were reimbursed for services not related to COVID testing and/or testing related services will be returned. Any amounts received for a patient that had insurance at the time of service will also be returned. The Hospital is in the process of implementing internal controls to ensure claims are not submitted for non-COVID-19 related services and for claims with insurance.