EIN: 450519724
UEI: WRJAJCLTEQH6
Audit also covers 3 related EINs: 352439501, 520608005, 522147800 · unlinked EINs have no separate FAC filing
Audited by: RSM US LLP
Oversight agency: 93 [Department of Health and Human Services]
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Data as of September 2, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on March 7, 2024. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by September 7, 2024 (726 days ago).
What is a management decision? →HRSA’s website indicated that the Company had received $1,222,565 of funds under this program for the period from July 1, 2019 through June 30, 2022. However, management was initially unaware that they had received funding from this program and could not provide an underlying detail of the patient visits that were reimbursed under this program. Management worked with both of the Company’s third-party billing providers, and after several months, provided a detail from July 1, 2019 through June 30, 2022 that totaled $905,771, which resulted in an initial, unreconciled difference of $316,794. Further, during testing procedures of the billing detail provided, which consisted of a sample of 120 items, we noted 47 instances where the patient visits did not appear to meet the allowable activities under the program. As a result, we identified total factual misstatements of $14,578, which projected to additional misstatements of $411,291. Effect: Due to the initial detail variance and the projected misstatements from testing, an audit adjustment of $742,663 was recorded, which reduced net patient service revenue and recorded a liability back to HRSA. Cause: The staff of the Company oversees and administers physician services within the emergency departments of nine area hospitals. The hospitals' personnel are assigned the task of patient registration, ensuring the precise entry of patients' insurance data into the medical records system. Subsequently, an error occurred as some patients were inaccurately marked as eligible for the HRSA uninsured program by the hospital staff. Consequently, this led to unintended discrepancies in the submission of claim reimbursements by the Company's third-party billing vendors to the program, some of which were not in accordance with the related compliance regulations. Recommendation: We recommend that management implement procedures and controls to ensure that they are fully aware of all federal funds that are being received, and that the Company’s policies and corresponding activities are in accordance with the related federal compliance guidelines, including discussions with the local area hospitals. Repeat finding: No Views of responsible officials and planned corrective actions: See attached letter. Reportable questioned costs: None Views of responsible officials and planned corrective actions: See attached letter.
Show full finding ▾Hide full finding ▴Criteria: The HRSA COVID-19 Uninsured Program, ALN 93.461, allows for reimbursement for COVID-19 testing and testing-related items, as well as for COVID-19 treatment for individuals who were either uninsured or under-insured at the time services were rendered. The guidance for this program provides specific diagnostic coding and treatments that are allowable to be reimbursed under this program. Condition: HRSA’s website indicated that the Company had received $1,222,565 of funds under this program for the period from July 1, 2019 through June 30, 2022. However, management was initially unaware that they had received funding from this program and could not provide an underlying detail of the patient visits that were reimbursed under this program. Management worked with both of the Company’s third-party billing providers, and after several months, provided a detail from July 1, 2019 through June 30, 2022 that totaled $905,771, which resulted in an initial, unreconciled difference of $316,794. Further, during testing procedures of the billing detail provided, which consisted of a sample of 120 items, we noted 47 instances where the patient visits did not appear to meet the allowable activities under the program. As a result, we identified total factual misstatements of $14,578, which projected to additional misstatements of $411,291. Effect: Due to the initial detail variance and the projected misstatements from testing, an audit adjustment of $742,663 was recorded, which reduced net patient service revenue and recorded a liability back to HRSA. Cause: The staff of the Company oversees and administers physician services within the emergency departments of nine area hospitals. The hospitals' personnel are assigned the task of patient registration, ensuring the precise entry of patients' insurance data into the medical records system. Subsequently, an error occurred as some patients were inaccurately marked as eligible for the HRSA uninsured program by the hospital staff. Consequently, this led to unintended discrepancies in the submission of claim reimbursements by the Company's third-party billing vendors to the program, some of which were not in accordance with the related compliance regulations. Recommendation: We recommend that management implement procedures and controls to ensure that they are fully aware of all federal funds that are being received, and that the Company’s policies and corresponding activities are in accordance with the related federal compliance guidelines, including discussions with the local area hospitals. Repeat finding: No Views of responsible officials and planned corrective actions: See attached letter. Reportable questioned costs: None Views of responsible officials and planned corrective actions: See attached letter.
To rectify the inaccurate marking of patients as eligible for the HRSA program by hospital staff and ensure compliance with related regulations in the submission of claim reimbursements. Although the issue arose unexpectedly due to the unique circumstances of the COVID-19 pandemic, MEMN is committed to addressing it promptly and collaboratively. By implementing these corrective actions and fostering open communication and cooperation, MEMN can rectify the inaccuracies in patient eligibility for the HRSA program and ensure compliance with related regulations in the submission of claim reimbursements. Additionally, the organization will incorporate lessons learned from this experience to build resilience and adaptability for future challenges. Actions: 1. Transparent Communication: • Clearly communicate to all stakeholders, including hospital staff, third-party billing vendors, and management, that the issue arose due to unforeseeable circumstances related to the COVID-19 pandemic and was not a result of management negligence. • Emphasize the collaborative effort needed to address the issue and prevent its recurrence. 2. Enhanced Documentation and Verification Processes: • Encourage hospital staff to Implement enhanced documentation procedures to capture accurate patient information, including insurance data, with a specific focus on eligibility for the HRSA program and establish robust verification processes to ensure the accuracy of patient eligibility status before marking them as such in the medical records system. 3. Monitoring: • Work with the third-party biller to monitor the submission of claim reimbursements to the HRSA program closely to verify compliance with regulations and accuracy of information. 4. Collaborative Problem-Solving: • Foster an environment of collaboration between MEMN, hospital staff, and third-party billing vendors to address the issue collectively. • Encourage open communication and the sharing of insights to identify systemic issues and implement effective solutions. 5. Adaptation and Resilience Building: • Recognize the lessons learned from the unforeseen challenges posed by the COVID-19 pandemic and incorporate them into future risk assessment and contingency planning efforts. • Build resilience within the organization to respond effectively to unexpected events and mitigate their impact on operations and compliance. Timeline: • Transparent Communication: Immediately upon implementation of the corrective action plan, February 2024 • Enhanced Documentation and Verification Processes: Implement within three months, May 2024 • Monitoring: Begin immediately and continue on an ongoing basis, February 2024 • Collaborative Problem-Solving: Establish protocols within one month and continue on an ongoing basis, March 2024 • Adaptation and Resilience Building: Ongoing, with periodic assessments and adjustments, June 2024 Monitoring and Evaluation: • Regular progress meetings to track the implementation of corrective actions. • Monitor the accuracy of patient data entry and claim submissions through internal audits and quality assurance reviews. • Conduct periodic reviews to assess the effectiveness of training and education efforts and make necessary adjustments. Contact: • Alain Viaud, aviaud@som.umaryland.edu, 667-214-2051
While management’s calculation of lost revenues for 2020 was determined to be accurate, as the 2019 and 2020 reported numbers in the portal submission reconciled and agreed to the Company’s audited net revenue amounts for those periods, the calculation of lost revenues for 2021 was not accurate. The reported amounts of net revenue from fiscal year 2021 and fiscal year 2022 (partially from calendar year 2021) did not reconcile or agree to the audited amounts of net patient revenue from these periods. Effect: The reporting in the portal inaccurately reported total lost revenues for each subsidiary’s portal submission. However, there were no questioned costs, as the 2020 reported lost revenues that were determined to be accurate, exceeded any amounts received from the Provider Relief Fund in the period under audit, and the cumulative receipts of Provider Relief Funding in all periods. Cause: The Company’s reporting over patient service revenue that was utilized in the compilation of the portal submission was inaccurate, and did not agree to the final 2021 audited amounts. In addition, there was no evidence that a secondary member of management reviewed the information prior to its submission. Recommendation: We recommend that management implement procedures and controls to ensure that all reporting and submissions to federal agencies are accurate and are sufficiently reviewed by another member of management prior to the submission. Repeat finding: No Views of responsible officials and planned corrective actions: See attached letter. Reportable questioned costs: None
Show full finding ▾Hide full finding ▴Criteria: The Provider Relief Funds are required to be reported through the Required Relief Funds Reporting Portal and include key items for Provider Relief Fund expenses and calculation of lost revenues. Condition: While management’s calculation of lost revenues for 2020 was determined to be accurate, as the 2019 and 2020 reported numbers in the portal submission reconciled and agreed to the Company’s audited net revenue amounts for those periods, the calculation of lost revenues for 2021 was not accurate. The reported amounts of net revenue from fiscal year 2021 and fiscal year 2022 (partially from calendar year 2021) did not reconcile or agree to the audited amounts of net patient revenue from these periods. Effect: The reporting in the portal inaccurately reported total lost revenues for each subsidiary’s portal submission. However, there were no questioned costs, as the 2020 reported lost revenues that were determined to be accurate, exceeded any amounts received from the Provider Relief Fund in the period under audit, and the cumulative receipts of Provider Relief Funding in all periods. Cause: The Company’s reporting over patient service revenue that was utilized in the compilation of the portal submission was inaccurate, and did not agree to the final 2021 audited amounts. In addition, there was no evidence that a secondary member of management reviewed the information prior to its submission. Recommendation: We recommend that management implement procedures and controls to ensure that all reporting and submissions to federal agencies are accurate and are sufficiently reviewed by another member of management prior to the submission. Repeat finding: No Views of responsible officials and planned corrective actions: See attached letter. Reportable questioned costs: None
While management’s calculation of lost revenues for 2020 was determined to be accurate, as the 2019 and 2020 reported numbers in the portal submission reconciled and agreed to MEMN’s audited net revenue amounts for those periods, the calculation of lost revenues for 2021 was not accurate. The reported amounts of net revenue from fiscal year 2021 and fiscal year 2022 (partially from calendar year 2021) did not reconcile or agree to the audited amounts of net patient revenue from these periods. Actions: 1. Establish Reporting Review Procedures: • Develop a formal procedure for reviewing all reports and submissions to federal agencies before submission. • Designate a responsible party within management to oversee the review process and ensure compliance with established procedures. 2. Documentation and Record-Keeping: • Implement a documentation system to track the review process for each report or submission. 3. Dual Review Requirement: • Ensure that all reports and submissions to federal agencies undergo a dual review process, when possible. • While we understand the importance of accuracy and compliance in our reporting processes, instituting a dual review requirement may not be feasible for MEMN given our size and resource constraints. As a small company, we operate with limited staff and resources, and imposing a dual review requirement could impose unnecessary burdens on our team members and hinder efficiency. Instead, we will explore alternative measures to ensure the accuracy of our reports and submissions. This includes implementing robust internal controls, enhancing documentation procedures, and providing guidance to staff involved in the reporting process. By strengthening our internal processes and promoting a culture of accountability and mindfulness, we can mitigate the risk of errors and discrepancies without imposing additional layers of review. Additionally, a more practical approach would be to designate a single individual within our organization to oversee the review process. This individual would be responsible for conducting a thorough review of each report or submission before it is finalized and submitted. This approach maintains accountability while avoiding the logistical challenges associated with implementing a dual review requirement. 4. Enhanced Reconciliation Procedures: • Improve reconciliation procedures between reported amounts and audited financial data. • Conduct regular reconciliations between reported net revenue figures and audited net patient revenue amounts to identify discrepancies promptly. 5. Internal Controls Enhancement: • Strengthen internal controls related to financial reporting and submissions to federal agencies. Timeline: • Establish Reporting Review Procedures and Documentation: Complete within three months, May 2024 • Review Requirement: Implement immediately, February 2024 • Enhanced Reconciliation Procedures: Begin within three months, May 2024 • Internal Controls Enhancement: Implement within four months, June 2024 Monitoring and Evaluation: • Regular progress meetings to track the implementation of corrective actions. • Monitor the effectiveness of the dual review process and reconciliation procedures through periodic assessments. • Conduct internal audits to evaluate compliance with established procedures and identify areas for improvement. Contact: • Alain Viaud, aviaud@som.umaryland.edu, 667-214-2051
The Company did not complete and submit their audit to the federal clearinghouse until February 2024. Effect: The late filing could potentially impact future funding from government agencies. Cause: Significant delays stemming from Finding 2022-003 related to the Uninsured Program caused the required audit procedures and the ultimate completion date to extend beyond the defined deadlines. Recommendation: We recommend that management implement procedures and controls to ensure future audits are filed timely with the federal clearinghouse. Repeat finding: No Views of responsible officials and planned corrective actions: See attached letter. Reportable questioned costs: None
Show full finding ▾Hide full finding ▴Criteria: Under 45 CFR Part 75, the Uniform Guidance requires that audits are submitted by the earlier of 30 calendar days after receipt of the auditor’s report or nine months after the end of the audit period. Condition: The Company did not complete and submit their audit to the federal clearinghouse until February 2024. Effect: The late filing could potentially impact future funding from government agencies. Cause: Significant delays stemming from Finding 2022-003 related to the Uninsured Program caused the required audit procedures and the ultimate completion date to extend beyond the defined deadlines. Recommendation: We recommend that management implement procedures and controls to ensure future audits are filed timely with the federal clearinghouse. Repeat finding: No Views of responsible officials and planned corrective actions: See attached letter. Reportable questioned costs: None
Significant delays resulted from Finding 2022-03 related to the Uninsured Program, causing the required audit procedures and the ultimate completion date to extend beyond defined deadlines. Actions: 1. Audit Efficiency Improvement: • Conduct a thorough review of audit processes to identify inefficiencies and implement measures to enhance efficiency. 2. Clear Communication with Auditors: • Establish clear communication channels with auditors to convey expectations, deadlines, and the importance of timely completion. • Regularly update auditors on any changes or developments that may impact the audit timeline. 3. Billing Company Data Timeliness: • Engage in proactive communication with the third-party billing company to emphasize the importance of providing data in a timely manner. • Implement contractual agreements specifying deadlines for data submission and consequences for delays. 4. Monitoring and Follow-Up: • Implement a monitoring system to track the progress of audit procedures and data submission from the third-party billing company. • Conduct regular follow-up with auditors and the third-party billing company to address any bottlenecks or delays promptly. Timeline: • Audit Efficiency Improvement: Implement immediately, February 2024 • Clear Communication with Auditors: Establish immediately, February 2024 • Billing Company Data Timeliness: Communicate deadlines to the third-party billing company within one month and enforce contractual agreements, March 2024 • Monitoring and Follow-Up: Begin monitoring system immediately and conduct regular follow-up, February 2024 Monitoring and Evaluation: • Regular progress meetings to track the implementation of corrective actions and monitor audit progress and data submission. • Assess the effectiveness of measures to improve auditor efficiency and ensure timely data submission through periodic reviews. • Solicit feedback from auditors and the third-party billing company to identify areas for improvement and adjustment. Contact: • Alain Viaud, aviaud@som.umaryland.edu, 667-214-2051
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