INTEGRIS Health Inc

Finding number 2021-001 Type of finding: Significant deficiency in internal control and noncompliance Federal program: HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund Federal agency: U.S. Department of Health & Human Services Pass-through entity: Not applicable Federal award year: July 1, 2020 to June 30, 2021 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs Criteria The specific requirements for activities allowed or unallowed are unique to each federal program and are found in the federal statutes, regulations, and the terms and conditions of the federal award pertaining to the program. Charges to the HRSA COVID-19 Uninsured Program must conform to, including the limitations and exclusions of the terms and conditions. As described in the terms and conditions of the HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund federal award, services not covered by traditional Medicare will not be covered under this program and services for any treatment without a COVID-19 primary diagnosis are excluded, except for pregnancy when the COVID-19 code may be listed as secondary; hospice services; and outpatient prescription drugs. Additionally, Section 200.303 of Title 2 U.S. Code of Federal Regulations Part 200 (2 CFR 200), Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance) indicate that the nonfederal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. The Uniform Guidance also indicates that these internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? (Green Book) 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 Office of Management and Budget (0MB) has clarified that the references to the Green Book and COSO were only provided as best practices and not requirements. Condition and Context During our test work, we selected a sample of 40 patients to verify the reimbursement was considered an allowable activity and charge per the program terms and conditions. We noted 2 patient samples of which services for treatment did not meet the COVID-19 primary diagnosis criteria, and therefore were not considered allowable activities or charges for reimbursement under the federal award. We further extended our sample by 20 patients and noted no further exceptions. We noted the organization?s process and controls for identifying applicable diagnosis codes for reimbursement under the terms and conditions of the grant did not prevent improper billing, specifically, to ensure the non-reimbursable portion of a non-COVID-19 related emergency department visit was not requested for reimbursement. Cause Emergency department claims through November 2021 were unable to be effectively allocated/identified between reimbursable COVID-19 tests and non-reimbursable emergency visits (non-COVID-19 primary diagnosis). These claims were not effectively reviewed prior to reimbursement under the federal award. The organization periodically completed an analysis for applicable refunds. Effect The organization requested and received reimbursement for unallowed activities under the federal grant and must refund unallowed cost. To determine the known question cost, management completed an analysis of all patient claims reported for the period to determine the claims of which the primary diagnostic code was not COVID-19 and the applicable charge. Questioned Costs Total program cost ? $13,553,248 Total sampled cost ? $837,484 Known questioned cost ? $53,456 Statistical Sample The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding A similar finding was not reported in prior year audit. Recommendation We recommend that management design and implement controls to ensure claims are appropriately reviewed for proper allowable activities and charges in accordance with the grant, contract, or award terms and conditions prior to the request for reimbursement, or complete a more prompt refund analysis prior to the organizations and federal award year-end. View of Responsible Officials Management concurs with the finding, conclusions, recommendation and corrective action plan of the organization which consists of management updating their billing process, completing reviews of all program claims and issuing applicable refunds during the program period.