STANFORD HEALTH CARENon-Profit

Cluster/Grantor: Department of Health and Human Services ? Health Resources and Services Administration (?HRSA?) Award Name: COVID-19 HRSA Claims for the Uninsured Program Award Year: September 1, 2020 ? August 31, 2021 Award Number: None listed Assistant Listing Number: 93.461 Criteria HRSA COVID-19 Uninsured Program requires health care providers to ensure that a patient is uninsured (that is has no medical coverage through an individual, employer-sponsored plan, a federal healthcare program, or the Federal Employees Health Benefits Program at the time services were rendered, and no other payer will reimburse the health care provide for COVID-19 vaccination, testing and/or care for that patient) and therefore eligible for reimbursement from this program. Condition In testing compliance with the eligibility requirement of the 60 claims we selected to test patient eligibility, we identified 18 claims, totaling $12,591 where management was unable to provide evidence that insurance verification had been performed at the time of service or prior to submission to the HRSA portal. All but two of these claims were appropriate to have been reimbursed by HRSA. Based on a retrospective evaluation of these claims, it was subsequently determined, using an independent data source (Experian Coverage Discovery), that for two patients, SHC received reimbursement from another source. SHC has corrected those submissions and refunded the HRSA program $1,401. Cause Through discussion with management, we understand that SHC did not consistently maintain evidence to support the operating effectiveness of the existing control where SHC ensures the patient is uninsured at the date of service and prior to requesting reimbursement from HRSA. This was due to two factors: limited resource availability to contact/screen patients at times when COVID-19 volumes were peaking. Workflow deviations/changes (adding HRSA at time of registration) and a system logic gap prevented the triggering of coverage discovery before the system automation uploaded the claim to the HRSA portal to request a HRSA Temporary ID. Effect The patient could have had insurance coverage at the time the service was performed, resulting in receiving funds from the HRSA COVID-19 Uninsured Program inappropriately. Questioned Costs: $1,401. Recommendation We recommend SHC enhance its controls and revise its procedures to ensure that all patients are being checked for eligibility through insurance verification at the time of service and prior to submitting a reimbursement claim to HRSA. Management?s Views and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the Summary Schedule of Prior Audit Findings and Status.

Criteria HRSA COVID-19 Uninsured Program requires health care providers to ensure that a patient is uninsured (that is has no medical coverage through an individual, employer-sponsored plan, a federal healthcare program, or the Federal Employees Health Benefits Program at the time services were rendered, and no other payer will reimburse the health care provide for COVID-19 vaccination, testing and/or care for that patient) and therefore eligible for reimbursement from this program. Condition In testing compliance with the eligibility requirement of the 60 claims we selected to test patient eligibility, we identified 18 claims, totaling $12,591 where management was unable to provide evidence that insurance verification had been performed at the time of service or prior to submission to the HRSA portal. All but two of these claims were appropriate to have been reimbursed by HRSA. Based on a retrospective evaluation of these claims, it was subsequently determined, using an independent data source (Experian Coverage Discovery), that for two patients, there were other available sources of reimbursement. SHC has corrected those submissions and refunded the HRSA program $1,401. Cause Through discussion with management, we understand that SHC did not consistently maintain evidence to support the operating effectiveness of the existing control where SHC ensures the patient is uninsured at the date of service and prior to requesting reimbursement from HRSA. This was due to two factors: limited resource availability to contact/screen patients at times when COVID-19 volumes were peaking. Workflow deviations/changes (adding HRSA at time of registration) and a system logic gap prevented the triggering of coverage discovery before the system automation uploaded the claim to the HRSA portal to request a HRSA Temporary ID. Effect The patient could have had insurance coverage at the time the service was performed, resulting in receiving funds from the HRSA COVID-19 Uninsured Program inappropriately. Questioned Costs: $1,401. Recommendation We recommend SHC enhance its controls and revise its procedures to ensure that all patients are being checked for eligibility through insurance verification at the time of service and prior to submitting a reimbursement claim to HRSA. Management?s Views and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the Summary Schedule of Prior Audit Findings and Status