On July 13, 2023 the Workplace of Audit Providers of the Division of Well being & Human Providers Workplace of Inspector Basic (OIG) launched the long-awaited audit (A-02-21-01013) of the Well being Sources and Providers Administration (HRSA) Uninsured Program (UIP) (Audit). The UIP reimbursed suppliers for provision of COVID-19 testing, remedy, and vaccination providers supplied to uninsured people. Whereas the UIP terminated on account of inadequate funding within the spring of 2022, the federal authorities paid out an infinite sum for UIP claims throughout and after this system’s operation – roughly $24.5 billion in keeping with the Audit report.

The Audit reviewed whether or not claims reimbursed by way of the UIP complied with federal necessities, together with the prohibition on affected person stability billing (which means {that a} affected person is billed immediately for costs not paid by the insurer), and as we deal with right here, the requirement that reimbursement solely be made for claims for COVID-19 associated providers to uninsured people.

The Audit report sheds mild on the processes employed by HRSA, and its third-party contractor working the UIP, to confirm declare validity earlier than cost. The report describes shortcomings in HRSA and its contractor’s procedures to confirm affected person insurance coverage standing and be sure that claims had been for gadgets and providers associated to COVID-19. Contemplating latest enforcement actions and allegations associated to alleged improper submission of claims to the UIP, the Audit report is well timed and informative as suppliers grapple with their potential legal responsibility for claims submitted to the UIP.

On this article, the primary in a two-part sequence on the HRSA UIP and enforcement dangers, we break down the Audit’s findings and talk about the implications for suppliers who submitted claims to the UIP. Partly two of this sequence, to comply with shortly, we analyze enforcement actions filed towards suppliers alleging submission of false or fraudulent claims to and paid by the UIP and can present predictions associated to the probably way forward for enforcement on this space.  

HRSA Paid Claims for Sufferers Who Have been Insured

The Audit discovered that HRSA made cost to suppliers for testing and remedy providers rendered to sufferers who weren’t uninsured (and thus weren’t eligible for funds underneath the UIP). Particularly, of the 300 sufferers sampled, HRSA reimbursed UIP claims for testing or remedy supplied to 38 sufferers who had medical health insurance protection. (Claims for vaccination providers weren’t included within the Audit.)

To submit claims to the UIP, suppliers needed to attest that they learn this system’s phrases and circumstances and confirmed that sufferers didn’t have medical health insurance. Anecdotally, these authors are conscious of assorted strategies employed by suppliers to confirm affected person insurance coverage standing, together with requesting insurance coverage info or an attestation as to insurance coverage standing in materials given to sufferers, and using sure third-party instruments to confirm insurance coverage standing by way of searches of exterior databases. Partly two of this sequence, we are going to analyze suppliers’ potential legal responsibility for failure to correctly confirm affected person insurance coverage standing earlier than submitting claims to the UIP.

After enrolling with the UIP, suppliers submitted rosters of sufferers who acquired COVID-19 associated providers to HRSA. Upon receipt, HRSA’s third-party contractor verified medical health insurance standing utilizing inner and exterior databases.

Regardless of this effort, OIG discovered that procedures used to confirm insurance coverage standing weren’t efficient, which means funds had been incorrectly issued on the expense of the UIP. Particularly, HRSA’s contractor may solely confirm affected person insurance coverage standing if suppliers submitted affected person social safety numbers. Nevertheless, suppliers weren’t required to submit social safety numbers and, in consequence, for the overwhelming majority of sufferers for whom a UIP declare was paid, there was not a social safety quantity related to their declare. OIG discovered that in 2020, 2021, and 2022, respectively, 82% (22.6 million of 27.7 million sufferers), 91% (106.9 million of 117.8 million sufferers), and 94% (29.8 million of 31.8 million sufferers) of sufferers for whom a UIP declare was paid didn’t embody a social safety quantity.

In consequence, HRSA’s contractor didn’t confirm insurance coverage standing for the overwhelming majority of claims and, in keeping with the OIG, relied solely on the supplier’s attestation of the affected person’s uninsured standing when deciding to pay claims underneath the UIP. OIG describes these procedures to confirm insurance coverage standing as “not efficient.” Furthermore, OIG discovered that 9 sufferers within the pattern who had been decided to have insurance coverage really had a social safety quantity related to their declare however, regardless of this, HRSA’s contractor incorrectly decided that the sufferers didn’t have insurance coverage (and the declare was paid by the UIP). OIG attributes this lapse to HRSA (and its contractor’s) failure to make sure that the information used to confirm affected person insurance coverage standing was sufficiently dependable.

HRSA Made Fee for Providers Not Associated to COVID-19

OIG discovered that for 22 of the 300 pattern sufferers, HRSA made funds for providers that had been both not rendered or not associated to COVID-19. OIG cites to some examples, together with claims submitted for the price of treating a affected person’s damaged ankle quite than solely the price of the COVID-19 take a look at the affected person underwent as a pre-surgical process.

OIG claims that improper cost was made on these claims as a result of HRSA didn’t have efficient measures to make sure providers had been associated to COVID-19, corresponding to prepayment edits or publish cost audits.

Implications for Suppliers

As we are going to talk about additional partly two of this sequence, we’re conscious of circumstances filed towards suppliers who allegedly submitted improper claims to the UIP. The Audit report foretells that extra enforcement is coming. In reality, OIG recommends that HRSA determine further improper UIP funds, which OIG estimates to equal $783.6 million. HRSA has already applied a strategy of assessing whether or not suppliers had been correctly reimbursed underneath the UIP, together with by way of overview of supplier procedures concerning identification of insurance coverage protection.

Suppliers who participated within the UIP ought to put together for potential audits of their claims submitted to the UIP and monitor enforcement developments on this space. Suppliers who’re winding down operations because the PHE sunsets needs to be significantly cautious to keep up their data for future scrutiny. 

Foley is right here that will help you tackle the short- and long-term impacts within the wake of regulatory adjustments. We’ve got the assets that will help you navigate these and different vital authorized concerns associated to enterprise operations and industry-specific points. Please attain out to the authors, your Foley relationship associate, or to our Well being Care Observe Group with any questions.