Court filing
HHS-OIG Audit A-02-21-01013 — HRSA COVID-19 Uninsured Program: Payments for Insured Individuals (July 2023, Full Report)
Filed July 1, 2023 in HHS OIG Provider Relief Fund; one of 6 filings from this case.
Record facts
| Court | HHS Office of Inspector General (OIG); audited: HRSA |
|---|---|
| Filed | 2023-07-01 |
Cited in: The HRSA Uninsured Testing Gold Rush
Full text
Department of Health and Human Services
OFFICE OF
INSPECTOR GENERAL
HRSA MADE COVID-19
UNINSURED PROGRAM
PAYMENTS TO PROVIDERS ON
BEHALF OF INDIVIDUALS WHO
HAD HEALTH INSURANCE
COVERAGE AND FOR SERVICES
UNRELATED TO COVID-19
Christi A. Grimm
Inspector General
July 2023
A-02-21-01013
Inquiries about this report may be addressed to the Office of Public Affairs at
Public.Affairs@oig.hhs.gov.
Office of Inspector General
https://oig.hhs.gov
The mission of the Office of Inspector General (OIG) is to provide objective oversight to
promote the economy, efficiency, effectiveness, and integrity of the Department of Health and
Human Services (HHS) programs, as well as the health and welfare of the people they serve.
Established by Public Law No. 95-452, as amended, OIG carries out its mission through audits,
investigations, and evaluations conducted by the following operating components:
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Notices
THIS REPORT IS AVAILABLE TO THE PUBLIC
at https://oig.hhs.gov
Section 8M of the Inspector General Act, 5 U.S.C. App., requires
that OIG post its publicly available reports on the OIG website.
OFFICE OF AUDIT SERVICES FINDINGS AND OPINIONS
The designation of financial or management practices as
questionable, a recommendation for the disallowance of costs
incurred or claimed, and any other conclusions and
recommendations in this report represent the findings and
opinions of OAS. Authorized officials of the HHS operating
divisions will make final determination on these matters.
Report in Brief
Date: July 2023
Report No. A-02-21-01013
HRSA Made COVID-19 Uninsured Program Payments
to Providers on Behalf of Individuals Who Had
Health Insurance Coverage and for Services
Unrelated to COVID-19
What OIG Found
In the context of unprecedented challenges related to the COVID-19 national
emergency, HRSA implemented a program to distribute funds to providers for
COVID-19 testing and treatment for uninsured individuals in a fast and
effective manner. However, we determined that HRSA made payments to
providers through the UIP for claims for COVID-19 testing and treatment
services that did not comply with Federal requirements.
For 240 of our 300 sampled patients, UIP payments to providers for claims for
COVID-19 services met program terms and conditions, and were made on
behalf of uninsured individuals. Furthermore, we determined that providers
in the sample had effective processes to ensure that they did not engage in
balance billing or charge patients any type of cost-sharing. However, UIP
payments for 58 sampled patients totaling $294,294 were improper because
they were made on behalf of individuals who had health insurance coverage
or were made for testing and treatment services that were not provided or
were unrelated to COVID-19. We were unable to determine whether UIP
payments for two other sampled patients complied with Federal
requirements because the providers were unresponsive to our requests for
supporting documentation.
On the basis of our sample results, we estimated that nearly $784 million of
$4.2 billion (or 19 percent) in UIP payments made to providers during our
audit period for approximately 3.7 million of 19.2 million patients were
improper. We understand that HRSA’s operational objective for the UIP was
to rapidly disburse funds for COVID-19 testing and treatment to ensure
uninsured individuals were receiving vital health care services and to prevent
the spread of COVID 19. However, if HRSA or another HHS agency
administers any programs of a similar nature in the future, the agency should
consider the information included in this report.
What OIG Recommends and HRSA Comments
We made a series of recommendations to HRSA, including that it recover
$294,294 in improper UIP payments identified in our sample and identify
additional improper UIP payments for services provided to insured individuals
or services unrelated to COVID-19, which we estimate to be nearly
$784 million, and take remedial action. We also made procedural
recommendations for HRSA to improve future programs of a similar nature.
Why OIG Did This Audit
Congress passed a series of bills to
provide funds to eligible hospitals
and other health care providers for
COVID-19 testing and treatment for
uninsured individuals. The Health
Resources and Services
Administration (HRSA), within HHS,
was selected to provide day-to-day
oversight and management of the
COVID-19 Uninsured Program (UIP).
HRSA entered into an agreement
with a contractor to administer the
UIP, which allowed providers to
enroll and submit claims for
reimbursement of COVID-19 testing
and treatment made to uninsured
individuals (patients). This audit is
part of OIG’s oversight of HHS’s
COVID-19 response and recovery
efforts.
Our objective was to determine
whether claims for COVID-19 testing
and treatment services reimbursed
through the UIP complied with
Federal requirements.
How OIG Did This Audit
Our audit covered claims for
19 million patients with associated
UIP provider payments totaling
$4.2 billion with service dates from
March 1 through December 31, 2020.
As part of our audit, we interviewed
HRSA officials and HRSA’s contractor
and analyzed health insurance
coverage data as well as medical and
billing records. We reviewed a
stratified random sample of 300
patients with associated provider
payments totaling $2.8 million.
The full report can be found at https://oig.hhs.gov/oas/reports/region2/A022101013.asp.
The full report can be found at https://oig.hhs.gov/oas/reports/region2/A022101013.asp.
In written comments on our draft report, HRSA partially concurred with our
first recommendation and concurred with our second and third
recommendations. In addition, HRSA provided information on actions that it
has taken or plans to take to address our recommendations.
We commend HRSA for its actions and acknowledge that the UIP was
administratively designed to be responsive to the pandemic and
expeditiously reimburse providers. Regarding HRSA’s comments on our first
recommendation, we note that payments per the UIP terms and conditions
were for testing or treatment of COVID-19 for individuals who did not have
any health insurance coverage at the time the services were provided.
Therefore, we maintain that our findings and associated recommendation
are valid because we determined that improper UIP payments were made to
providers on behalf of individuals who had health insurance coverage at the
time of services.
Health Resources and Services Administration’s COVID-19 Uninsured Program (A-02-21-01013)
TABLE OF CONTENTS
INTRODUCTION ......................................................................................................................... 1
Why We Did This Audit ................................................................................................... 1
Objective ......................................................................................................................... 2
Background ..................................................................................................................... 2
COVID-19 National Emergency and Funding
for the COVID-19 Uninsured Program .............................................................. 2
Administration of the COVID-19 Uninsured Program ......................................... 3
How We Conducted This Audit ....................................................................................... 6
FINDINGS .................................................................................................................................. 7
Providers Appropriately Did Not Engage in Balance Billing or Charge
Any Type of Cost-Sharing for Uninsured Program Services .......................................... 8
HRSA Made Uninsured Program Payments to Providers on Behalf of Individuals
Who Had Health Insurance Coverage .......................................................................... 8
Health Insurance Coverage Verifications Were Not Performed for Patients
for Whom Social Security Numbers Were Not Provided .................................. 9
Patients for Whom Social Security Numbers Were Provided Were Incorrectly
Determined to Not Have Health Insurance Coverage ...................................... 10
HRSA Made Uninsured Program Payments to Providers for Testing and
Treatment Services That Were Not Provided or Related to COVID-19 ......................... 11
RECOMMENDATIONS ................................................................................................................ 13
HRSA COMMENTS AND OFFICE OF INSPECTOR GENERAL RESPONSE ....................................... 13
APPENDICES
A: Audit Scope and Methodology ................................................................................... 15
B: Statistical Sampling Methodology .............................................................................. 17
C: Sample Results and Estimates .................................................................................... 19
D: HRSA Comments ......................................................................................................... 20
Health Resources and Services Administration’s COVID-19 Uninsured Program (A-02-21-01013)
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INTRODUCTION
WHY WE DID THIS AUDIT
On March 13, 2020, then-President Trump declared the COVID-19 outbreak a national
emergency. In response, Congress passed the Families First Coronavirus Response Act (FFCRA)
and the Paycheck Protection Program and Health Care Enhancement Act (PPP), which together
appropriated $2 billion to reimburse eligible hospitals and other health care providers
(providers) for conducting COVID-19 testing and testing-related items and services for the
uninsured. The FFCRA defines an uninsured individual as someone who is not enrolled in:
(1) a Federal health care program (e.g., Medicare or Medicaid), (2) an individual health
insurance coverage or a group health plan, or (3) the Federal Employees Health Benefits
Program.
Congress also appropriated $178 billion to the Provider Relief Fund (PRF) to provide funds to
providers for health care-related expenses or lost revenue (e.g., revenue lost due to canceled
elective services) attributable to COVID-19.1 The Department of Health and Human Services
(HHS) used a portion of the PRF for the treatment of uninsured individuals with a primary
COVID-19 diagnosis and to reimburse providers for administering COVID-19 vaccines to
uninsured individuals.
The national emergency posed unprecedented challenges to HHS to distribute funds to
providers for COVID-19 testing and treatment services for uninsured individuals in a fast, fair,
and transparent manner and to provide immediate financial relief to providers on the front
lines of the COVID-19 response. HHS was responsible for program oversight and policy
decisions, and the Health Resources and Services Administration (HRSA), within HHS, was
selected to administer the COVID-19 Uninsured Program (UIP). Approximately 1 month after
the national emergency declaration, HRSA established an online UIP portal, which allowed
providers to begin enrolling in the UIP. Providers were then able to submit claims for
reimbursement of COVID-19 testing and treatment of uninsured individuals to the UIP.
This audit assessed claims for COVID-19 testing and treatment services for uninsured individuals
provided during the period from March through December 2020 and reimbursed through the
UIP. This audit is one of several Office of Inspector General (OIG) audits of various aspects of
PRF payments, including HHS’s and HRSA’s controls related to the requirements for submission
of revenue information and attestation of rejection of PRF payments, HHS’s and HRSA’s
controls over PRF payment calculations and provider eligibility, and providers’ compliance with
Federal requirements for reporting and using PRF payments.2
1 The Coronavirus Aid, Relief, and Economic Security Act, P.L. No. 116-136, signed into law on Mar. 27, 2020; the
PPP, P.L. No. 116-139; and the Consolidated Appropriations Act, 2021, P.L. No. 116-260, signed into law on Dec. 27,
2020.
2 The first audit, HHS's and HRSA's Controls Related to Selected Provider Relief Fund Program Requirements Could
Be Improved (A-09-21-06001), was issued Sept. 26, 2022.
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COVID-19 has created extraordinary challenges for the delivery of health care and human
services to the American people. As the oversight agency for HHS, OIG oversees HHS’s
COVID-19 response and recovery efforts. This audit is part of OIG’s COVID-19 response
strategic plan.3
OBJECTIVE
The objective of our audit was to determine whether claims for COVID-19 testing and
treatment services reimbursed through the UIP complied with Federal requirements.
BACKGROUND
COVID-19 National Emergency and Funding for the COVID-19 Uninsured Program
COVID-19 is a disease caused by a highly contagious coronavirus called SARS-CoV-2. On
January 30, 2020, the World Health Organization (WHO) declared the COVID-19 outbreak a
Public Health Emergency of International Concern, and on March 11, 2020, WHO characterized
COVID-19 as a pandemic.4 Later, on March 13, 2020, then-President Trump declared the
COVID-19 outbreak a national emergency.
In response to the national emergency, Congress passed the FFCRA, P.L. No. 116-127, and the
PPP, P.L. No. 116-139, which together appropriated $2 billion to reimburse providers for
conducting COVID-19 testing and testing-related items and services for the uninsured.5 The
FFCRA defines an uninsured individual as someone who is not enrolled in: (1) a Federal health
care program (e.g., Medicare or Medicaid), (2) individual health insurance coverage or a group
health plan, or (3) the Federal Employees Health Benefits Program.6
Congress also appropriated $178 billion to the PRF to provide funds to eligible providers for
health care-related expenses or lost revenue (e.g., revenue lost due to canceled elective
services) attributable to COVID-19. HHS used a portion of the PRF for the treatment of
3 OIG’s COVID-19 response strategic plan and oversight activities can be accessed at HHS-OIG's Oversight of
COVID-19 Response and Recovery | HHS-OIG.
4 A pandemic is an epidemic that has spread over several countries or continents, usually affecting many people.
An epidemic is an increase, often sudden, in the number of cases of a disease above what is normally expected in
a population in a specific area.
5 The FFCRA was signed into law on Mar. 18, 2020. The PPP was signed into law on Apr. 24, 2020.
6 After our audit period, HHS allocated additional funding to the UIP from funds appropriated by Congress for
COVID-19 testing in the American Rescue Plan Act of 2021, P.L. No. 117-2, signed into law on Mar. 11, 2021.
Health Resources and Services Administration’s COVID-19 Uninsured Program (A-02-21-01013)
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uninsured individuals with a primary diagnosis of COVID-19, as well as to reimburse providers
for administering COVID-19 vaccines to uninsured individuals.7
Because of the unprecedented national emergency, HHS faced substantial challenges in
distributing funds to providers for COVID-19 testing and treatment for uninsured individuals in
a fast and effective manner. In order to quickly set up a program and reimburse providers for
COVID-19 testing and treatment of uninsured individuals, HRSA held limited competitions to
evaluate prospective vendors’ abilities to administer the UIP.8 Approximately 1 month after the
national emergency declaration, HRSA entered into an agreement with a contractor to
administer the UIP portal, which allowed providers to begin enrolling in the UIP.9 Providers
were then able to submit claims for reimbursement of COVID-19 testing and treatment of
uninsured individuals to the UIP.
Administration of the COVID-19 Uninsured Program
As the Federal agency responsible for administration of the UIP, HRSA entered into an
agreement with a contractor to launch the online UIP portal. The portal was used by providers
to enroll in the UIP, submit patient rosters to verify patient eligibility, and access customer
support and resources.
HRSA’s contractor administered the UIP portal and enrolled eligible providers. The contractor
was also tasked with verifying patients’ health insurance coverage status, processing UIP claims,
and reimbursing providers for eligible services. UIP reimbursement was generally paid at
Medicare rates for qualifying COVID-19 testing and treatment services. The UIP stopped
accepting testing and treatment claims for reimbursement on March 22, 2022, as well as
vaccine administration claims on April 5, 2022, due to insufficient funding. As of December
2022, the Federal Government had paid providers approximately $24.5 billion for UIP claims.10
Processes To Ensure That COVID-19 Uninsured Program Patients Were Uninsured
To submit claims for reimbursement, providers submitted patient rosters to the UIP portal.
Each roster listed a provider’s patients who received COVID-19 testing and treatment services
7 UIP claims for vaccine administration began after our audit period; therefore, these services were not covered in
our audit.
8 In Mar. 2020, HHS issued a class justification and approval for all HHS acquisition offices to use procedures other
than full and open competition in order for HHS agencies and offices to have adequate flexibility to respond to the
COVID-19 pandemic.
9 Specifically, HRSA entered into an agreement with HRSA’s contractor on Apr. 16, 2020. Providers began
submitting claims for services previously provided on May 6, 2020. Reimbursements to providers began May 18,
2020.
10 Even though HRSA was no longer accepting UIP claims, HRSA’s contractor was continuing to adjudicate and pay
claims that were submitted before the program submission deadlines.
Health Resources and Services Administration’s COVID-19 Uninsured Program (A-02-21-01013)
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and were determined to be uninsured (i.e., did not have individual or employer-sponsored
health insurance coverage, Medicare, or Medicaid). Providers also attested that they had read
and agreed to the UIP’s terms and conditions, checked that these patients did not have any
health insurance coverage, confirmed that the patients were uninsured, and agreed to accept
UIP reimbursement as payment in full and not balance bill the patient.11 HRSA’s contractor
indicated that once providers submitted their attestations, the contactor used a health
insurance coverage validation process to check for third-party health insurance coverage based
on available internal and external data. If no health insurance coverage was identified, HRSA’s
contractor assigned patient identification numbers (patient IDs) for providers to use when
submitting claims for UIP services.
According to HRSA, HHS made a policy decision that a provider would not be required to submit
a patient’s Social Security Number (SSN) as part of a provider’s patient roster before HRSA’s
contractor assigned a patient ID. This decision was made to ensure that a patient’s fear of
providing an SSN (or the inability to do so) would not preclude the patient from receiving
COVID-19 testing or treatment, and providers who provided services to patients unwilling to
provide SSNs would not be precluded from receiving claims reimbursements. However, HRSA
indicated that its contractor was unable to verify a patient’s health insurance coverage status
unless an SSN was provided. Therefore, HRSA’s contractor only verified a patient’s health
insurance coverage status if the patient’s SSN was submitted by the provider. When an SSN
was collected by the provider, HRSA’s contractor checked for third-party health insurance
coverage using the patient’s name, gender, date of birth, and SSN.12 If the patient was
determined to have health insurance coverage as a result of this search, HRSA’s contractor did
not issue a patient ID and shared the health insurance coverage information with the provider.
When no active health insurance coverage was identified, HRSA’s contractor issued patient IDs
for providers to use when submitting claims for COVID-19 testing and/or treatment services. If
the provider did not collect or report an SSN, HRSA’s contractor relied on the provider’s
attestation that health insurance coverage had been checked and the patient’s status as
uninsured had been confirmed. HRSA’s contractor then provided a patient ID for providers to
use when filing claims.
Additionally, HRSA stated that its contractor performed retroactive health insurance
verification checks for patients for whom an SSN was submitted by the provider 30, 60, and 90
days after providers received reimbursement from the UIP. HRSA’s contractor performed each
check to determine whether there were any changes to a patient’s health insurance coverage
11 Balance billing occurs when a provider bills a patient for the difference between the provider’s charge for a
service and the allowed amount to be reimbursed for that service. For example, if the provider’s charge is $100 for
a service and the allowed reimbursement amount is $70, the provider may use balance billing to bill the patient for
the remaining $30.
12 HRSA relied on the HRSA contractor’s internal and external (i.e., third-party vendor) data sources for health
insurance coverage information, including Medicaid and Medicare. The HRSA contractor’s third-party vendor
obtained Medicaid data directly from the States’ Medicaid Management Information Systems, and Medicare data
were queried against the third-party vendor’s Coordination of Benefits solution’s data lake (i.e., the centralized
data repository).
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status. When other health insurance coverage was found, HRSA’s contractor updated the
patient’s eligibility dates and any associated claims submitted during that period. Furthermore,
HRSA’s contractor initiated recovery of payments for any claims already paid to a provider.
Figure 1 illustrates the processes for verifying patient health insurance coverage status under
the UIP.
Figure 1: Processes for Verifying Patient Health Insurance Coverage
Processes for Submitting COVID-19 Uninsured Program Claims and Reimbursing Providers
Once HRSA’s contractor approved a provider’s patient roster and assigned patient IDs, a
provider was able to submit claims to the UIP. Claims for COVID-19 testing and testing-related
items and services were eligible for reimbursement if one of six eligible COVID-19-related
diagnoses codes was included on the claim. A claim for COVID-19 treatment services was
eligible for reimbursement if COVID-19 was the primary diagnosis code on the claim.13 HRSA’s
13 For dates of service on or after Apr. 1, 2020, providers were instructed to use primary diagnosis U07.1 to
indicate that COVID-19 was the primary reason for treatment except for pregnancy, for which providers were
instructed to use O98.5 as the primary diagnosis and U07.1 as the secondary diagnosis. For dates of services or
discharges prior to Apr. 1, 2020, there was no equivalent diagnosis to indicate COVID-19; therefore, providers were
instructed to use B97.29 as the primary diagnosis.
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contractor indicated that it had system edits in place to verify that: (1) the appropriate
diagnoses codes were included on each claim and (2) the patient ID included on the claim was
valid in order to be processed for reimbursement. HRSA stated that claims were adjudicated
using industry standard edits and Medicare correct-coding guidelines and were generally paid
at Medicare rates. Providers were required to accept reimbursement from the UIP for services
provided as payment in full and were not to engage in balance billing or charge patients any
type of cost-sharing. Figure 2 illustrates the processes for reviewing and reimbursing UIP
claims.
Figure 2: Processes for Reviewing and Reimbursing Uninsured Program Claims
HOW WE CONDUCTED THIS AUDIT
Our audit covered UIP claims for COVID-19 services for 19,191,091 patient IDs (patients) with
associated provider payments totaling $4,183,094,053 with service dates from March 1 through
December 31, 2020. We reviewed a stratified random sample of 300 patients with associated
provider payments totaling $2,838,023. We divided the sampling frame into six strata based on
whether an identification number (SSN or State ID) was submitted by the provider for the
Health Resources and Services Administration’s COVID-19 Uninsured Program (A-02-21-01013)
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patient, and then by the total payment amount for all associated claims.14, 15 For each sampled
patient, we obtained and reviewed the associated providers’ medical documentation
supporting UIP payments made for claims for COVID-19 services and any associated Medicare
and Medicaid health insurance coverage status information. In addition, we obtained and
reviewed the associated providers’ billing documentation to determine whether providers
engaged in balance billing or charged any type of cost-sharing for UIP services.
We conducted this performance audit in accordance with generally accepted government
auditing standards. Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions
based on our audit objectives. We believe that the evidence obtained provides a reasonable
basis for our findings and conclusions based on our audit objectives.
Appendix A contains the details of our audit scope and methodology, Appendix B contains our
statistical sampling methodology, and Appendix C contains our sample results and estimates.
FINDINGS
HRSA made some payments to providers through its UIP for claims for COVID-19 testing and
treatment services that did not comply with Federal requirements. For 240 of 300 sampled
patients, UIP payments to providers for claims for COVID-19 services met program terms and
conditions, and were made on behalf of uninsured individuals. Furthermore, we determined
that providers in the sample had effective processes to ensure that they did not engage in
balance billing or charge patients any type of cost-sharing for which they already received UIP
payments. However, UIP payments for 58 sampled patients totaling $294,294 were improper
because they were made on behalf of individuals who had health insurance coverage or were
for testing and treatment services not provided or unrelated to COVID-19. For the two
remaining sampled patients—with UIP payments totaling $1,220—the providers were
unresponsive to our requests for supporting documentation. As a result, we were unable to
determine whether the related payments for UIP claims complied with Federal requirements.16
On the basis of our sample results, we estimated that nearly $784 million, or 19 percent, of
$4.2 billion in UIP payments made to providers during our audit period for approximately
3.7 million of 19.2 million patients were improper because they were made on behalf of
14 According to the HRSA COVID-19 FAQs, a patient’s SSN or State ID (e.g., a driver’s license) was needed to verify
health insurance coverage status. However, after we selected our sample HRSA indicated that HRSA’s contractor
was unable to use a patient’s State ID to verify health insurance coverage status.
15 Specifically, an identification number was submitted by a provider for each of 100 sampled patients (88 sampled
patients with an SSN and 12 sampled patients with a State ID), and no identification number was submitted for
each of 200 sampled patients.
16 Since we consider these payments to be potentially improper, they were not included in our estimate of
improper UIP payments. We submitted the claims information associated with these providers to HRSA for
potential action.
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individuals who had health insurance coverage or were for testing and treatment services that
were not provided or were unrelated to COVID-19.
We understand that HRSA’s operational objective at the beginning of the national emergency
was to rapidly disburse funds for COVID-19 testing and treatment to ensure uninsured
individuals were receiving vital health care services and to prevent the spread of COVID-19.
HRSA established procedures with its contractor that were not effective at ensuring that the
UIP only reimbursed claims for services to uninsured individuals or for services related to the
testing and treatment of COVID-19. If HRSA or another HHS agency administers any programs
of a similar nature in the future, the agency should consider the information included in this
report.
PROVIDERS APPROPRIATELY DID NOT ENGAGE IN BALANCE BILLING OR CHARGE
ANY TYPE OF COST-SHARING FOR UNINSURED PROGRAM SERVICES
Providers were required to attest that they agreed to accept defined UIP reimbursements, as
determined by HRSA, as payment in full and would not balance bill patients or charge any type
of cost-sharing.17
We determined that providers in the sample had effective processes to ensure that they did not
engage in balance billing or charge patients any type of cost-sharing for which they already
received UIP payments. For 297 of the 300 sampled patients, we did not identify any instances
in which the provider balance billed the patient or charged any type of cost-sharing.18
HRSA MADE UNINSURED PROGRAM PAYMENTS TO PROVIDERS ON BEHALF OF INDIVIDUALS
WHO HAD HEALTH INSURANCE COVERAGE
During our audit period, the UIP had two definitions of an uninsured individual based on the
type of COVID-19 services the patient received. For COVID-19 testing and testing-related
services, a patient was considered uninsured if the patient did not have coverage through an
individual, employer-sponsored plan, Federal health care program (e.g., Medicare and
17 HRSA COVID-19 Uninsured Program Terms and Conditions—Testing and Treatment Services, and HRSA
COVID-19 FAQs.
18 Providers associated with two other sampled patients were unresponsive to our requests for supporting
documentation, and we were unable to determine whether the related payments for UIP claims complied with
Federal requirements. The provider associated with the remaining sampled patient reimbursed the uninsured
individual for excess payments made by the uninsured individual. We determined that the excess payments were
due to a clerical oversight by the provider.
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Medicaid), or the Federal Employees Health Benefits Program.19, 20 For COVID-19 treatment
services, a patient was considered uninsured if the patient did not have any health care
coverage at the time the services were provided.21, 22 In order for claims to be eligible for
reimbursement from the UIP, providers were required to attest that they had checked for
health care coverage eligibility and confirmed patients were uninsured.
For 38 of the 300 sampled patients, HRSA reimbursed UIP claims totaling $148,432 to providers
on behalf of individuals who had health insurance coverage (i.e., patients who did not meet the
definition of an uninsured individual based on the testing or treatment services provided).
Based on our understanding of the processes HRSA established with its contractor for verifying
patients’ health insurance coverage, we determined that there is a risk that providers may have
been improperly reimbursed for UIP claims on behalf of patients not eligible for the UIP. This
may have led to UIP funds being depleted before they could be used for their intended purpose
(i.e., the purpose of reimbursing providers for services to uninsured individuals).
Health Insurance Coverage Verifications Were Not Performed for Patients
for Whom Social Security Numbers Were Not Provided
For 29 of the 38 sampled patients who had health insurance coverage, HRSA’s contractor did
not perform its processes for verifying health insurance coverage because the patients’ SSNs
were not provided. As a result, HRSA’s contractor did not identify that these patients had
health insurance coverage.
This occurred because the procedures for verifying health insurance coverage that HRSA
established with its contractor were not effective. Specifically, HRSA’s contractor verified a
patient’s health insurance coverage status only if the patient’s SSN was submitted by the
provider (emphasis added). HRSA’s contractor indicated that it was unable to check its internal
and third-party databases to verify a patient’s health insurance coverage status unless an SSN
was provided.23 However, for 25 of the 29 sampled patients we were able to independently
19 FFCRA Division A, Title V, HRSA COVID-19 Uninsured Program Terms and Conditions—Testing Services, and HRSA
COVID-19 FAQs.
20 The definition of an uninsured individual changed for testing and testing-related items and services after
May 31, 2021, after the $2 billion allocated by the FFCRA and PPP for these services were fully expended.
21 HRSA COVID-19 Uninsured Program Terms and Conditions—Treatment Services, and HRSA COVID-19 FAQs.
22 Individuals who were enrolled in limited benefit Medicaid plans (e.g., family planning services) did not meet the
definition of “uninsured” for the purposes of reimbursing providers for COVID-19 testing services. However, these
individuals were considered uninsured for the purposes of reimbursing providers for COVID-19 treatment services.
23 As previously described, HRSA stated that HRSA’s contractor verified a patient’s health insurance coverage status
by comparing the patient’s SSN with internal and external databases that contained certain Medicare, Medicaid,
and private health insurance coverage information. When no SSN was submitted, HRSA’s contractor processed a
UIP claim for payment based solely on the provider’s attestation that the patient was uninsured.
Health Resources and Services Administration’s COVID-19 Uninsured Program (A-02-21-01013)
10
verify that the patients had Medicare and/or Medicaid coverage through CMS’s Integrated Data
Repository (IDR) using additional data fields collected by HRSA’s contractor (e.g., a patient’s
first name, last name, date of birth, and address).24, 25 Furthermore, HRSA stated that it
intended to conduct postpayment reviews of claims associated with patients for whom SSNs
were not provided. However, HRSA’s UIP assessment strategy for reviewing postpayment
provider claims did not include any steps other than reviews of patient information initially
collected by providers and provider billing records.26 Therefore, HRSA did not establish a
prepayment check or a postpayment review process to verify health insurance coverage when a
patient’s SSN was not submitted on a UIP claim.
As a result, health insurance coverage status was not verified for the vast majority of patients
for whom claims were reimbursed by the UIP. Specifically, the percentages of patients for
whom paid UIP claims did not include an associated SSN in 2020, 2021, and 2022 were
82 percent (22.6 million of 27.7 million patients), 91 percent (106.9 million of 117.8 million
patients), and 94 percent (29.8 million of 31.8 million patients), respectively.
Patients for Whom Social Security Numbers Were Provided
Were Incorrectly Determined to Not Have Health Insurance Coverage
For 9 of the 38 sampled patients who had health insurance coverage, HRSA’s contractor
performed health insurance verifications through its internal and external data sources using
the patients’ SSNs. However, we determined that HRSA’s contractor incorrectly determined
that these patients did not have health insurance coverage.27
This occurred because HRSA did not ensure that the data used by its contractor was sufficiently
reliable to identify health insurance coverage for every patient who provided an SSN. As
24 For each of the four remaining sampled patients, the provider acknowledged that the patient had health
insurance coverage for the dates of UIP services and either: (1) inappropriately billed the UIP or (2) did not return
the associated UIP payment when the patient was retroactively approved for Medicaid. We did not have access to
databases containing individual or employer-sponsored health insurance coverage information. Therefore, we
were unable to independently verify whether our sampled patients had private health insurance.
25 We note that in July 2020 (after the start of our audit period), HHS’s Office of the National Coordinator for
Health Information Technology (ONC) established a standardized set of data elements to be used among health
care professionals nationwide for exchanging a patient’s health information that does not include an SSN. ONC is
organizationally within the Office of the Secretary for HHS and is the principal Federal entity charged with
coordinating nationwide efforts to implement the most advanced health information technology and the
electronic exchange of this information.
26 HRSA’s UIP assessment strategy steps would identify health insurance coverage documented in a provider’s
patient or billing records but would not verify health insurance coverage status independent of a provider record
review.
27 For eight of the nine sampled patients, we used the patients’ SSNs and additional data fields to identify Medicare
and/or Medicaid coverage through the IDR. For the remaining sampled patient, the provider acknowledged that
the patient had health insurance coverage for the dates of UIP services.
Health Resources and Services Administration’s COVID-19 Uninsured Program (A-02-21-01013)
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previously described, HRSA relied on its contractor’s internal and external (third-party vendor)
data sources for health insurance coverage information, including Medicaid and Medicare.28
HRSA stated that it did not have access to its contractor’s third-party vendor’s data because the
vendor was not a HRSA contractor; therefore, HRSA could not conduct an independent analysis
of the completeness and accuracy of the data.
HRSA MADE UNINSURED PROGRAM PAYMENTS TO PROVIDERS FOR TESTING
AND TREATMENT SERVICES THAT WERE NOT PROVIDED OR RELATED TO COVID-19
To be eligible for UIP payments, providers were required to attest that they had read and
agreed to the applicable UIP terms and conditions for testing and treatment services, including
the UIP’s definitions of eligible services. The terms and conditions stated that UIP testing was
eligible to be claimed for reimbursement for in vitro diagnostic tests for detecting SARS-CoV–2
or diagnosing the virus that causes COVID–19, and the administration of such tests.
Furthermore, testing-related items and services were eligible to be claimed for reimbursement
if provided to an individual during an office, telehealth, urgent care, or emergency room (ER)
visit that resulted in an order for or administration of a COVID-19 test, but only to the extent
that the items and services related to the test or an evaluation of the individual for the need of
such a test.29 UIP treatment services were eligible to be claimed for reimbursement if a patient
had a primary COVID-19 diagnosis and the services were for the care or treatment of COVID-19
and its complications.30
HRSA did not provide guidance on UIP claim-coding to providers. Rather, HRSA provided billing
guidelines to allow providers to identify and submit only claims eligible for reimbursement
under the UIP.31
28 HRSA stated that the HRSA contractor’s third-party vendor obtains Medicaid data directly from the States’
Medicaid Management Information Systems. The vendor queries Medicare data against its own Coordination of
Benefits solution’s data lake.
29 FFCRA Division F, Sec. 6001., HRSA COVID-19 Uninsured Program Terms and Conditions—Testing Services, and
HRSA COVID-19 FAQs.
30 HRSA COVID-19 Uninsured Program Terms and Conditions—Treatment Services, and HRSA COVID 19 FAQs.
31 As described earlier, providers had to submit testing claims with one of six eligible COVID-19-related diagnoses
codes (i.e., Z03.818, Z11.59, Z20.828, Z11.52, Z20.822, or Z86.16) included in the claim. In addition, providers had
to submit treatment claims with a primary diagnosis code (i.e., U07.1) that indicated that COVID-19 was the
primary reason for treatment. The only exception to this requirement was for pregnant patients. For pregnant
patients, COVID-19 would be a secondary reason for treatment.
Health Resources and Services Administration’s COVID-19 Uninsured Program (A-02-21-01013)
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For 22 of the 300 sampled patients, HRSA made UIP payments for claims for COVID-19 services
totaling $161,465 to providers for testing or treatment services that were not provided or were
unrelated to COVID-19.32 Specifically:
• For 14 sampled patients, HRSA made UIP payments to providers for claims for items
or services that met UIP billing guidelines but were either not provided or were not
related to COVID-19 testing. For example, one sampled patient was admitted to an
ER for a broken ankle. The patient was subsequently admitted for observation and
had surgery to repair the ankle the following day. The medical records indicated
that the patient was tested for COVID-19 as a presurgical procedure, with a negative
result. The ER visit, hospital observation, surgery, and related items and services
were billed as a COVID-19 testing claim, and the provider was reimbursed by the UIP
for $6,505.33 Per UIP testing terms and conditions, only the $100 COVID-19 test was
eligible for reimbursement; therefore, the remaining UIP payment of $6,405 was
improper.
• For 8 sampled patients, HRSA made UIP payments for claims for treatment services
that met UIP billing guidelines; however, COVID-19 was not the primary reason for
the services. For example, one sampled patient went to an ER after vomiting blood.
The patient was admitted for further care and found to be COVID-19-positive.
However, the patient’s medical records noted: (1) COVID-19 was an “incidental
finding,” (2) the patient did not have any respiratory symptoms, and (3) the patient
did not require treatment for COVID-19 at that time. Additionally, COVID-19 was
not listed as the primary reason for admitting the patient or the primary diagnosis
on the patient’s discharge paperwork.34 Per UIP treatment terms and conditions,
the total claim amount of $14,063 was improper.
These deficiencies occurred because HRSA did not have effective procedures to ensure that the
UIP only paid provider claims for services related to the testing or treatment of COVID-19.
Specifically, HRSA primarily relied on providers’ attestations that claims were for eligible
services under the UIP and HRSA’s contractor reimbursed UIP claims after ensuring claims
contained correct diagnosis codes in order to be processed for payment. HRSA excluded only
select services from claims (i.e., hospice services and most outpatient prescription drugs) and
did not employ any prepayment edits or postpayment analyses of additional diagnosis codes on
32 The error counts and improper UIP payments related to the sampled patients who either had health insurance
coverage or services that were not provided, or were unrelated to COVID-19, do not total to the overall improper
payment amount. This occurred because two sampled patients, with UIP payments totaling $15,603, had health
insurance coverage and services reimbursed by the UIP that were not related to COVID-19.
33 The provider included a diagnosis code on the claim related to observation for suspected exposure to COVID-19
and to rule out other biological agents.
34 The diagnosis code for COVID-19 (U07.1) was included on the associated UIP claim as the primary diagnosis;
however, “gastrointestinal hemorrhage” was listed as the primary diagnosis in the patient’s medical records. The
provider subsequently confirmed that COVID-19 was not the primary reason for treatment.
Health Resources and Services Administration’s COVID-19 Uninsured Program (A-02-21-01013)
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claims to identify claims for services potentially unrelated to COVID-19.35 Additionally, although
HRSA planned to conduct postpayment medical reviews of claims for selected providers
through a comprehensive assessment strategy, it did not begin conducting these assessments
until March 2022.36 Due to a delayed start for these assessments, program recoveries of
improper payments are likely to be significantly delayed.
RECOMMENDATIONS
We recommend that HRSA:
• recover the $294,294 in improper UIP payments identified in our sample;
• identify additional improper UIP payments for services provided to insured individuals
or services unrelated to COVID-19, which we estimate to be $783.6 million, and take
remedial action; and
• commit to strengthening its procedures that may apply to future programs of a similar
nature to:
o expand insurance verifications using additional data fields on each patient for
whom an SSN is not submitted as part of a prepayment check or postpayment
review process to identify potential exact matches for health insurance
coverage,
o ensure data sources used to verify health insurance coverage are reliable, and
o develop in a timely manner an assessment strategy to ensure claims are
appropriately reimbursed to providers.
HRSA COMMENTS AND OFFICE OF INSPECTOR GENERAL RESPONSE
In written comments on our draft report, HRSA partially concurred with our first
recommendation and concurred with our second and third recommendations. In addition,
HRSA provided information on actions that it has taken or plans to take to address our
recommendations. HRSA also provided technical comments on our draft report, which we
addressed as appropriate. HRSA’s comments, excluding the technical comments, are included
as Appendix D.
35 HRSA stated that the UIP was designed as an administrative program and that no medical review was conducted
prior to making UIP payments.
36 Additionally, beginning in Mar. 2021, HRSA developed an interim standard operating procedure to flag providers
with abnormal billing patterns and conducted reviews of these providers.
Health Resources and Services Administration’s COVID-19 Uninsured Program (A-02-21-01013)
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Regarding our first recommendation, HRSA concurred with our determinations related to
improper UIP payments to providers for testing and treatment services that were not provided
or related to COVID-19 and stated that it is seeking repayment from those providers (i.e., for 22
sampled patients). However, for our determinations related to UIP payments to providers on
behalf of individuals who had health insurance coverage (i.e., on behalf of 38 sampled patients),
HRSA stated that it will analyze the claims associated with these payments and take appropriate
action based on the results of that analysis, including seeking repayment.37 HRSA stated that it
will review as part of its analysis whether providers complied with UIP terms and conditions,
which included certifying that, to the best of the providers’ knowledge, patients were uninsured
at the time of services.
HRSA concurred with our second recommendation and stated that HRSA has already taken
action to address the issue. Specifically, HRSA stated that as part of its UIP assessment strategy,
which was implemented in March 2022, HRSA obtained providers’ policies and procedures
detailing how providers determined patient health insurance coverage status and reviewed
patient intake forms. HRSA also stated that it selected a sample of claims from providers and
reviewed associated medical documentation to determine whether testing and treatment of
COVID-19 were medically necessary. HRSA stated that it will take remedial action, including
seeking repayment if HRSA determines a provider submitted any claims for individuals
identified to have health insurance coverage or that services were not medically necessary.
Finally, HRSA concurred with our third recommendation and indicated that if charged with
implementing another claims reimbursement program in the future, HRSA would work with
Congress, HHS, and other agencies to implement additional tools that would be suitable, based
on the circumstances.
We commend HRSA for its actions and acknowledge that the UIP was administratively designed
to be responsive to the pandemic and expeditiously reimburse providers. Regarding HRSA’s
comments on our first recommendation, we note that payments per the UIP terms and
conditions were for testing or treatment of COVID-19 for individuals who did not have any
health insurance coverage at the time the services were provided. Therefore, we maintain that
our findings and associated recommendation are valid because we determined that improper
UIP payments were made to providers on behalf of individuals who had health insurance
coverage at the time of services. Nevertheless, we believe it is an appropriate step for HRSA in
its role as the Federal agency administering the UIP to conduct its own analysis of these UIP
payments and to take appropriate action.
37 The count of sampled patients with improper payments does not equal 58 (the total number of sampled patients
with improper payments) because 2 sampled patients had health insurance coverage and services reimbursed by
the UIP that were not related to COVID-19.
Health Resources and Services Administration’s COVID-19 Uninsured Program (A-02-21-01013)
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APPENDIX A: AUDIT SCOPE AND METHODOLOGY
SCOPE
Our audit covered claims for 19,191,091 patient IDs with provider payments totaling
$4,183,094,053 with service dates from March 1 through December 31, 2020 (audit period).
We reviewed a stratified random sample of 300 patients with provider payments totaling
$2,838,023.
We assessed the design of HRSA’s internal controls applicable to the administration of UIP
payments to providers for claims for COVID-19 items and services furnished to uninsured
individuals. However, we limited our assessments of the implementation and operating
effectiveness of HRSA’s internal controls to the review of our sampled patients. Our
assessments included reviewing the results of the HRSA contractor’s health insurance
verification checks (when applicable) and providers’ medical and billing documentation to
support UIP claims.
We conducted our audit from June 2021 through February 2023.
METHODOLOGY
To accomplish our objective, we:
• reviewed applicable Federal laws, regulations, and other requirements (e.g.,
HRSA UIP FAQs) related to the administration of the UIP;
• met with officials from HRSA and HRSA’s contractor to develop an understanding of
their processes for administering UIP payments;
• obtained from HRSA data on all UIP payments with service dates during our audit
period;
• created a sampling frame of 19,191,091 patient IDs with UIP claim payment amounts
totaling $4,183,094,053;
• selected a stratified random sample of 300 patients for whom UIP payments were made
to providers,38 and for each sampled patient we obtained and reviewed:
o providers’ medical documentation supporting UIP payments made for claims for
COVID-19 services;
38 We considered any adjustments made to UIP payment amounts for our selected sample as of the July 3, 2021,
update of the uninsured paid claims file provided by HRSA.
Health Resources and Services Administration’s COVID-19 Uninsured Program (A-02-21-01013)
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o providers’ billing documentation to determine whether providers engaged in
balance billing or charged any type of cost-sharing for UIP services; and
o any Medicare and Medicaid health insurance coverage status information in
CMS’s IDR;
• used the results of the sample to estimate the total number of patient IDs with
associated improper UIP payments and the total dollar value of improper UIP payments
in the sampling frame; and
• discussed the results of our audit with HRSA officials.
We conducted this performance audit in accordance with generally accepted government
auditing standards. Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions
based on our audit objectives. We believe that the evidence obtained provides a reasonable
basis for our findings and conclusions based on our audit objectives.
Health Resources and Services Administration’s COVID-19 Uninsured Program (A-02-21-01013)
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APPENDIX B: STATISTICAL SAMPLING METHODOLOGY
SAMPLING FRAME
Our sampling frame contained 19,191,091 patient IDs with HRSA UIP claim payments greater
than $0, totaling $4,183,094,053, for services provided during the period from March 1, 2020,
through December 31, 2020.39
SAMPLE UNIT
The sample unit was a patient ID.40
SAMPLE DESIGN AND SAMPLE SIZE
We used a stratified random sample. We divided the sampling frame into six strata based on
whether an SSN or State ID was submitted by the provider for the patient ID and then by the
total payment amount for all associated claims:
Stratum
SSN or
State ID
Submission
Status
Dollar Range of Total
Payments
Number of
Patient IDs
in Frame
Frame Payments
Amount
Sample
Size
1
SSN or
State ID
> $0 and ≤ $589.32
4,897,374
$625,298,100
30
2
SSN or
State ID
> $589.32 and ≤ $15,431.26
315,133
625,305,426
40
3
SSN or
State ID
> $15,431.26
18,920
625,288,287
30
4
No SSN or
State ID
> $0 and ≤ $100
11,359,040
937,796,103
65
5
No SSN or
State ID
> $100 and ≤ $5,909.70
2,565,954
600,615,399
65
6
No SSN or
State ID
> $5,909.70
34,670
768,790,739
70
Totals
19,191,091
$4,183,094,05341
300
39 We used the Mar. 30, 2021, update of the UIP paid claims file provided by HRSA.
40 Throughout the report, we refer to “patient ID” as a patient who received UIP services.
41 The individual stratum values do not add to the total value because of rounding.
Health Resources and Services Administration’s COVID-19 Uninsured Program (A-02-21-01013)
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SOURCE OF RANDOM NUMBERS
We generated the random numbers with the OIG, Office of Audit Services (OAS) statistical
software.
METHOD FOR SELECTING SAMPLE UNITS
We sorted the items in each stratum by patient ID and then consecutively numbered the items
in each stratum in the sampling frame. After generating 300 random numbers, we selected the
corresponding frame items.
ESTIMATION METHODOLOGY
We used the OIG-OAS statistical software to calculate the point estimate and 90-percent
confidence interval for the total number of patient IDs with associated improper UIP claim
payments in the sampling frame. We also used this software to calculate the point estimate
and 90-percent confidence interval for the total dollar value of improper UIP claim payments in
the sampling frame. Note that in the latter case, we calculated the 90-percent confidence
interval using the empirical likelihood option.
Health Resources and Services Administration’s COVID-19 Uninsured Program (A-02-21-01013)
19
APPENDIX C: SAMPLE RESULTS AND ESTIMATES
Sample Detail and Results
Stratum
Number
Number of
Patient IDs
in Frame
Sample
Size
Value of
Sample
Number of Patient
IDs With Associated
Improper UIP
Payments
Value of
Improper UIP
Payments
1
4,897,374
30
$4,490
4
$623
2
315,133
40
71,691
12
14,262
3
18,920
30
1,401,570
2
45,151
4
11,359,040
65
5,663
14
1,039
5
2,565,954
65
16,910
12
6,266
6
34,670
70
1,337,699
14
226,952
Totals
19,191,091
300
$2,838,023
58
$294,29442
Estimated Number of Patient IDs With Associated Improper UIP Payments and Estimated
Value of Improper UIP Payments in the Sampling Frame
(Limits Calculated at the 90-Percent Confidence Level)
Total Number of
Patient IDs With
Associated
Improper UIP
Payments
Total Value of
Improper UIP
Payments
Point Estimate
3,675,995
$783,933,831
Lower Limit
2,569,786
539,801,945
Upper Limit
4,782,205
$1,284,370,802
42 The individual stratum values do not add to the total value because of rounding.
OF HEALTH & HUMAN SERVICES
TO:
Juliet T. Hodgkins
Principal Deputy Inspector General
FROM:
Carole Johnson L-j;, ,;/. /iL. ~
Administrator r/,,_,__ .
~
DATE:
April 13, 2023
llealth Resources and Services
Administration
Rockville, .MD 20857
SUBJECT:
Office of Inspector General Draft Report: HRSA Made COVJTJ-19 Uninsured
Program Payments to Providers on Beha(f of individuals Who Had Health
Jmw·ance Coverage and for Services Unrelated to COVJD-19 (A-02-21-01013)
Attached is the Health Resources and Services Administration' s response to the Office of
Inspector General draft report A-02-21-01013. If you have any questions, please contact Sandy
Seaton in HRSA' s Office of Federal Assistance Management at (301) 443-2432.
APPENDIX D: HRSA COMMENTS
Health Resources and Services Administration’s COVID-19 Uninsured Program (A-02-21-01013)
20
Resources and Services Administration's Comments on the OIG Draft Report
"HRSA Made COVID-19 Uninsured Program Payments to Providers on Behalf of
Individuals Who Had Health Insurance Coverage and for Services Unrelated to
COVID-19" (A-02-21-01013)
General Comments
The Health Resources and Services Administration (HRSA) appreciates the opportunity to
review the Office of Inspector General's (OIG) audit of claims reimbursed in 2020 by the
COVID-19 Uninsured Program (UIP).
As the OIG notes, in 2020, then-President Trump declared the COVID-19 outbreak a national
emergency and Congress passed both the Families First Coronavirus Response Act
and the Paycheck Protection Program and Health Care Enhancement Act directing resources to
reimburse eligible hospitals and other health care providers for conducting COVID-19 testing
and testing-related items and services for the uninsured. Subsequently, these efforts included
treatment and vaccine administration. The OIG further notes that "(T)he national emergency
posed unprecedented challenges to HHS to distribute funds to providers for COVID-19 testing
and treatment services for uninsured individuals in a fast, fair, and transparent manner and to
provide immediate financial relief to providers on the frontlines of the COVID-19 response." In
addition, "approximately 1 month after the national emergency declaration, HRSA established an
online UIP portal, which allowed providers to enroll in the UIP and submit claims for
reimbursement ofCOVID-19 testing and treatment of uninsured individuals."
The UIP played an important role in the federal government's response to the COVID-19
pandemic. The aim of the UIP was to reduce community spread ofCOVID-19 and ensure access
to COVID testing and treatment, and later vaccines. The program reimbursed providers for
delivering these services and eliminated financial barriers for uninsured individuals to get tested,
treated, and vaccinated. Optimizing COVID-19 testing and vaccination rates, particularly among
higher risk groups, was critical to curbing the spread of the pandemic and its negative impacts
across the entire population.
The OIG report reviewed UIP claims for COVID-19 services between March 1, 2020 and
December 31, 2020. In conducting its review, OIG notes their understanding that the operational
objective at the beginning of the national emergency was to rapidly disburse funds for COVID-
19 response to ensure uninsured individuals were receiving vital health care services and to
prevent the spread ofCOVID-19. The UIP was administratively designed to be most responsive
to the pandemic's unprecedented impact and scale while expeditiously reimbursing providers
serving uninsured patients. The UIP required providers to attest that they checked for health care
coverage eligibility and confirmed that the patient was uninsured. Additionally, providers
attested to the programs' terms and conditions which stipulated the medical necessity
requirement. At the start of the program in April 2020, HHS officials made the policy decision
to conduct any medical review post-payment and to pay claims that did not include a Social
Security Number provided that providers had certified uninsured status per program
requirements. In addition to the recommendations outlined below, the OIG found that providers
had effective processes to ensure that they did not engage in balance billing or charge any type of
cost-sharing for program services for which they received reimbursement.
Health Resources and Services Administration’s COVID-19 Uninsured Program (A-02-21-01013)
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Resources and Services Administration's Comments on the OIG Draft Report
"HRSA Made COVID-19 Uninsured Program Payments to Providers on Behalf of
Individuals Who Had Health Insurance Coverage and for Services Unrelated to
COVID-19" (A-02-21-01013)
HRSA continues to use post-payment controls to identify claims processing errors, potential
misuse of funds, or other instances where further reviews or actions are needed.
HRS A's response to the OIG draft recommendations are as follows:
OIG Recommendation
OIG recommends that HRSA recover the $294,294 in improper UIP payments identified in our
sample.
HRSA Response
HRSA partially concurs with OIG's recommendation.
OIG recommends recovery of $294,294 in UIP payments for 58 of 300 sampled patients. Of the
sampled patients, OIG identified UIP payments for 22 patients as ineligible claims unrelated to
COVID-19. HRSA concurs and is seeking repayment from the providers. OIG also identified 38
UIP payments during its review that the OIG deemed to have been made on behalf of individuals
who had health insurance. In accordance with the program's standard post-payment oversight
processes, HRSA will analyze the claims associated with these payments. This includes
reviewing whether the providers complied with the UIP Terms and Conditions, including
certifying that to the best of their knowledge the patient identified on the claim was an uninsured
individual at the time of service. Based on the results of that analysis, HRSA will take
appropriate action including seeking repayment.
OIG Recommendation
OIG recommends that HRSA identify additional improper UIP payments for services provided to
insured individuals or services unrelated to COVID-19, which we estimate to be $783.6 million,
and take remedial action.
HRSA Response
HRSA concurs with OIG's recommendation and has already taken action to address this
recommendation. HRSA implemented a UIP Assessment Strategy in March 2022 to review
payments to providers and determine whether the sampled providers were properly reimbursed
for submitted claims in accordance with the authorizing statute and UIP Terms and Conditions.
As part of the assessment, HRSA obtains the provider's policies and procedures regarding
identification of insurance coverage, and reviews patient intake forms. HRSA also reviews
medical documentation from a sample of claims to verify that submitted claims were medically
necessary to provide for testing and treatment ofCOVID-19. In addition, it verifies submitted
claims were medically necessary for prevention ofCOVID-19 (e.g., vaccinations). IfHRSA
determines a provider submitted claims for insured individuals or services that were not
Health Resources and Services Administration’s COVID-19 Uninsured Program (A-02-21-01013)
22
Resources and Services Administration's Comments on the OIG Draft Report
"HRSA Made COVID-19 Uninsured Program Payments to Providers on Behalf of
Individuals Who Had Health Insurance Coverage and for Services Unrelated to
COVID-19" (A-02-21-01013)
medically necessary in accordance with authorizing statute and UIP Terms and Conditions, the
agency will take remedial action including seeking repayment.
OIG Recommendation
OIG recommends that HRSA commit to strengthening its procedures that may apply to future
programs of a similar nature to:
•
expand insurance verifications using additional data field on each patient for whom an
SSN is not submitted as part of a prepayment check or post-payment review process to
identify potential exact matches for health insurance coverage,
•
ensure data sources used to verify health insurance coverage are reliable, and
•
develop in a timely manner an assessment strategy to ensure claims are appropriately
reimbursed to providers.
HRSA Response
HRSA concurs with OIG's recommendation. If the agency were to be charged with
implementing other claims reimbursement programs in the future, HRSA would work with the
Congress, the Department and other Agencies on additional implementation tools appropriate for
the circumstances, such as an unprecedented public health emergency that required urgent
response.
Health Resources and Services Administration’s COVID-19 Uninsured Program (A-02-21-01013)
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- Original
- oig.hhs.gov