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HRSA audit preparation: All you need to know

11.03.22

Read this if you think your organization may have to prepare an HRSA audit.

Many healthcare providers who have never done an audit before may be required by the Health Resources and Services Administration (HRSA) agency to do so this year because they received Provider Relief Funding (PRF). We’re helping you prepare by answering some common queries about the PRF audit:

Will my organization have to complete a PRF audit?

The HRSA requires organizations to complete a federal single audit when they expend more than $750,000 of federal funding in one year, regardless of whether those federally sourced funds came directly from the federal government or were passed from a state or local government. Healthcare providers who received $10,000 or more from the PRF during a given period must report on usage.

For many providers, this is the first time they’ve received over $750,000 in federal funding. As a result, these providers will need to complete the single audit for the first time.

Other providers, especially physician practices, may not meet the single audit expense threshold, but that doesn’t mean they’re free from audit obligations. While they may not have to complete a single audit, if they received funding from the PRF, they may need to complete a HRSA-required audit—and the data requests for these audits are, in some cases, more involved than those for the single audit.

What will the HRSA’s PRF audit look like?

The audit will address the data used by the providers to report on their usage of PRF money. That means they will need to provide support for lost revenue and expenses that justify the use of the funds that they received.

The HRSA is going to drill down on the revenue numbers, specifically looking at the general ledger (GL) and other select revenue tests. On the expenses side, they’re going to look at the GL, invoice dates, payments and more.

To complete this audit, HRSA will require a significant amount of supporting documentation. Ideally, most of these documents should already have been copied and set aside as support in anticipation of financial reporting requirements. Below is a partial list of items that could be requested during the audit:

  • General Ledger details
  • Listing of expenses reimbursed with PRF payments grouped into specified categories
  • Listing of patient care revenue by payer
  • Listing of other sources of assistance
  • Listing of expenses reimbursed with the other assistance received
  • Detailed inventory listing of IT supplies
  • Budget attestation from CEO or CFO and board minutes showing ratification of the budget before March 27, 2020
  • Documentation of lost revenue methodologies
  • Audit financial statements
  • CMS cost reports for Medicare and Medicaid
  • Other supporting documentation

If certain documentation isn’t available, providers will need to request copies from their vendors. Missing documentation may make it difficult to justify the use of funds, in which case, providers may have to repay a portion or all of their provider relief funding.

It’s possible that certain expenses were not allowable under PRF. However, that doesn’t necessarily mean providers will have to repay their funds. Providers may have other lost revenue or expenses that would be allowed under PRF—but only if they have the documentation to prove it. That’s why it’s crucial that providers have all relevant documentation for expenses and lost revenue over the periods they received provider relief funding.

What challenges should I anticipate when it comes to completing the audit?

According to the 2022 BDO Healthcare CFO Outlook Survey, 35% of respondents identified CARES Act/PRF reporting as a regulatory concern.

Much of this concern likely stems from a lack of resources as well as audit inexperience. Many providers who will have to complete an HRSA audit don’t have the necessary resources to dedicate to navigating the process. In addition, they may not know the type, scope, or time frame of documentation they need to pull. They may also struggle to locate certain documentation, especially documentation that’s more than two years old.

Finding the right people to sift through the information to ensure its accuracy can be extremely difficult, especially if the documents are not filed electronically. This problem is even greater right now, given the professional services labor shortage that makes it difficult to hire the right people for the job if they aren’t already employed at your organization.

What should my next steps be?

To get ready for a potential HRSA audit, there are at least three immediate steps you should take:

  1. Select a responsible point person. One person should be responsible for coordinating the process to ensure that nothing falls through the cracks or is overlooked.
  2. Keep your PRF filing reports on hand. Pull any related supporting documentation and collate it into one place if it isn’t already.
  3. Identify what support is needed by doing a gap analysis. Determine where you need additional support or expertise and seek to close these gaps before the notification of any audit process.

Insufficient documentation may result in the recapture of provider relief funding by the HRSA. Fortunately, a lack of documentation is preventable with the right support and resources in place.

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Read this if your facility or organization has received provider relief funds.

The rules over the use of the provider relief funds (PRF) have been in a constant state of flux since the funds started to show up in your bank accounts back in April. Here is a summary of where we are as of November 30, 2020 with allowable uses of the funds.
 
The most recent Post-Payment Notice of Reporting Requirements is dated November 2, 2020. In accordance with the notice, PRF may be used for two purposes:

  1. Healthcare-related expenses attributable to coronavirus that another source has not reimbursed and is not obligated to reimburse
  2. Lost revenue, up to the amount of the difference between 2019 and 2020 actual patient care revenue

The Department of Health and Human Services (HHS) has issued FAQs as recently as November 18, 2020.  The FAQs include the following clarifications on the allowable uses:

Healthcare related expenses attributable to the coronavirus

  1. PRF may be used for the marginal increased expenses or incremental expenses related to coronavirus.
  2. Expenses cannot be reimbursed by another source or another source cannot be obligated to reimburse the expense.
  3. Other sources include, but are not limited to, direct patient billing, commercial insurance, Medicare/Medicaid/Children’s Health Insurance Program (CHIP), or other funds received from the Federal Emergency Management Agency (FEMA), the Provider Relief Fund COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured, and the Small Business Administration (SBA) and Department of Treasury’s Paycheck Protection Program (PPP). This would also include any state and federal grants received as a result of the coronavirus.
  4. Providers should apply reasonable assumptions when estimating the portion of costs that are reimbursed from other sources.
  5. The examples in the FAQs for increased cost of an office visit and patient billing seem to point to only supplemental coronavirus related reimbursement needing to be offset against the increased expense.
  6. PRF may be used for the full cost of equipment or facility projects if the purchase was directly related to preventing, preparing for and responding to the coronavirus; however, if you claim the full cost, you cannot also claim the depreciation for any items capitalized.
  7. PRF cannot be used to pay salaries at a rate in excess of Executive Level II which is currently set at $197,300.

Lost revenues attributable to the coronavirus

  1. Lost revenues attributable to coronavirus are calculated based upon a calendar year comparison of 2019 to 2020 actual revenue/net charges from patient care (prior to netting with expenses).
  2. Any unexpended PRF at 12/31/20 is then eligible for use through June 30, 2021 and calculated lost revenues in 2021 are compared to January to June 2019.
  3. Reported patient care revenue is net of uncollectible patient service revenue recognized as bad debts and includes 340B contract pharmacy revenue.
  4. This comparison is cumulative, for example, if your net income improves in Q4, it will reduce lost revenues from Q2.
  5. Retroactive cost report settlements or other payments received that are not related to care provided in 2019 or 2020 can be excluded from the calculation.

Whether you are tracking expenses or lost revenues, the accounting treatment for both is to be consistent with your normal basis of accounting (cash or accrual).
 
As a reminder, the first reporting period (through December 31, 2020) is due February 15, 2021. The reporting portal is supposed to open January 15, 2021. Any unexpended PRF at December 31, 2020 can be used from January 1, 2021 through June 30, 2021, with final reporting due July 31, 2021.

The guidance continues to change rapidly and new FAQs are issued each week. Please check back here for any updates, or contact Mary Dowes for more information.

Article
Provider relief funds: Allowable usesĀ 

Read this if you are an administrator, manager, or director at a Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC).

The following outlines key due dates related to various CARES Act funding streams that you may have received. Updated as of April 27, 2020.

1. Round two of the Paycheck Protection Program (PPP) was just signed last week. If you have not applied and plan to do so, please do so ASAP as the funds are likely to be exhausted quickly.
2. Your 12-month budget for the CARES Act funding is due on May 8, 2020. As you prepare your budget, please consider the following:
a. If you were lucky enough to get approved for PPP loans, use these funds first to pay for salaries and wages as they are for eight weeks only.
b. We encourage including federal grant expenses in all budget categories to enable you to take advantage of the flexibility HRSA has provided you by allowing reclassifications between budget categories up to the lesser of 25% of the federal award or $250,000 without asking for prior approval. If you wish to reclassify amounts to a budget category which didn’t previously have federal funds budgeted, you will have to submit a budget revision to HRSA for approval. This guidance applies to your base 330 grant as well. 
c. Remember, if an employee is paid more than $197,300 (Executive II salary level as of January 1, 2020), you can only charge $197,300 to any HRSA grant. This salary limitation does not apply to consultants or contracted employees.
d. Use of these funds is very likely to undergo audits, similar to the ARRA funding a number of years ago, therefore make sure you properly track how you use these funds (audit trail).
e. Have your personnel policies been modified for consistency with any new practices you’ve implemented as a result of the public health emergency (for example, hazard pay, family and sick leave and remote working)?

Click here for a list of HRSA’s examples of the allowable uses of the CARES Act funding.    
 
3. The initial distribution you received on April 20, 2020 from the CARES Act Provider Relief Fund has an attestation due on May 10, 2020. There are various provisions governing the use of the funds and we suggest you consider the ability to use these funds to offset lost earnings so you do not have to complete with the other funding programs you have received.

Article
CARES Act funding deadlines: Update for FQHCs and RHCs

Read this if you are an administrator, manager, or director at a Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC).

CMS just released an article outlining new and expanded flexibilities for RHCs and FQHCs during the COVID-19 public health emergency (PHE). The article includes the following information:

  • Payment rate for telehealth services
  • How to bill for telehealth services
  • Expanded virtual communications services

Payment for telehealth health services during the PHE (from January 27, 2020 through the end of the PHE) is $92. Billing for telehealth is segmented into two periods:

  1. January 27, 2020 – June 30, 2020, bill using the 95 modifier
  2. July 1, 2020 – end of PHE, bill using code G2025

The article further outlines that for telehealth services billed through June 30, they will be paid at the PPS rate. The claims will then be automatically reprocessed in July and a recoupment will occur for the difference between the $92 and your PPS rate. 

It will be important for you to keep track of the telehealth visits paid at your PPS rate and what the recoupment by Medicare will be so that when it occurs you will not be caught unawares.

Virtual communication services have been expanded to include digital evaluation and management services. Online digital evaluation and management services are non-face-to-face, patient initiated, digital communications using a secure patient portal. 

Additionally, the payment rate for these services will be $24.76 beginning March 1, 2020 through the end of the PHE instead of the CY 2020 rate of $13.53, and should bill using code G0071. 

Consider how the medical records component of your system interfaces with the billing component to ensure you capture these services for billing.

The full article can be accessed here: MLN Matters Special Edition Article 20016.
 

Article
CMS expands flexibility for RHCs and FQHCs

Read this if you are a director, manager, or administrator at a Federally Qualified Health Centers (FQHC) or Rural Health Clinic (RHC).

The latest COVID-19 bill, the Coronavirus Aid, Relief, and Economic Security (CARES) Act included enhancing Medicare telehealth services for FQHCs and RHCs. This legislation waives the Section 1834(m) restriction on FQHCs and RHCs that prohibits them from serving as distant sites. This means during the COVID-19 State of Emergency, FQHCs and RHCs will be able to serve as distant sites to provide telehealth services to patients in their homes and other eligible locations. The legislation will reimburse FQHCs and RHCs at a rate that is similar to payment for comparable telehealth services under the physician fee schedule (Medicare Part B). FQHCs and RHCs will not be paid the Medicare PPS rate for these services.

Currently, Medicare, unlike many Medicaid programs and commercial payers, still requires the video component for telehealth. Effective immediately, the Office for Civil Rights at the Department of Health and Human Services will exercise its enforcement discretion and will not impose penalties for noncompliance with the regulatory requirements under the HIPAA Rules against covered health care providers in connection with the good faith provision of telehealth during the COVID-19 State of Emergency. Providers who want to use audio or video communication technology to provide telehealth during the COVID-19 State of Emergency can use any non-public facing remote communication product that is available to communicate with patients. Examples of acceptable platforms (non-public facing) include Apple FaceTime, Google G Suite Hangouts Meet, and Skype for Business.

We would also like to remind you of the ability to bill for virtual communication services. Virtual communication services are a brief, non-face-to-face check-in with a patient via communication technology, to assess whether the patient's condition necessitates an office visit. The call must be initiated by the patient and to be billable, the call must be between the patient and a physician, nurse practitioner, physician assistant, certified nurse midwife, clinical psychologist, or clinical social worker. If the discussion is conducted by a nurse, health educator, or other clinical personnel, it is not billable as a virtual communication service. There is no video component required for virtual communication services. The check-in cannot relate to a visit with the patient during the previous seven days or result in a visit with the patient within the next 24 hours (or next available appointment). Read the FAQs from Medicare on the virtual communication services.

We continue to be here to support you. If you have any questions or concerns, please do not hesitate to reach out to any of us. 

Article
The CARES Act and telehealth services for FQHCs

The Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020, which provides $8.3 billion in emergency funding for federal agencies to respond to the COVID-19 outbreak, has earmarked $100 million for FQHCs to prevent, prepare for, and respond to the COVID-19 national emergency. Pre-award costs will be supported by this funding and may date back to January 20, 2020. We recommend tracking your expenditures related to the coronavirus to the best of your ability. This may be helpful or necessary in providing your organization much needed financial relief.  

As a reminder, FQHCs cannot bill Medicare for telehealth services under the PPS rate. Telehealth can be billed to Medicare under Part B with the FQHC as an originating site and reimbursement is approximately $26. If you do not have home visits on Form 5, be sure to add home visits to 5C as soon as possible.

Amidst rapid hourly changes in contending with the coronavirus and its far-reaching impacts, we are sharing some HRSA and CMS guidance that may be helpful to you: 

Here is a link to HRSA FAQs related to COVID-19

Although we are working remotely, we are available to support you. If you have any questions or concerns, please do not hesitate to reach out to any of us.

Article
COVID-19 emergency funding for FQHCs: What you need to know

Read this if your company is a benefit plan sponsor.

While plan sponsors have been able to amend their 401(k) plans to include a post-tax deferral contribution called Roth for more than a decade, only 86% of plan sponsors have made it available to participants, according to the Plan Sponsor Council of America. Meanwhile, despite the potential benefits of such plans, just a quarter of participants who have access to the Roth 401(k) option use it. Plan sponsors may want to consider adding a Roth 401(k) option to their lineup because of the potential tax benefits and other advantages for plan participants.

A well-designed Roth 401(k) may be an attractive option for many plan participants, and it is important for plan sponsors considering such a feature to design the plan with the needs of their workforce in mind. It is also critical to clearly communicate the differences from the pre-tax option, specific timing rules required, and the tax-free growth it offers. Additionally, plan sponsors should be mindful of potential administrative costs and other compliance requirements in connection with allowing the Roth option.

Roth 401(k)s: The basics

A Roth is a separate contribution source within a 401(k) or 403(b) plan that differs from traditional retirement accounts because it allows participants to contribute post-tax dollars. Since participants pay taxes on these contributions before they are invested in the account, plan participants may make qualified withdrawals of Roth monies on a tax-free basis, and their accounts grow tax-free as well.

Participants of any income level may participate in a Roth 401(k) and may contribute a maximum of $20,500 in 2022—the same limit as a pre-tax 401(k). Contributions and earnings in a Roth 401(k) may be withdrawn without paying taxes and penalties if participants are at least 59½ and it’s been at least five years since the first Roth contribution was made to the plan. Participants may make catch-up contributions after age 50, and they may split their contributions between Roth and pre-tax. Similar to pre-tax 401(k) accounts, Roth 401(k) assets are considered when determining minimum distributions required at age 72, or 70 ½ if they reached that age by Jan. 1, 2020.

Only employee elective deferrals may be contributed post-tax into Roth 401(k) accounts. Employer contributions made by the plan sponsor, such as matching and profit sharing, are always pre-tax contributions. If the plan allows, participants may convert pre-tax 401(k) assets into a Roth account, but it is critical to remember that doing so triggers taxable income and participants must be prepared to pay any required tax. In addition, plan sponsors must be careful to offer Roth 401(k)s equally to all participants rather than just a select group of employees.

Qualified distributions from a designated Roth account are excluded from gross income. A qualified distribution is one that occurs at least five years after the year of the employee’s first designated Roth contribution (counting the first year as part of the five) and is made on or after age 59½, on account of the employee’s disability, or on or after the employee’s death. Non-qualified distributions will be subject to tax on the earnings portion only, and the 10% penalty on early withdrawals may apply to the part of the distribution that is included in gross income. Participants may take out loans if permitted in the plan document. 

First steps for plan sponsors

A common misconception among plan sponsors is that a Roth offering requires a completely different investment vehicle. The feature is simply an added contribution option; therefore, no separate product is needed.

When considering the addition of a Roth 401(k) option, it is important for plan sponsors to check with service providers to determine whether payroll may be set up properly to add a separate deduction for the participant. Plan sponsors may also need to consider guidelines for conversions, withdrawals, loans, and other features associated with the Roth contribution source to ensure the plan document is prepared and followed accurately.

Education is an important component of any new plan feature or offering. Plan sponsors should check with service providers to see how they may help to explain the feature and optimize its rollout for the plan. One-on-one meetings with participants may be very helpful in educating them about a Roth account.

A word about conversions

If permitted by the plan document, participants may convert pre-tax 401(k) plan assets (deferrals and employer contributions) to the Roth source within their plan account. The plan document may allow for entire account conversions or just a stated portion. When assets are converted, participants must pay income taxes on the converted amount, and the additional 10% early withdrawal tax won’t apply to the rollover. Plan sponsors should educate participants on the benefits of converting to the Roth inside the company 401(k).

Collaborate with the right service providers to educate your participants

The right service providers may review your current plan design, set up accounts properly, actively engage and educate your participants, and offer financial planning based on individual circumstances to show how design features like a Roth account may benefit their situation. If you would like to start the conversation about adding a Roth option or enhancing your participant education program, contact our employee benefits team. We are here to help. 

Article
Plan sponsor alert: Roth 401(k) remains underutilized despite potential benefits

Read this if you are a Maine business or pay taxes in Maine.

Maine Revenue Services has created the new Maine Tax Portal, which makes paying, filing, and managing your state taxes faster, more efficient, convenient, and accessible. The portal replaces a number of outdated services and can be used for a number of tax filings, including:

  • Corporate income tax
  • Estate tax
  • Healthcare provider tax
  • Insurance premium tax
  • Withholding
  • Sales and use tax
  • Service provider tax
  • Pass-through entity withholding
  • BETR

The Maine Tax Portal is being rolled out in four phases, with two of the four phases already completed. Most tax filings for both businesses and individuals are now available. A complete listing can be found on maine.gov. Instructional videos and FAQs can also be found on this site.

In an effort to educate businesses and individuals on the use of the new portal, Maine Revenue Services has been hosting various training sessions. The upcoming schedule can be found on maine.gov

Article
New Maine Tax Portal: What you need to know