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The CARES Act and telehealth services for FQHCs

03.31.20

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. 

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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.

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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.

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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.
 

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CMS expands flexibility for RHCs and 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.

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

Read this if you use QuickBooks Online.

You should be running reports in QuickBooks Online on a weekly—if not daily—basis. Here’s what you need to know.

You can do a lot of your accounting work in QuickBooks Online by generating reports. You can maintain your customer and vendor profiles. Create and send transactions like invoices and sales receipts, and record payments. Enter and pay bills. Create time records and coordinate projects. Track your mileage and, if you have employees, process payroll.

These activities help you document your daily financial workflow. But if you’re not using QuickBooks Online’s reports, you can’t know how individual elements of your business like sales and purchases are doing. And you don’t know how all of those individual pieces fit together to create a comprehensive picture of how your business is performing. 

QuickBooks Online’s reports are plentiful. They’re customizable. They’re easy to create. And they’re critical to your understanding of your company’s financial state. They answer the small questions, like, How many widgets do I need to order?, and the larger, all-encompassing questions like, Will my business make a profit this year?

Getting the lay of the land

Let’s look at how reports are organized in QuickBooks Online. Click Reports in the toolbar. You’ll see they are divided into three areas that you can access by clicking the labeled tabs. Standard refers to the comprehensive list of reports that QuickBooks Online offers, displayed in related groups. Custom reports are reports that you’ve customized and saved so you can use the same format later. And Management reports are very flexible, specialized reports that can be used by company owners and managers.


A partial view of the list of QuickBooks Online’s Standard reports 

Standard reports

The Standard Reports area is where you’ll do most—if not all—of your reporting work. The list of available reports is divided into 10 categories. You’re most likely to spend most of your time in just a few of them, including:

  • Favorites. You’ll be able to designate reports that you run often as Favorites and access them here, at the top of the list.
  • Who owes you. These are your receivables reports. You’ll come here when you need to know, for example, who is behind on making payments to you, how much individual customers owe you, and what billable charges and time haven’t been billed.
  • Sales and customers. What’s selling and what’s not? What have individual customers been buying? Which customers have accumulated billable time?
  • What you owe. These are your payables reports. They tell you, for example, which bills you haven’t paid, the total amount of your unpaid bills (grouped by days past due), and your balances with individual vendors.
  • Expenses and vendors. What have I purchased (grouped by vendor, product, or class)? What expenses have individual vendors incurred? Do I have any open purchase orders?

The Business Overview contains advanced financial reports that we can run and analyze for you. The same goes for the For my accountant reports. Sales tax, Employees, and Payroll will be important to you if they’re applicable for your company.

Working with individual reports


Each individual report in QuickBooks Online has three related task options.

To open any report, you just click its title. If you want more information before you do that, just hover your cursor over the label. Click the question mark to see a brief description of the report. If you want to make the report a Favorite, click the star so it turns green. And clicking the three vertical dots opens the Customize link. 

When you click the Customize link, a vertical panel slides out from the right, and the actual report is behind it, grayed out. Customization options vary from report to report. Some are quite complex, and others offer fewer options. The Sales by Customer Detail report, for example, provides a number of ways for you to modify the content of your report so it represents exactly the “slice” of data you want. So you can indicate your preferences in areas like:

  • Report period
  • Accounting method (cash or accrual)
  • Rows/columns (you can select which columns should appear and in what order, and group them by Account, Customer, Day, etc.)
  • Filter (choose the data group you want represented from several options, including Transaction Type, Product/Service, Payment Method, and Sales Rep)

Once you’ve run the report, you can click Save customization in the upper right corner and complete the fields in the window that opens. Your modification options will then be available when you click Custom reports, so you can run it again anytime with fresh data.


You can customize QuickBooks Online’s reports in a variety of ways.

We’ll go into more depth about report customization in a future article. For now, we encourage you to explore QuickBooks Online’s reports and their modification options so that you’re familiar with them and can put them to use anytime. Contact our Outsourced Accounting team if you have any questions about the site’s reports, or if you need help making your use of QuickBooks Online more effective and productive.

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Getting started with reports in QuickBooks Online

Read this if you use QuickBooks Online.

Are you taking on a worker who’s not an employee? QuickBooks Online includes tools for tracking and paying independent contractors.

The COVID-19 pandemic created millions of self-employed individuals and small businesses. Whether they chose to, or circumstances forced them to, these new entrepreneurs had to learn new ways to get paid and to prepare their income taxes.

If you’re thinking about taking on a contract worker, you, too, will have to educate yourself on the paperwork and processes required to comply with the IRS’ rules for his or her compensation. It’s much easier than hiring a full-time employee, but it still takes some knowledge of how QuickBooks Online handles these individuals.

You’ll also need to make certain that the person you’re hiring is indeed an independent contractor and not an employee. The IRS takes this distinction very seriously. If you’re at all unsure of your new hire’s employment status, we can help you sort it out.

Creating records for contractors

Once new contractors have accepted your offer, you’ll need to have then fill out an IRS Form W-9. You can download a copy here. Employees complete the more detailed Form W-4 so that the employer can withhold income taxes correctly, but you won’t have to withhold taxes for your contract workers. They will be responsible for calculating and paying quarterly estimated taxes and filing an IRS Form 1040 every year. 

You, though, will be responsible for sending them an IRS Form 1099-NEC (Non-Employee Compensation) every January if you paid them more than $600 during the previous year. You do not need to send a 1099-NEC to a corporation or to an LLC that is treated as a C Corp or an S Corp. 

You can complete the Vendor Information window for each independent contractor, checking the box in front of Track payments for 1099.

Using the information the contractors provide, you can create records for them in QuickBooks Online. If you don’t have a QuickBooks Payroll subscription, you can set them up as 1099 vendors. Click the Expenses tab in the toolbar and then on the Vendors tab. Click New vendor in the upper right to open the Vendor Information window. Complete the fields for the worker and be sure to check the box in front of Track payments for 1099, as shown in the partial image above.

The vendor records you create will appear in QuickBooks Online’s Vendors list (again, Expenses | Vendors). Click on one to open it. You can toggle between two tabs here. The first, Transaction List, will eventually display all your financial dealings with that contractor. Vendor Details opens the record you just created, which you can edit from this screen.

Paying contractors

When independent contractors send you invoices, you’ll return to this same screen. There are three ways you can pay them. Click the down arrow next to New Transaction in the upper right corner to see your options (or look down at the end of the row while you’re in list view). You can record the debt as a Bill if you want to pay it later (or if that’s the way you structure your recordkeeping). If you’re paying it right away, you can create an Expense or write a Check

You can choose an option from this vendor action menu to pay your independent contractors.

When you click one of these, QuickBooks Online opens a form with many of the contractors’ details already filled in. You’ll need to complete any additional fields at the top of the screen, and then either record the payment or debt under Category details or Item details, depending on how you do your bookkeeping. Either way, you’ll be able to enter the quantity and rate and/or amount and mark it billable (with a markup percentage, if you’d like) to a customer or project.

You’re probably going to want our help here, since there’s more than one way to pay independent contractors. If you subscribe to QuickBooks Payroll, you can use the service’s contractor features, which include the ability to invite your contractors to fill out their own records in QuickBooks Online. You may also want to add an account to your Chart of Accounts, and we’d want to offer guidance there. And you need to ensure that you’re classifying payments correctly, so they’ll appear in 1099 reports and 1099s themselves.

Creating records for independent contractors and paying these individuals seem like they should be simple operations. But anytime you’re dealing with payroll issues, you’re dealing with peoples’ livelihoods – and the IRS. We strongly encourage you to let us help you get this right. Contact the Outsourced Accounting team, and we’ll make sure you’re handling your worker payments with absolute accuracy.

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Hiring an independent contractor? How QuickBooks Online can help

Read this if you are a not-for-profit organization.

With springtime upon us, it may be difficult to start thinking about this upcoming fall, but that is exactly what many folks in the nonprofit sector are starting to do. The reason for this? It’s because 2022 brings with it the mid-term election cycle. While technically an off-year election, many congressional and gubernatorial races are being contested, in addition to a myriad of questions that will appear on ballots across the country. It is around this time of year we start to see many questions from clients in the nonprofit sector in the area of political campaign activities, lobbying (both direct and grassroots), and education/advocacy.

This article will discuss the three major types of activities nonprofit organizations may or may not undertake in this arena and will offer guidance to give organizations the vote of confidence they need to not run afoul of the potential pitfalls when it comes to undertaking these activities.

Political campaign activity

Political campaign activities include participating or intervening in any political campaign on behalf of (or in opposition to) any candidate for elective public office, be it at the federal, state, or local level. Examples of such activities include contributions to political campaigns as well as making public statements in favor of or in opposition to any candidate. The IRS explicitly prohibits section 501(c)(3) organizations from conducting political campaign activities, the consequence of doing so being loss of exempt status. However, other types of exempt organizations (such as 501(c)(4) organizations) are allowed to engage in such activities, so long as those activities are not the organization’s primary activity. Only Section 527 organizations may engage in political campaign activities as their primary purpose. 

Direct lobbying

Direct lobbing activities attempt to influence legislation by directly communicating with legislative members regarding specific legislation. Examples of direct lobbying include contacting members of Congress and asking them to vote for or against a specific piece of legislation.

Grassroots lobbying

Grassroots lobbying, on the other hand, attempts to influence legislation by affecting the opinions of the general public and include a call to action. Examples of grassroots lobbying include requesting members of the general public to contact their representatives to urge them to vote for or against specific legislation.  

A quick way to remember the difference:
Political = think “P” for People – advocating for or against a specific candidate 
Lobbying = think “L” for Legislation – advocating for or against a specific bill

Education/advocacy

Organizations may engage in activities designed to educate or advocate for a particular cause so long as it does not take a specific position. For example, telling members of Congress how grants helped constituents would be considered an educational activity. However, attempting to get a member of Congress to vote for or against specific piece of legislation that would affect grant funding would be considered lobbying. Another example would be educating or informing the general public about a specific piece of legislation. Organizations need to be mindful here as taking a specific position one way or the other would lend itself to the activity being deemed to be lobbying, and not merely education of the general public. There is no limit on how much education/advocacy activity a nonprofit organization may conduct.

Why does this matter?

As you can see, there is a very fine line between lobbying and education, so it is important to understand the differences so that an organization conducting educational activities does not inadvertently end up conducting lobbying activities.

Organizations exempt under Code Section 501(c)(3) can conduct only lobbying activities that are not substantial to its overall activities. A 501(c)(3) organization may risk losing its exempt status and may face excise taxes on the lobbying expenditures if it is deemed to be conducting excess lobbying, whereas section 501(c)(4), (c)(5), and (c)(6) organizations may engage in an unlimited amount of lobbying activity.

What is substantial?

Unfortunately, there is no bright line test for determining what is considered substantial versus insubstantial. As an industry standard, many practitioners have taken a position that insubstantial means five percent or less of total expenditures, but that position is not codified and could be challenged by the IRS. 

Section 501(c)(3) organizations that intend to conduct lobbying activities on a regular basis may want to consider making an election under Code Section 501(h). This election is only applicable to 501(c)(3) organizations and provides a defined amount of lobbying activity an organization may conduct without jeopardizing its exempt status or becoming subject to excise tax. The 501(h) election limit is based on total organization expenditures with a maximum allowance of $1 million for “large organizations” (defined as an organization with total expenditures over $17,000,000). 

While the 501(h) election provides some clarity as to how much lobbying activity can be conducted, it may be prohibitive for some organizations whose total expenditures greatly exceed the $17,000,000 threshold. Another item to be aware of is that the lobbying threshold applies to all members of an affiliated group combined, which means the entire group shares the maximum threshold allowed. 

Another option for those engaging in lobbying is to create a separate entity (such as a 501(c)(4) organization) which conducts all lobbying activities, insulating the 501(c)(3) organization from these activities. As previously mentioned, organizations exempt under Code Section 501(c)(4) can conduct an unlimited amount of lobbying activities but can only conduct limited political campaign activities.

What about political campaign activities?

Section 527 organizations, known as political action committees, are exempt organizations dedicated specifically to conducting political campaign activities. If a 501(c)(4), (c)(5), or (c)(6) organization makes a contribution to a 527 organization, it may be required to file a Form 1120-POL and be subject to tax at the corporate tax rate (currently a flat 21%) based on the lesser of the political campaign expenditures or the organization’s net investment income. State income taxes may also be applicable. Section 501(c)(3) organizations may not make contributions to 527 organizations. 

If your organization is considering participation in any of the above activities, we would recommend you reach out to your not-for-profit tax team for additional information. We’re here to help!

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Lobbying and politics and education, oh my!

Read this if you are interested in grant compliance in healthcare. 

This is a companion article to the podcast, Mitigating the compliance and revenue integrity risk of grant funded healthcare programs.

The BerryDunn Healthcare Practice Group boasts professionals who have expertise all across the spectrum of healthcare, including regulatory, revenue, integrity, general compliance, and risk management issues. This article covers the very specific arena of grant compliance affecting many of BerryDunn’s healthcare, not-for-profit, and government clients.

After starting as a newly minted MBA financial analyst with an academic medical center in Northern New England, I (Markes) worked my way into the world of grants and contracts supported by my interest in federal regulations and the non-clinical revenue streams. Fascinated to navigate through waters where it seemed no one was the expert, or really had the time or patience to figure things out, I worked to stand up a grant office in finance on the hospital side, separate from the medical school which was the usual repository for grant funding. We moved this direction because hospital leadership realized grant funding was tipping toward the clinical setting and was less focused on bench or clinical research. Put another way, less NIH and more CDC, HRSA, and CMS.

BerryDunn Senior Manager Regina Alexander advises, “wherever there is complexity, there is compliance risk.” Whether from a federal agency like HHS, HRSA, NIH, or CDC, a state Medicaid program, foundation, or private source, grants always come with requirements, typically very specific requirements. Because the dollars are being ‘given’, those requirements for how the funds are used may be much more restrictive than loans.

Like other areas of regulatory compliance, it is reasonable to assume that grant programs often have compliance gaps that go unnoticed. For many of our clients, both in healthcare and not-for-profit, and in the government space, grant revenue has become a significant source of funding. Any kind of healthcare delivery organization, including academic medical centers, federally qualified health centers, community hospitals, behavioral health service organizations, home health providers, visiting nurse associations, and others can end up with significant portions of their income for the year being sourced by federal grants.

Grant compliance categories

We all can’t be experts in every domain of regulatory compliance, and grant compliance has a lot of breadth. Thankfully, at BerryDunn, we have a team of grant experts who work collaboratively across practice groups. When I was working on setting up the grant office and establishing a proprietary clinical FTE reporting process and system earlier in my career, I would have greatly benefited from the perspectives of other experts at the table.

When we think about grant compliance, four categories are helpful to keep in mind:

  1. Restricted funding
  2. Single audit
  3. Indirect rate
  4. Time and effort

Restricted funding

Firstly, and most universally understood and applied is that grant monies are, pretty much by definition, restricted. Aside from very specific and rare instances of monies being granted to beneficiaries who have no responsibility, all grant funding is awarded with the expectation that the funds will be expended in a specific way. 

Any funder, from the federal government to your local community organization like the Lions Club or the VFW, will likely require individuals and entities awarded a grant must promise to use the funds only for the purpose laid out in the award and proposal. Compliance with grant terms typically includes following the requested reporting requirements of that funder as well. Though this category may sound obvious, it's actually pretty far-reaching, as it usually affects sub-recipients (those entities who are partnered with the direct recipient to accomplish the grant purpose). For example, where the money goes after the initial awardee receives it, or rules about who can do the work, what type of organization, how you choose a vendor, etc.—all sorts of categories.

It should be noted that many of these grant award requirements are not dissimilar from work we already do in the healthcare compliance space to assist our clients in avoiding anti-kickback statutes and Stark risks. This is because grant compliance is grounded in the same basic concepts—no favoritism, no bribes or shady deals, and avoiding fraud, waste, and abuse. Especially if you're spending federal monies, you need to prove that you choose the vendor based on verifiable best practices, and consideration was afforded to organizations owned by women, veterans, and minorities.

Single audit 

The second category, Single Audit, is applicable to all federal funding of $750,000 or more annually. My colleague from BerryDunn’s Not-for-Profit practice group, Katie Balukas, explains: 

"The federal Single Audit Act is a requirement for entities to undergo an independent financial and compliance audit when the entity has expended over $750,000 in federal awards. These audits are conducted following guidance issued through the Governmental Auditing Standards and the United States Office of Management and Budgets' Uniform Guidance. The main focus of the compliance audit is to assess the entity's compliance with the requirements set forth by the federal agency that administered the grant funds. That includes, but is not limited to determining if the funds were utilized for allowable costs and activities and expanded within the proper grant period and that the reporting and performance objectives were met."

It is important to note that adequate, appropriately scaled internal resources are essential for any organization receiving grants and even more so with larger grants. Though the phrase has been overused, it really does “take a village”. Grant management isn't something an organization should do on the side, assigning grant accounting to someone who already has a full-time role, but unfortunately this is common and also unfortunate because under resourcing tends to lead to compliance concerns, as well as just plain old poor funding management. 

Indirect rate

Speaking of funding, the third type of grant compliance is very focused on a component of the grant world that really has a life of its own: The indirect rate. Though there is an accounting definition of ‘indirect’, the way it is defined regarding grant funding is pretty specific, and there is an entire body of work organizations undertake to get a federally approved indirect rate.

There's an awful lot to think about with the indirect rate. On the one hand, you could say it's pretty simple. For example, a lot of foundation funders and even some federal funders will offer you a 5% or 10% indirect rate without any need to make a calculation. That's because they know that if you take time to do the math, you'll come up with a number much higher than 5% or 10%. When it comes to federal grants and healthcare services organizations, the indirect rate is dependent on how an organization measures costs. For hospitals, of course, the method of measurement is driven by the Medicare cost report, and that's where we would do the fancy math to derive the indirect rate. But the reality is far from simple or straightforward. 

Time and effort

The fourth and final area of grant compliance, time and effort, is also the one I'm actually most passionate about and is probably the most minimized, or at the very least, misapplied. 

In one way, “time & effort” is exactly what it sounds like. Much of granted dollars, especially from the federal government, get appropriately spent on program staff. The challenge is to match time and effort to those dollars, but that isn't as clear as it sounds, because the standard way of measuring staff time is usually in a payroll system of some sort, which can't prove how time was spent.

Most payroll systems can be programmed to account for FTE (full-time equivalent) allocations; however, there is often a breakdown between theory and practice. Putting allocations into payroll, usually done without employee interaction, may show how an employee “should” spend their time, but it is really no guarantee that that's actually how they're spending their time.

So how does the organization typically go about assuring that? Now, I don't want to speak for everyone, but let's just say I happen to know that there's a place for two or three (or maybe 10,000) that basically put allocations into payroll, and then, unfortunately, often well after the fact and/or more than once, send that allocation to the employee to sign off on without really any option to disagree, or even to modify. We all know that is not compliant…but in the organization's defense, there really haven't been very good alternatives to that kind of woeful and frustrating process, at least none that have been widely shared or understood.

As often is the case in the compliance world, rules are not followed because there is no perceived risk, but that is not a winning strategy.

Though many people involved in grant management do not have any experience or even knowledge of time and effort violations meeting with any consequences, organization interest and grant compliance have more implications than just preventing front page news. What I find in the conversations with organizations, both large and small, is that loose time and effort management costs the organization in two major ways. 

Firstly, it is inefficient to scramble around at the close of each federal grant to fix time and effort allocations. The extra time spent by grant staff, project coordinators, managers, and the finance team to sort things out because they didn't get them right the first time is the worst kind of inefficient—poor use of time with an equally poor outcome. 

Secondly, loose time and effort is costly in direct salary dollars. Most grant staff are not dedicated to one project, so we need to consider the value of their other work. Whether that is on other grants or, for example, seeing patients in the clinic as many principal investigators in healthcare do, having inaccurate or fluctuating understandings of their ability costs the organization directly in wasted salary dollars or indirectly as the opportunity cost of those providers (or other roles in other organizations). 

Digging in and fixing these issues is the work I really enjoy. It's relatively simple to build a compliant model, whether that requires very little payroll redo and is just a simple recurring attestation process in built in Excel, or more complex integrated models with triggered attestations in PDF format in a database that manages the overall FTE of principal investigators. It might even drive the available clinical provider time. It can all be done. We just need to know what the goal is. 

Working in this space so rewarding, because like so much of compliance, it's about doing something better—not just being compliant—but setting organizations up to better meet their goals and fulfill their mission.

The compliance or accounting professional might still ask, “But why aren’t payroll allocations sufficient for meeting Uniform Guidance?” The truth is, when UG came into effect and superseded the A-110, 122, 133, and others, the bar was effectively lowered. Historically, organizations abiding by the old OMB circulars had to make an attestation at least twice a year, which doesn’t really seem helpful, as who can accurately allocate their time from 5 or 6 months ago? So UG did away with the timeframe reference, relying on the idea that the payroll allocations and distributions would be all that would be needed, and in the absence of those, a monthly ‘look back’ by professional staff would be in order.

I say all this, because as a result, the interpretation of ‘payroll allocations’ then becomes the standard and we have forgotten about the other elements spoken of in the regulation. Remember, for anyone salaried (the vast majority of physicians and most of the higher level grant personnel), the ‘payroll allocation’ doesn’t pass muster. It is a static allocation that has no mooring in actual activity. This is why UG calls for monthly “current and reasonable estimates” of time and effort.

So what can organizations do in response? They need to seek a solution, a process, and a method that will both pass audit muster, as well as help the organization properly manage their resources. Almost every organization manages their productivity and finances on a regular basis: monthly! That’s why the same standard should apply to grant time and effort management. It's much more reasonable to ask you how you spent your effort this month, asking you to make a reasonable estimate of your time allocations to the different efforts you worked on.

So to summarize, the four key areas of grant compliance are (1) grants are restricted funding, (2) single audit requirement for federal funding over $750,000 annually, (3) the indirect rate and related agreement, and (4) time and effort.

Of course, I would be remiss to not point out that undergirding all this is the organization’s approach to policy. Any organization that considers grant funding a regular piece of their annual income needs to have dedicated grant management policies, covering all of the above topics, with particular focus on those arenas that are unique to the world of federal funding, and being mindful to follow or otherwise update for changes in processes and/or regulations.

Final takeaways: 

  • First, what grant focused infrastructure do you have in place? If you are subject to a single audit, there should be dedicated administrative grant staff. And I don’t mean the programmatic people actually working on the grant, but people outside the grant funding—also why you have an indirect rate. 
  • Second, how are you handling time and effort? If the process relies on any long after-the-fact attestations or payroll-generated reporting, it is unlikely to be truly following the spirit…or the letter…of Uniform Guidance. 
  • Third, review your policies regarding grants. You may not actually have policies focused on grant activities, leaving them under ‘general finance’. That isn’t sufficient to cover federal funding requirements. Many have grant policies in place, but are they actually being followed through the lifecycle of your grant programs? 
  • Lastly, the grant world is a whole ball game unto itself. BerryDunn has some great resources internally to offer assistance in all phases of grant management and administration. 
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