Healthcare providers must reverse COVID reimbursement missteps | Newsletters | Law360
A health resource and services administration program, “COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured,” has been a huge source of funding for COVID-19 services. 19 during the public health emergency.
The uninsured HRSA program has paid about $18 billion in claims, including about $11.4 billion for testing, $5.85 billion for treatment and $1.6 billion for vaccines.1
In recent weeks, the HRSA has stopped accepting COVID-19 test and treatment requests, as well as COVID-19 vaccination requests.2
The program was funded by federal legislation, including the Families-First Coronavirus Response Act; the Coronavirus Aid, Relief and Economic Security Act; the law on additional credits for intervention and relief against the coronavirus; and the 2021 U.S. bailout. The program provided reimbursement for healthcare providers who provided COVID-19 testing, treatment and vaccination services to uninsured people.
The huge amount of money paid to claimants through the uninsured HRSA program makes the program ripe for government auditing and oversight to ensure compliance with federal requirements. review.3 Additionally, the U.S. Department of Health and Human Services Office of Inspector General’s work plan includes an audit of the HRSA uninsured program to determine whether COVID-19 test and treatment requests complied with federal requirements. .4
The OIG originally announced a planned release date for the FY2021 audit, but has since changed the date to FY2022.
Government enforcement and potential liability for non-compliance
To receive reimbursement from the program, providers have registered and attested to the terms and conditions of the program, and failure to comply may expose a provider to administrative, civil or criminal liability.
In addition to terms and conditions, program guidance has been in the form of information posted on the HRSA website, including frequently asked questions.5 It is unclear if or to what extent the Centers for Medicare & Medicaid Services guidelines apply to the program.
CMS guidelines are referenced repeatedly in program materials, and there is a strong implication that HHS, the parent agency of CMS and HRSA, may require participating providers to comply with certain regulations and guidelines of the CMS.
It is important to note that the FAQ for the program indicates that HRSA has a program to identify overpayments and collect overpaid funds from the payment of future claims. The FAQ also outlines a process for providers who self-identify overpayments to return funds.
To date, application of the HRSA uninsured program has been limited, but press releases from the OIG and the US Department of Justice reveal the government’s focus on COVID-19 fraud in general,6 and news stories suggest focus on the program and signal the potential for greater application to come.
In this article, we outline the requirements of the HRSA Uninsured Program and some of the risks providers may face, including potential penalties that may result from not meeting program requirements.
Claims must be for medically necessary services
Providers were required to certify that all items and services for which reimbursement is requested are medically necessary. HHS, the U.S. Department of Labor, and the U.S. Department of Treasury issued guidance interpreting the FFCRA provision requiring payers to cover COVID-19 testing services and clarifying that payers are not required to provide coverage for drug testing or testing for employment purposes.7
While it’s unclear whether government guidance would apply to the program, it’s likely that by submitting requests to the HRSA for tests that are not medically necessary, providers could be subject to government scrutiny. .
At least one provider has reached a settlement agreement with the OIG after disclosing alleged violations of civil monetary penalties law for allegedly submitting claims to the HRSA uninsured program for services rendered to patients without a primary diagnosis of COVID-19.
Patients must be uninsured
The program is intended to reimburse uninsured patient claims only, and providers must certify that to the best of their knowledge, the patients identified on each claim form were uninsured at the time the service was rendered.
With the speed at which providers began offering COVID-19 testing and treatment services to meet the significant needs during the public health emergency, providers may not have procedures in place. appropriate to determine patients’ insurance status. Failure to take steps to determine if patients are uninsured may expose providers to liability for non-compliance with program terms and conditions.
Provider may not balance patient bill
Providers were required to certify that they would not engage in balance billing or charge any type of cost sharing for services provided to uninsured persons for whom reimbursement is sought from the uninsured HRSA program.
Similarly, providers who charged uninsured people a fee for testing before signing the terms and conditions were required to communicate with the uninsured person that they did not owe money for the services and return any payment already made to the person. uninsured.
The HRSA guidelines do not talk about remedial action following instances where providers balance patients’ bills after signing terms and conditions. Accordingly, Suppliers may be subject to government enforcement.
Providers cannot claim reimbursement for expenses reimbursed from other sources
Providers have certified that they will not use program reimbursement for expenses or losses that have been reimbursed by other sources or that other sources are obligated to reimburse.
Instances of potential non-compliance with this requirement may be uncovered through data analysis, including for those who have received other sources of federal COVID-19 relief funding, including the provider’s or program’s relief fund. paycheck protection.
The HRSA Uninsured Program has provided a critical source of reimbursement for providers providing COVID-19-related services to uninsured individuals. However, failure to comply with program requirements may subject providers to administrative, civil or criminal penalties.
Suppliers who have participated in and submitted claims to the program must assess their operations to ensure that they complied with the program’s terms and conditions and guidelines. Similarly, providers who detect non-compliance with program requirements should consider corrective action.
This article was originally published by Law360 and is reproduced here with permission.