Is Your Organization Ready to Deal with Provider Relief Fund (PRF) Audit Contractors?

October 15th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Categories:   Audits/Auditing  
0 Votes - Sign in to vote or comment.

As we predicted over a year ago, federal audits are now underway to uncover any fraudulent misuse of emergency relief funds administered through the Provider Relief Fund (PRF). The PRF was a $175 billion fund created through the CARES Act to provide financial relief to healthcare providers during the public health emergency (PHE) caused by the COVID-19 pandemic. Over the past year, the Department of Health and Human Services (HHS) has hired outside contractors KPMG, Grant Thornton, PricewaterhouseCoopers, Kearney & Company, and Creative Solutions Consulting to audit PRF recipients, demonstrating their intent to ensure PRF monies have been justly disbursed. 

Audits will be conducted to determine if providers properly reported the information required to obtain their portion of each phase of disbursement: 

  • Phase 1 - $50 billion (initial $30 billion followed by an additional $20 billion) paid to:
    • Eligible facilities/providers who received Medicare fee-for-service (FFS) reimbursements in 2019
    • Certain facilities/providers who closed their doors due to the COVID-19 pandemic
  • Phase 2 - $18 billion available but only $5.98 billion paid due to fewer eligible candidates (60,832 recipients):
    • Providers of state Medicaid programs (including MCOs), Children’s Health Insurance Program (CHIP), certain Medicare providers, assisted living facilities, and certain dentists. 
  • Phase 3 - $24.5 billion paid to 97,433 recipients:
    • Providers previously eligible/paid during an earlier phase (deducting prior payment from eligible distribution)
    • Previously ineligible providers meeting certain eligibility criteria
    • Expanded group of behavioral health providers
    • Healthcare providers performing COVID-19 testing, diagnosis, and administering COVID-19 vaccines to uninsured individuals 
    • Providers administering vaccines on or after December 14, 2020 to underinsured patients.
  • Phase 4 - $25.5 billion (new funding), to be paid to:
    • Healthcare providers who provided diagnosis, testing, or care for individuals with possible or actual COVID-19 after January 31, 2020
    • Providers who serve rural Medicaid, CHIP, or Medicare patients

Audits are underway for providers who received/retained PRF payments and will require submission of supporting documentation such as: 

  • Data identifying how PRF funds were used
  • Documentation supporting compliance with the terms and conditions of PRF payments
  • Reports including: 
    • healthcare-related expenses attributable to coronavirus
    • lost revenue attributable to coronavirus
    • any other pandemic assistance received
    • specifically requested administrative data (e.g., personnel, supplies) in greater detail for providers who received more than $500,000 in aggregate payments

Audit resources that should be thoroughly reviewed include: 

  • 45 CFR § 75 Subpart F
    • 45 CFR § 75.302 - Financial management
    • 45 CFR § 75.361-75.365 - Record Retention and Access 
    • 45 CFR § 75.305(b)(8) - Applicable exceptions 
  • Copies of original applications and documents submitted to request PRF funds

The initial provider/facility reporting was due September 30, 2021 and includes: 

  • Phase 1- General Distribution: Most payments
  • Phase 2- General Distribution: Some payments.
                  Targeted Distributions: Some payments.

Please be advised that with some of these prestigious accounting and financial firms acting as PRF auditing contractors, details in submitted documentation is going to be very important. Be sure to begin your own internal audits now, prepare the necessary documentation for submission in a timely manner, and consult your healthcare attorney regarding any and all audit notifications. 

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Delving Into the 360 Assessment Fraud Complaint
November 17th, 2021 - Jessica Hocker, CPC, CPB
The Department of Justice is pursuing claims of healthcare fraud against Cigna Health-Spring Medicare Advantage plan based on how they used data from their 360 Program in 2012. A review of the allegations may help other payers avoid similar accusations.
Lessons Learned from a RADV Audit Report
November 16th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
If given an opportunity to know ahead of time the questions that would be asked of you in an upcoming interview or quiz, it is likely the outcome would be significantly better than if you were surprised by the questions. This same concept may be applied to audits of risk ...
Changes in RPM for 2021! Now, Wait for it... New RTM Codes for 2022
November 11th, 2021 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
Remote physiologic monitoring and clinical data monitoring is a relatively new concept thriving and growing as an essential component for telehealth services. According to global consumer trends, a company called Dynata reported, "Among the 39% of people who consulted a healthcare professional, two-thirds used telemedicine, many of them for the first time ...
Reporting and Auditing Drug Testing Services
November 9th, 2021 - Aimee Wilcox CPMA, CCS-P, CST, MA, MT
Drug testing is a common medical service used to manage prescription medications, verify someone is not taking illegal substances or too much of a prescribed substance, and monitor for toxicity and therapeutic dosing. It is customary for patients in treatment programs for chronic pain management or substance use disorders (SUD) to undergo random urine drug testing (UDT) or urine drug screening (UDS) as part of their individual treatment plan. Drug testing is regulated by federal and state laws (e.g., OSHA, CLIA), which must be carefully adhered to.
Understanding ASCs and APCs: Indicators and Place of Service
October 28th, 2021 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
The decision regarding the most appropriate care setting for a given surgical procedure is determined by the physician based on the patient's individual clinical needs and preferences. Of course, there is a difference in reimbursement, and the billing depends on where the procedure took place, such as an office setting, inpatient ...
Are You Keeping up with the Official ICD-10-CM Guideline Changes for COVID-19?
October 25th, 2021 - Wyn Staheli, Director of Research
The COVID-19 public health emergency (PHE) has made it interesting and challenging for organizations to keep an eye on the evolving changes to the ICD-10-CM Official Guidelines for Coding and Reporting. Have you been keeping up with these changes?
Is Your Organization Ready to Deal with Provider Relief Fund (PRF) Audit Contractors?
October 15th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Audits are currently underway to verify the monies distributed through the CARES Act were warranted and properly used by those organizations that received them. The federal government has contracted with financial institutions such as KPMG and PricewaterhouseCoopers, among others, to perform these audits referred to as Provider Relief Fund (PRF) audit contractors, funded with monies from the very same program. There were four phases of funding disbursements with phase 1 audits beginning in September. How ready are you to be audited?



Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2021 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association