Health Resources and Services Administration (HRSA) - Provider Relief Fund Uninsured

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Program level Payment Integrity results

Sponsoring agency: Department of Health and Human Services

PROGRAM METRICS

Did not report

in FY 2022

PROGRAM METRICS

$19,269 M

in FY 2024 outlays, with a

99.1%

payment accuracy rate

  • Improper payment estimates over time
    View as:

    Chart toggle amounts:
    Proper payments
    Overpayment
    Underpayment
    Technically improper
    Unknown

Payment Integrity results

Unknown Payment Details

Evaluation of corrective actions

Future payment integrity outlook

Additional programmatic information

The COVID-19 UIP was determined to be risk-susceptible in FY 2021. Payments for testing and treatment claims began in May 2020, and vaccine administration began in Feb 2021. HHS developed, submitted, and began to implement the improper payment estimation methodology. However, due to the timing constraints of testing claims, HHS was unable to complete the statistical sampling methodology and subsequent extrapolation procedures to identify and report improper and unknown improper payments in FY 2022. HHS expects to complete testing and report an improper payment estimate for this program in FY 2023.

  • FY 2024 improper payment estimates

    Chart legend and breakdown

    Payment accuracy rate

    Improper payment rate

    Unknown payment rate


    Sampling & estimation methodology details

    Sampling timeframe:

    03/2021 - 03/2023


    Confidence interval:

    95% to <100%


    Margin of error:

    +/-1.0

  • Actions taken & planned to mitigate improper payments

    Mitigation strategy Description of the corrective action Completion date Status
    Training
    HHS offered training to personnel and contractors on conducting TIN matching, documentation retention to enable efficient assessments of UIP claims.
    FY2024 Q1
    Completed
    Change Process
    HHS prioritized the need to gather historical records of policy and program decisions already made into accessible locations. HHS reprocessed claims incorrectly paid due to federal government error, such as internal adjudication or payment errors.
    FY2024 Q1
    Completed
    Audit
    Recipients of the UIP are subject to review as set forth in the UIP Terms and Conditions. HHS conducts reviews of UIP claims reimbursement recipients to ensure compliance with applicable legislation and the UIP Terms and Conditions.
    FY2024 Q4
    Completed
    Change Process
    HHS will continue to prioritize the need to gather historical records of policy and program decisions already made into accessible locations.
    FY2025
    Planned

Overpayments

The overpayments within the agency control were due to pricing errors (incorrect claims reimbursements due to pricing errors associated with Healthcare Common Procedure Coding System (HCPCS) rates) and incorrect calculation (incorrect claims reimbursements due to the use of prior published rates when calculating payments or recalculated amounts not reconciling). There is inadequate documentation to support some claim payments.
Overpayment root cause Overpayment amount
Amount of overpayments within the agency's control $92.14 M
Amount of overpayments that occurred because the data/information needed to validate payment accuracy prior to making a payment does not exist $92.14 M
The amount of overpayments that occurred because of an inability to access the data/information needed to validate payment accuracy prior to making a payment $0.0 M
The amount of overpayments that occurred because of a failure to access data/information needed to validate payment accuracy prior to making a payment $0.0 M

Overpayment root cause Overpayment amount
Amount of overpayments outside the agency's control $0.0 M

Overpayment type Eligibility element/information needed Eligibility amount
Overpayments Within Agency Control Contractor or Provider Status $92.14 M

Overpayment type Mitigation strategies taken Mitigation strategies planned
Overpayments within the agency’s control Audit, Change Process, Training Change Process

Underpayments

Underpayment root cause Underpayment amount
Amount of underpayments $81.38 M
The amount of underpayments that occurred because the data/information needed to validate payment accuracy prior to making a payment does not exist $81.38 M
The amount of underpayments that occurred because of an inability to access the data/information needed to validate payment accuracy prior to making a payment $0.0 M
The amount of underpayments that occurred because of a failure to access data/information needed to validate payment accuracy prior to making a payment $0.0 M

Eligibility element/information needed Eligibility amount
Contractor or Provider Status $81.38 M

Mitigation strategies taken Mitigation strategies planned
Audit, Change Process, Training Change Process

Technically improper payments

The amount of improper payments that were paid to the right recipient for the correct amount but were considered technically improper because of failure to follow statute or regulation $0.0 M

Additional information

$81.38 M

Unknown Payment Details

A payment is considered “Unknown” when an agency is unable to obtain the documentation needed for a reviewer to determine whether the payment was made to the right recipient and/or for the right amount. Concerning FY24 UIP testing, HRSA had some “unknown payments” because health-care providers’ eligibility could not be verified due to the Tax Identification Number (TINs) per the sample data not matching the TINs in the supporting documentation, and HRSA could not determine if the payments were made the right health-care providers.

The amount of payments that could either be proper or improper but the agency is unable to determine whether they were proper or improper as a result of insufficient or lack of documentation is $2.29 M


Cause of insufficient or lack of documentation & why the documentation is needed for determination of payment type
Payment cause Amount Description of the documentation that was not provided and explanation of why the program is unable to conclude whether the payment is proper or improper without that documentation
States $2.29 M One of HRSA's test is to determine the eligibility of recipient of claims by ensuring that appropriate and sufficient documents were reviewed. When HRSA is unable to receive appropriate documentation to determine the eligibility of health-care providers, any payment to such providers is considered as unknown payments. HRSA determined that the Tax Identification Number (TINs) of four health-care providers that received claims did not match the Tax Identification Number (TINs) of the health-care providers that provided services and submitted claims for the some claimed that were paid.

Mitigation strategies taken Mitigation strategies planned
Audit,Change Process,Training Change Process

Evaluation of corrective actions

Coupled with the historical records, HHS continues to work with the UIP contractor to address any data needs and brainstorm methods to address these needs, including any data integrity or quality issues. HHS is working with our IT and security partners as well as the UIP contractor, to bring UIP data in-house in a secure manner, which can then be used for various requests, audits, and assessments and has reprocessed claims that were incorrectly paid due to government error, such as internal adjudication or payment errors. Prior to the passage of the FRA, HHS had planned to reprocess claims that were underpaid as a result of the incorrect fee schedule used to pay certain services.

HHS is working with the UIP contractor to address any data needs and brainstormed methods to address these needs, including any data integrity or quality issues. HHS is working with IT and Security partners and the UIP contractor to bring UIP data in-house securely to use for various requests, audits, and assessments.

HHS conducts reviews of UIP claims reimbursement recipient to ensure compliance with applicable legislation and the UIP Terms and Conditions and resolves single and commercial audit findings associated with the UIP and recovered disallowed costs.

HHS continued to work with the UIP contractor to address any data needs and brainstormed methods to address these needs, including any data integrity or quality issues. HHS is working with IT and security partners and the UIP contractor to bring UIP data in-house in a secure manner to use forvarious requests, audits, and assessments and reprocessed claims incorrectly paid due to government error, such as internal adjudication or payment errors. Prior to the passage of the FRA, HHS had planned to reprocess claims that were underpaid as a result of the incorrect fee schedule used to pay certain services.

Future payment integrity outlook

Health Resources and Services Administration (HRSA) - Provider Relief Fund Uninsured has NOT established a baseline.

The program's current year improper payment and unknown payment rate of 0.91 % has been achieved with a balance of payment integrity risk and controls and represents the lowest rate that can be achieved without disproportionally increasing another risk, therefore it is the tolerable rate.

Unknown because the agency has not yet determined the tolerable rate for this program.

Unknown because the agency has not yet determined the tolerable rate for this program.

Unknown because the agency has not yet determined the tolerable rate for this program.

Additional programmatic information

The UIP program rounded up in FY 2023. Due to a lack of sufficient funds, the UIP stopped accepting testing and treatment claims on March 22, 2022, at11:59 p.m. ET and on April 5, 2022, at 11:59 p.m. ET for vaccine administration claims. On June 3, 2023, the Fiscal Responsibility Act (FRA) of 2023 was enacted. With the passage of FRA and the related rescission of program funds, no additional claims will be reimbursed under the UIP. Therefore, FY2024will be the last year for UIP testing.

Accountability for detecting, preventing, and recovering improper payments

HHS has performance management programs to develop goals and strategies for staff through which success can be measured and rewarded. Performance Management Appraisal Program (PMAP) is one component of the ongoing process of performance management. It sets goals for performance and shares those goals while establishing the performance plan and required mid-year and annual review discussions. PMAP includes two critical elements that track back to the HHS and HRSA strategic plan and align with the goals and initiatives of senior leadership. Administrative Requirements is one category of critical element that are required of all agency staff as part of their job duties and responsibilities to identify and address weaknesses to ensure recovery of improper payments and to reduce the number of improper payments made by the Department.