Health Care Entities, September 2017
AICPA Audit and Accounting Guide 2. Aufl.
It is critical that auditors understand the complexities of the specialized accounting and regulatory requirements of the health care industry. This guide is considered the industry standard resource and the 2017 update contains practical, "how-to" guidance for accounting and auditing of health care entities. Prepared and reviewed by industry experts to provide hands on, practical guidance for those who work in and with health care entities, this 2017 edition includes relevant GASB and FASB updates (including those related to private companies), and auditor involvement with municipal securities findings. Further, SAS No. 133, Auditor Involvement With Exempt Offering Documents will be important in this industry. The clarification made by this standard will be very helpful to auditors in understanding their requirements related to public offering documents that include audited financial statements.
Table of Contents xix Chapter Paragraph 1 Overview and Unique Considerations of Health Care Entities .01-.14 Purpose .01 Applicability .02-.06 Classification of Health Care Entities .07-.08 Regulatory Environment .09-.14 Health Care Reform .12-.14 2 General Auditing Considerations .01-.116 Overview .01-.02 An Audit of Financial Statements .03-.09 Audit Risk .05-.09 Terms of Engagement .10-.14 Business Associate Agreements .14 Audit Planning .15-.18 Group Audits .19-.24 Multi-Location Audits Versus Group Audits .23 Complex Transactions .24 Materiality .25-.30 Performance Materiality .29-.30 Qualitative Aspects of Materiality .31-.32 Use of Assertions in Assessment of Risks of Material Misstatement .33-.34 Risk Assessment Procedures .35-.57 Risk Assessment Procedures and Related Activities .37-.43 The Entity and Its Environment .44-.57 Additional Audit Considerations .58-.96 Analytical Procedures .58-.59 Accounting Estimates .60-.62 Transactions Processed by Service Organizations .63-.66 Compliance With Laws and Regulations .67-.77 Going-Concern Considerations .78-.89 Written Representations .90-.96 Independent Auditor’s Reports .97-.99 Single Audit Act and Related Audit Considerations .100-.106 Statutory Reporting Considerations for Health Plans .107-.116 Risk-Based Capital Requirements .111-.112 Deficiencies in Internal Control .113 Communicating Internal Control Matters in an Audit .114 Communications With Regulators .115-.116 Chapter Paragraph 3 Unique Financial Statement Considerations for Not-for-Profit Business-Oriented Health Care Entities .01-.43 Complete Set of Financial Statements .02-.05 Balance Sheet .06-.08 Statement of Operations .09-.28 Performance Indicator .12-.17 Other Intermediate Subtotals . .18-.20 Discontinued Operations and Accounting Changes .21-.22 Revenues .23-.25 Expenses .26-.28 Statement of Changes in Net Assets (or Equity) . .29-.32 Statement of Cash Flows .33-.37 Notes to the Financial Statements .38 Subsequent Events . .39-.41 Example Financial Statements .42-.43 4 Cash, Cash Equivalents, and Investments .01-.75 Cash and Cash Equivalents .01-.11 Centralized Cash Management Arrangements .03-.06 Cash From Restricted Donations .07 Other Restricted or Designated Cash Amounts .08-.11 Investments .12-.73 Fair Value Option .17-.22 Investments in Debt Securities and Certain Equity Securities With a Readily Determinable Fair Value That Are Not Recorded Under the Fair Value Option . .23-.35 Investments in Certain Other Financial Instruments Without a Readily Determinable Fair Value That Are Not Recorded Under the Fair Value Option .36-.38 Investment Pools . .39-.47 Fair Value Measurements .48 Impairment of Investments .49-.59 Securities Lending Activities .60 Transfers of Assets to an NFP or Charitable Trust for Investment .61-.63 Regulation .64 Other Financial Statement Presentation Matters .65-.73 Auditing .74-.75 5 Derivatives .01-.44 Introduction .01-.05 General Guidance . .06-.07 Accounting for Changes in Fair Value of Derivative Instruments .08-.12 Fair Value Hedges .09 Cash Flow Hedges .10-.11 Derivatives Not Designated as a Hedging Instrument .12 Hedge Accounting Requirements .13-.28 Shortcut Method .20-.28 Hybrid Instruments, Host Contracts, and Embedded Derivatives .29-.37 Calls and Puts in Debt .33-.34 Derivatives Embedded in Split-Interest Agreements .35-.37 Other Matters .38-.43 Changes in Fair Value of Hedged Item .38 Termination of Cash Flow Hedge by Debt Extinguishment .39 Additional Presentation and Disclosure Requirements for NFP Business-Oriented Health Care Entities .40-.43 Auditing .44 6 Property and Equipment and Other Assets .01-.53 Overview .01-.05 Capitalized Interest . .06-.11 Supplies, Rebates, and Discounts .12-.13 Lessee Involvement in Fixed Asset Construction .14-.17 Asset Retirement and Environmental Remediation Obligations .18-.20 Impairment or Disposal .21-.31 Discontinued Operations .28-.31 Nonreciprocal Transfers .32-.34 Other Long-Lived Assets .35-.43 Financial Statement Presentation . .44-.47 Auditing .48-.53 7 Municipal Bond Financing .01-.107 Introduction .01-.13 Conduit Bonds That Trade in Public Markets . .06-.08 Credit Enhancement .09-.11 Issuance of Municipal Bonds . .12-.13 Extinguishment and Modification Transactions . .14-.17 Calls and Mode Conversions .18-.39 Defeasance .20-.26 Modifications .27-.31 Gain or Loss on Debt Extinguishment .32-.33 Debt Issuance Costs Incurred in Connection With an Exchange or Modification of Debt Instruments .34-.36 Puts or Tender Options .37-.39 IRS Considerations . .40-.44 Chapter Paragraph Financial Statement Presentation and Disclosure .45-.72 Balance Sheet .45-.63 Statement of Operations .64-.65 Disclosures .66-.72 Obligated Group Reporting .73-.74 Interim Financial Reporting .75-.76 Auditing .77-.106 General .77-.85 Auditor Involvement With Municipal Securities Filings .86-.96 Letters for Underwriters .97-.103 Attestation Engagements Related to Securities Issuance . .104-.106 Appendix—Municipal Securities Regulation .107 8 Contingencies and Other Liabilities .01-.128 Contingencies and Commitments .02-.61 The Essentials of Recognition, Measurement, and Disclosure for Contingencies .03-.09 Managing Risk of Loss .10-.12 Medical Malpractice .13-.47 Disclosures for Medical Malpractice .48-.53 Physician Guarantees and Other Agreements With Physicians .54-.61 Other Liabilities .62-.85 Asset Retirement Obligations . .62-.64 Compensation and Related Benefits .65-.76 Joint and Several Liability Arrangements .77-.81 Agency Funds .82-.83 Fees Paid to the Federal Government by Health Insurers . .84-.85 Tax Considerations for NFP Health Care Entities .86-.100 Private Inurement and Intermediate Sanctions .93-.94 Unrelated Business Income .95 State and Local Taxes .96 Tax Positions .97-.98 Medicaid Voluntary Contribution or Taxation Programs . .99-.100 Risks and Uncertainties .101-.107 Auditing Contingencies and Other Liabilities .108-.126 Auditing Medical Malpractice Loss Contingencies .109-.112 Auditing Accounting Estimates .113-.118 Use of Actuaries and Actuarial Methods .119-.122 Evaluating Lawyers’ Responses .123-.126 Income Taxes .127 Auditing Considerations .128 Chapter Paragraph 9 Net Assets (Equity) .01-.38 Investor-Owned Health Care Entities .01 Not-for-Profit Entities . .02-.25 Net Asset Classes .05-.18 Reclassifications . .19-.25 Classification of Donor-Restricted Endowment Funds .26-.32 Disclosure .33-.37 Auditing .38 10 Health Care Service Revenue and Related Receivables .01-.60 Overview of the Health Care Environment .01-.15 Rate Setting With Third-Party Payors .05-.10 The Government Payer Environment .11-.14 Charity Care .15 Types of Health Care Revenue .16 Types of Payment Methodologies .17 Patient (or Resident) Service Revenue .18-.36 Revenue Recognition .18-.29 Accounting and Financial Reporting Requirements .30-.36 Premium and Capitation Revenues .37-.40 Patient Receivables . .41-.45 Estimated Final Settlements .46-.54 Auditing .55-.60 Accounts Receivable Confirmations .58-.60 11 Contributions Received and Made .01-.66 Distinguishing Contributions From Other Transactions .03-.08 Contributions Received .09-.32 Expiration of Donor-Imposed Restrictions .12-.14 Promises to Give in Future Periods (Pledges) . .15-.24 Contributions of Long-Lived Assets, the Use of Long-Lived Assets, or Resources to Acquire Them .25-.27 Contributed Services .28-.32 Reporting the Cost of Special Events and Other Fund-Raising Activities .33-.40 Naming Opportunities .36-.39 Investments Gain or Loss Related to Donor-Restricted Contributions . .40 Transfers of Assets to an NFP or Charitable Trust That Raises or Holds Contributions for Others .41-.48 Contributions Made . .49 Other Considerations .50-.58 Auditing .59-.65 Appendix—Q&A Section 6400, Health Care Entities .66 12 The Reporting Entity and Related Entities .01-.118 Overview .01-.02 Reporting by NFP Health Care Entities .03-.58 Relationships With Another NFP .06-.25 Relationships With a For-Profit Entity .26-.48 Special Entities .49-.58 Reporting by Investor-Owned Health Care Entities .59-.62 Presentation of Consolidated and Combined Financial Statements .63-.73 Accounting for Transfers Between Related Entities .74-.87 Equity Transfers .75-.78 Equity Transactions .79-.82 Other Transfers .83-.87 Disclosure .88-.89 Mergers and Acquisitions .90-.116 Merger of NFPs . .96-.97 Acquisition by an NFP .98-.110 Acquisition by an Investor-Owned Entity, Including a For-Profit Subsidiary of an NFP Health Care Entity .111-.114 Disclosures .115 Acquired Entities . .116 Auditing .117 Appendix—Flowcharts .118 13 Financial Accounting and Reporting for Managed Care Services .01-.30 Overview .01-.02 Recognition and Classification of Revenue .03-.12 Capitation Arrangements .07 Accounting for Health Care Costs .08-.12 Accounting for Loss Contracts .13-.17 Consideration of Anticipated Investment Income .17 Accounting for Stop-Loss Insurance .18-.19 General and Administrative Expenses .20 Acquisition Costs .21-.22 Financial Statement Display Considerations .23-.29 Balance Sheet .23-.24 Income and Cash Flow Statement .25-.29 Disclosures .30 14 Financial Accounting and Reporting by Continuing Care Retirement Communities .01-.49 Overview .01-.05 Types of Contracts . .06-.10 Advance Fees .08 Chapter Paragraph Periodic Fees .09 Use Fees .10 Types of Living Accommodations .11-.12 Fees and Payment Methods .13-.15 Accounting for Refundable Advance Fees .16-.20 Accounting for Fees Refundable to Residents Only From Reoccupancy Proceeds of a Contract Holder’s Unit .21-.23 Accounting for Nonrefundable Advance Fees . .24-.25 Classification of Refundable Advance Fees .26-.30 Accounting for the Obligation to Provide Future Services and the Use of Facilities to Current Residents .31-.35 Accounting for the Costs of Acquiring Initial Continuing-Care Contracts .36 Financial Statements .37-.43 Auditing .44-.49 15 Unique Considerations of State and Local Government Health Care Entities .01-.206 Introduction .01-.02 Applicability of This Chapter .03-.04 GAAP Hierarchy for Governmental Health Care Entities .05-.11 Applicability of FASB and AICPA Pronouncements .09-.11 Basic Financial Statements .12-.33 Statement of Net Position .13-.18 Statement of Revenues, Expenses, and Changes in Net Position .19-.26 Statement of Cash Flows .27 Segment Reporting .28-.29 RSI, Including MD&A .30-.33 Measurement Attributes .34-.35 Cash, Cash Equivalents, and Investments .36-.58 Cash and Cash Equivalents .36-.38 Investments and Certain Equity Interests .39-.58 Derivatives .59-.65 Property and Equipment and Other Assets .66-.85 Capital Assets—General .67-.70 Capital Asset Impairment .71-.73 Intangible Assets . .74-.76 Excess Consideration Provided in a Governmental Acquisition (Known as Goodwill in Nongovernmental Entities) .77-.79 Leased Assets .80 Service Concession Arrangements .81-.84 Chapter Paragraph Disclosures .85 Municipal Bond Financing and Other Long-Term Debt .86-.94 Debt Defeasance and Extinguishment .89-.92 Debt Issuance Costs .93 Disclosures .94 Contingencies and Other Liabilities .95-.122 Insurance-Related Contingencies .95-.101 Nonexchange Financial Guarantees .102-.104 Asset Retirement and Pollution Remediation Obligations .105-.106 Other Contingencies .107 Compensation and Related Benefits .108-.118 Tax Considerations .119-.120 Disclosures .121-.122 Net Position .123-.132 Financial Reporting of Net Position .131-.132 Health Care Service Revenue and Receivables .133-.136 Contributions and Other Nonexchange Transactions .137-.147 The Reporting Entity and Related Entities .148-.190 Identifying Component Units . .150-.154 Presentation of Component Units .155-.162 Equity Interests .163-.169 Institutionally-Related Foundations .170-.175 Government Combinations .176-.190 General Auditing Considerations for Governmental Health Care Entities .191-.204 Independent Auditor’s Reports .197-.198 Supplementary Information and Supporting Information, Including RSI . .199-.206 Supplement A—Statement of Position 00-1, Auditing Health Care Third-Party Revenues and Related Receivables Appendix A Overview of Statements on Quality Control Standards B References to AICPA Technical Questions and Answers C The New Revenue Recognition Standard: FASB ASC 606 D Accounting for Financial Instruments E Information Sources F Category B Guidance G The New Leases Standard: FASB ASU No. 2016-02 H The New Not-for-Profit Financial Reporting Model Standards: FASB ASU No. 2016-14 I Schedule of Changes Made to the Text From the Previous Edition Glossary Index of Pronouncements anOther Technical Guidance Subject Index
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