January 22, 2022

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Tax Administration: Opportunities Exist to Improve Oversight of Hospitals’ Tax-Exempt Status

15 min read
<div>Nonprofit hospitals must satisfy three sets of requirements to obtain and maintain a nonprofit tax exemption (see figure). Requirements for Nonprofit Hospitals to Obtain and Maintain a Tax-Exemption While PPACA established requirements to better ensure hospitals are serving their communities, the law is unclear about what community benefit activities hospitals should be engaged in to justify their tax exemption. The Internal Revenue Service (IRS) identified factors that can demonstrate community benefits, but they are not requirements. IRS does not have authority to specify activities hospitals must undertake and makes determinations based on facts and circumstances. This lack of clarity makes IRS's oversight challenging. Congress could help by adding specificity to the Internal Revenue Code (IRC). While IRS is required to review hospitals' community benefit activities at least once every 3 years, it does not have a well-documented process to ensure that those activities are being reviewed. IRS referred almost 1,000 hospitals to its audit division for potential PPACA violations from 2015 through 2019. However, IRS could not identify if any of these referrals related to community benefits. GAO's analysis of IRS data identified 30 hospitals that reported no spending on community benefits in 2016, indicating potential noncompliance with providing community benefits. A well-documented process, such as clear instructions for addressing community benefits in the PPACA reviews or risk-based methods for selecting cases, would help IRS ensure it is effectively reviewing hospitals' community benefit activities. Further, according to IRS officials, hospitals with little to no community benefit expenses would indicate potential noncompliance. However, IRS was unable to provide evidence that it conducts reviews related to hospitals' community benefits because it does not have codes to track such audits. Slightly more than half of community hospitals in the United States are private, nonprofit organizations. IRS and the Department of the Treasury have recognized the promotion of health as a charitable purpose and have specified that nonprofit hospitals are eligible for a tax exemption. IRS has further stated that these hospitals can demonstrate their charitable purpose by providing services that benefit their communities as a whole. In 2010, Congress and the President enacted PPACA, which established additional requirements for tax-exempt hospitals to meet to maintain their tax exemption. GAO was asked to review IRS's implementation of requirements for tax-exempt hospitals. This report assesses IRS's (1) oversight of how tax-exempt hospitals provide community benefits, and (2) enforcement of PPACA requirements related to tax-exempt hospitals. GAO is making one matter for congressional consideration to specify in the IRC what services and activities Congress considers sufficient community benefit. GAO is also making four recommendations to IRS, including to establish a well-documented process to ensure hospitals' community benefit activities are being reviewed, and to create codes to track audit activity related to hospitals' community benefit activities. IRS agreed with GAO's recommendations. For more information, contact Jessica Lucas-Judy at (202) 512-9110 or lucasjudyj@gao.gov.</div>

What GAO Found

Nonprofit hospitals must satisfy three sets of requirements to obtain and maintain a nonprofit tax exemption (see figure).

Requirements for Nonprofit Hospitals to Obtain and Maintain a Tax-Exemption

While PPACA established requirements to better ensure hospitals are serving their communities, the law is unclear about what community benefit activities hospitals should be engaged in to justify their tax exemption. The Internal Revenue Service (IRS) identified factors that can demonstrate community benefits, but they are not requirements. IRS does not have authority to specify activities hospitals must undertake and makes determinations based on facts and circumstances. This lack of clarity makes IRS’s oversight challenging. Congress could help by adding specificity to the Internal Revenue Code (IRC).

While IRS is required to review hospitals’ community benefit activities at least once every 3 years, it does not have a well-documented process to ensure that those activities are being reviewed. IRS referred almost 1,000 hospitals to its audit division for potential PPACA violations from 2015 through 2019. However, IRS could not identify if any of these referrals related to community benefits. GAO’s analysis of IRS data identified 30 hospitals that reported no spending on community benefits in 2016, indicating potential noncompliance with providing community benefits. A well-documented process, such as clear instructions for addressing community benefits in the PPACA reviews or risk-based methods for selecting cases, would help IRS ensure it is effectively reviewing hospitals’ community benefit activities.

Further, according to IRS officials, hospitals with little to no community benefit expenses would indicate potential noncompliance. However, IRS was unable to provide evidence that it conducts reviews related to hospitals’ community benefits because it does not have codes to track such audits.

Why GAO Did This Study

Slightly more than half of community hospitals in the United States are private, nonprofit organizations. IRS and the Department of the Treasury have recognized the promotion of health as a charitable purpose and have specified that nonprofit hospitals are eligible for a tax exemption. IRS has further stated that these hospitals can demonstrate their charitable purpose by providing services that benefit their communities as a whole.

In 2010, Congress and the President enacted PPACA, which established additional requirements for tax-exempt hospitals to meet to maintain their tax exemption.

GAO was asked to review IRS’s implementation of requirements for tax-exempt hospitals. This report assesses IRS’s (1) oversight of how tax-exempt hospitals provide community benefits, and (2) enforcement of PPACA requirements related to tax-exempt hospitals.

What GAO Recommends

GAO is making one matter for congressional consideration to specify in the IRC what services and activities Congress considers sufficient community benefit. GAO is also making four recommendations to IRS, including to establish a well-documented process to ensure hospitals’ community benefit activities are being reviewed, and to create codes to track audit activity related to hospitals’ community benefit activities. IRS agreed with GAO’s recommendations.

For more information, contact Jessica Lucas-Judy at (202) 512-9110 or lucasjudyj@gao.gov.

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    In U.S GAO News
    What GAO Found The U.S. government awarded contracts valued at about $12 billion to foreign-located firms, of which about $5 billion went to firms with reported locations in the other six main parties to the World Trade Organization Agreement on Government Procurement (GPA) and the North American Free Trade Agreement (NAFTA) (see figure). Conversely, government procurement databases indicated the central governments of these parties awarded an estimated $7 billion to foreign sources, out of which about $2 billion was U.S.-sourced. Canada and Mexico awarded most of the U.S.-sourced contracts. GAO was able to determine that the U.S. government awarded more, by contract value, to foreign-owned firms located abroad than to foreign-owned, U.S.-located firms. Moreover, more than 80 percent of U.S. government contracts awarded to foreign-owned firms located abroad were Department of Defense contracts performed abroad. Overall, while available contract data enable broad cross-country comparisons, they do not necessarily show where the goods are produced, where the services are delivered, or where the profits go, among other economic effects. Estimated Bilateral Procurement Flows between Central Governments of the United States and the Other Six Main Parties to Selected International Procurement Agreements, 2015 Foreign sourcing by the seven GPA and NAFTA parties within the scope of the study, using two alternative methods, is less than 20 percent of overall central government procurement. Foreign sourcing by central governments, estimated from government procurement databases of the United States and the other six main parties, varied in value by party from about 2 to 19 percent of overall central government procurement. Foreign sourcing by all levels of government, estimated from data on trade and public sector purchases, showed that the governments' imports likely ranged from about 7 to 18 percent of the goods and services the governments purchased. In addition, contract data show that U.S., South Korean, and Mexican central government foreign sourcing was greater in value under contracts covered by GPA and NAFTA than under noncovered contracts, but the opposite was true for Canada and Norway. For the European Union and Japan, GAO found little difference or could not calculate an estimate. Why GAO Did This Study Globally, government procurement constitutes about a $4 trillion market for international trade. However, little is known about foreign sourcing in government procurement—how much governments procure from foreign-located suppliers or how much they acquire in foreign-made goods. GAO was asked to review the extent of foreign sourcing in government procurement across countries. GAO focused on the United States and the other six main parties to the GPA and NAFTA, selected international agreements that open procurement markets on a reciprocal basis. This report, the fourth of a related series, (1) provides broad estimates of foreign sourcing by the U.S. government and central governments of the other six main parties, and (2) assesses foreign sourcing as a share of estimated central government procurement and of estimated procurement by all levels of government, and the extent to which central government contracts that are covered under selected international procurement agreements are foreign-sourced. GAO analyzed the most recent comparable data available from two sources: (1) government procurement databases used in Canada, the European Union, South Korea, Mexico, Norway, and the United States, for 2015, and (2) 2014 trade data merged with data on the types of goods and services purchased by the public sector. Since Japan does not have a government procurement database, data for Japan were based on its 2015 GPA submission of 2013 data. GAO also interviewed cognizant government officials in Washington, D.C.; Ottawa, Canada; Mexico City, Mexico; Seoul, South Korea; and Tokyo, Japan. For more information, contact Kimberly Gianopoulos at (202) 512-8612 or gianopoulosk@gao.gov.
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  • Justice Department Statement on Law Enforcement Assistance to the Haitian Government
    In Crime News
    The U.S. Department of Justice today released the following statement from spokesman Anthony Coley on department efforts to provide law enforcement assistance to the people and Government of Haiti:
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  • Secretary Antony J. Blinken and Colombian Vice President and Foreign Minister Marta Lucia Ramirez De Rincon Before Their Meeting
    In Crime Control and Security News
    Antony J. Blinken, [Read More…]
  • Former NGO Procurement Official Sentenced to Prison for Bribery
    In Crime News
    A former non-governmental organization (NGO) official was sentenced today to 40 months in prison for paying bribes to NGO officers in exchange for sensitive procurement information related to NGO contracts funded in part by the U.S. Agency for International Development (USAID).
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  • Haiti Reconstruction: Factors Contributing to Delays in USAID Infrastructure Construction
    In U.S GAO News
    On January 12, 2010, a powerful earthquake struck Haiti, resulting in an estimated 230,000 deaths, including more than 16,000 Haitian government personnel, and the destruction of many ministry buildings. In addition to immediate relief efforts, in July 2010, Congress appropriated $1.14 billion in supplemental funds for reconstruction, most of which was provided to the U.S. Agency for International Development (USAID) and the Department of State (State). USAID and State are administering about $412 million in supplemental and regular fiscal year appropriations for infrastructure construction activities. In May 2011, in response to a congressional mandate, GAO reported on overall U.S. plans for assistance to Haiti. This report addresses infrastructure construction activities, including (1) USAID and State obligations and expenditures; (2) USAID staffing; (3) USAID planning; and (4) potential sustainability challenges USAID faces. GAO reviewed documents and interviewed U.S. officials in Washington, D.C., and Haiti, and visited ongoing and planned construction sites in Haiti..USAID and State have obligated and expended a small amount of funds for infrastructure construction activities in six sectors: energy, ports, shelter, health, food security, and governance and rule of law. As of September 30, 2011, USAID and State had allocated almost $412 million for infrastructure construction activities, obligated approximately $48.4 million (11.8 percent), and expended approximately $3.1 million (0.8 percent). Of the almost $412 million, about 87 percent was allocated from the 2010 Supplemental Appropriations Act and 13 percent from regular fiscal year appropriations. USAID accounts for about 89 percent of the $412 million, including funds for construction in the energy, ports, shelter, health, and food security sectors. State activities in the governance and rule of law sector account for the remaining 11 percent. USAID had difficulty staffing the Haiti mission after the earthquake, a factor that has contributed to delays in infrastructure construction activities. Soon after the earthquake, 10 of the 17 U.S. citizen Foreign Service Officers, known as U.S. direct-hire staff, in Haiti left. USAID, lacking a process for expediting the movement of staff to post-disaster situations, had difficulty replacing them and recruiting additional staff. These staff included key technical personnel such as engineers and contracting officers needed to plan and implement infrastructure activities in sectors such as energy and ports, where the mission had not previously worked. With limited U.S. direct-hire staff on board, the mission relied heavily on temporary staff, and remaining staff assumed duties outside their normal areas of expertise. The mission plans to have all U.S. direct-hire staff on board by February 2012. Since infrastructure activities will continue until at least 2015, the mission will need to maintain sufficient staff for several years to manage the activities supported by the increase in Haiti reconstruction funds. USAID and State are planning activities in Haiti, but various challenges have contributed to some of USAID's delays. As of October 2011, USAID had drafted eight Activity Approval Documents (AADs) that include planned activities, costs, risks, and assumptions. AADs for the education, energy, food security, governance and rule of law, health, and shelter sectors have been approved. The AAD process has been more comprehensive and involved than is typical for such efforts, according to USAID officials. Although USAID made progress in planning, construction of some activities was delayed for various reasons, and some activities do not yet have planned start dates. For example, the mission was delayed in awarding contracts in the shelter sector due to issues such as identifying sites for shelter and obtaining land title. The sustainability of USAID-funded infrastructure depends, in part, on improvements to the Haitian government's long-standing economic and institutional weaknesses. USAID has considered various sustainability issues and is planning institutional strengthening activities, such as management reform of the power utility, but USAID planning documents acknowledge that these reforms will be challenging and that infrastructure activities face risks. These challenges are consistent with prior GAO reports that address sustainability of U.S. infrastructure projects in other countries. To facilitate USAID's progress in planning and implementing its many post-earthquake infrastructure construction activities in Haiti over the next several years, particularly those requiring key technical staff, GAO recommends that the USAID Administrator ensure that U.S. direct-hire staff are placed at the mission within time frames that avoid future staffing gaps or delays. USAID described certain actions it is currently taking that, if continued, could address the recommendation.
    [Read More…]
  • Justice Department Files Lawsuit Alleging Disability-Based Discrimination by Architect and Owners of 15 Complexes in Four States
    In Crime News
    The Justice Department announced the filing today of a lawsuit against J. Randolph Parry Architects, P.C. and eight owners of multifamily properties designed by the architectural firm.
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  • U.S. Promoter of Foreign Cryptocurrency Companies Pleads Guilty for Role in Multimillion-Dollar Securities Fraud Scheme
    In Crime News
    A California man pleaded guilty today in the Eastern District of New York for his participation in a coordinated cryptocurrency and securities fraud scheme through purported digital currency platforms and foreign-based financial accounts.
    [Read More…]

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