Audit 367364

Finding No. SA 2024-001 – Inaccurate Application of Sliding Fee Discounts (Significant Deficiency) Federal Assistance Listing Number: 93.224 Federal Program Title: Health Center Program Cluster Federal Agency: U.S. Department of Health and Human Services Award Period: Fiscal year 2024 Program Identification Numbers: H80CS00850 H8N54038 Criteria: Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted based on the patient’s ability to pay. The patient’s ability to pay is determined based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services (HHS). The poverty guidelines are issued each year in the Federal Register and HHS maintains a web page that provides the poverty guidelines. Non-grant funds (State, local, and other operational funding and fees, premiums, and third-party reimbursements which the project may reasonably be expected to receive, including any such funds in excess of those originally expected), shall be used as permitted under the law and may be used for such other purposes as are not specifically prohibited under the law if such use furthers the objectives of the project. Condition: WHC has a schedule of fees and has adopted the Sliding Fee Discount Policy. WHC determines the amount of fees to be charged to a patient based on the patient’s income, expenses, and number of dependents in conjunction with the sliding fee schedule. Of the 60 patients selected for testing, we noted the following: • Seven patients were charged with the incorrect sliding fee amount, which resulted in overcharging the patients by a total of $154. • One patient did not have any supporting documentation on file to validate their sliding fee determination as of the date of service. Due to the absence of this documentation, we were unable to confirm the patient’s eligibility for the sliding fee discount. As a result, the patient may have been incorrectly charged a reduced amount instead of the full rate of $221, leading to a potential undercharge of $181. • Thirteen patients with incomes above 200% of Federal Poverty Guidelines (FPG) were charged a reduced amount instead of the full rate, which resulted in undercharging the patients by a total of $2,652. Cause: WHC has identified the root causes of the issue as staff error in assessing the patient’s ability to pay and insufficient training on the sliding fee program requirements, failing to properly link nominal charges to the corresponding coded procedures, and improper application of the sliding fee schedule to patients with incomes above 200% of FPG, contrary to policy. Effect: The deficiencies resulted in inaccurate billing and an increased risk of noncompliance with the HRSA sliding fee discount program requirements. Questioned Costs: $2,679 in net undercharged sliding fee for patients sampled. Recommendation: We recommend that WHC strengthen internal controls over the sliding fee application process to ensure the following: 1. Income declarations are properly verified and adequately documented to support eligibility for the sliding fee discount. 2. Sliding fee discounts are accurately determined and consistently applied in accordance with program guidelines. Additionally, WHC should ensure staff receive periodic refresher training focused on income verification, documentation retention, and proper use of the sliding fee schedule, and enhance monitoring by conducting periodic audits and documentation of corrective actions taken. Views of responsible officials and planned corrective actions: Management will implement the following corrective actions to address the root causes and prevent recurrence: • Policy Clarification – Categories A–D of the sliding fee schedule apply only to patients at or below 200% FPG. Category E is designated as a deposit/minimum payment category for patients above 200% FPG, with no discount applied. • Patient Reclassification – All previously misclassified patients are being reclassified to full-pay status. Prior balances will be reconciled in accordance with HRSA requirements and organizational policy. • Staff Training – Front office, billing, and eligibility staff will undergo mandatory refresher training on the Sliding Fee Discount Program, income verification, and proper application of the fee schedule. Additional refresher training on Self-Pay procedures will be led by the Director of Member Services. • Ongoing Monitoring – A quarterly compliance audit of the sliding fee program has been implemented. Results will be reviewed by management, with corrective actions taken as necessary. • Transparency & Communication – Patients will be notified in writing of their payment category. Appeals or questions will be addressed per organizational policy and HRSA guidelines. • Financial Remediation – Refunds will be issued to patients who were overcharged. For cases involving undercharges, the outstanding balance will be applied to the patient’s next visit. Personnel responsible for implementation: Jose Juarez, Director of Member Services Date of implementation: August 31, 2025