Audit 378015

Criteria: The Health Center Program Compliance Manual requires that a health center establish and maintain systems for determining sliding fee eligibility. The Organization should implement procedures to assess and reassess all patients’ income and family size in accordance with board-approved policies and applicable poverty guidelines. Additionally, management should establish a defined cutoff date for updating poverty guidelines in the billing system and implement a review process to ensure that patient records are properly updated when discrepancies between applied categories and recorded information occur. Condition: During our testing of sliding fee applications, we noted that one of the patients tested was assigned an incorrect sliding fee category based on available income information. In addition, for three patients, data extracted from the billing system reflected a different sliding fee category than that shown in the patient’s individual profile. Management attributed these discrepancies to a system glitch and to timing differences in updating the poverty guidelines within the billing system. Cause: Although management has established “Sliding Fee Scale Procedure” policies, the registration guidelines are not being consistently followed. Furthermore, monitoring procedures in the Athena system have not been sufficient to detect or prevent these recurring discrepancies. Effect: Failure to properly apply the sliding fee scale may result in patients being charged an incorrect fee or no fee, a condition could be placed on the grant’s Notice of Award if HRSA determines that the Organization is not demonstrating compliance with the sliding fee program requirements. Recommendation: We recommend that management provide periodic training to intake personnel to ensure accurate application of the sliding fee scale based on verified income and household information. In addition, management should enhance review and monitoring procedures within the Athena system to ensure the accuracy of patient data and coordinate with billing staff as needed to update poverty guidelines by a designated cut-off date. Management's response: Management agrees with auditor's recommendation. Refer to Corrective Action Plan for expected date of completion.