Audit 396538

Criteria: In accordance with 42 CFR 56.303, 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 U.S. Department of Health and Human Services (HHS). The schedule of discounts must provide for a full discount to individuals and families with annual incomes at or below those set forth in the most recent poverty income guidelines (except that nominal fees for service may be collected from such individuals and families) and for no discount to individuals and families with annual incomes greater than twice those set forth in such Guidelines. Condition: The Organization determines the amount of fees to be charged to the patients based on their annual gross income and household size in conjunction with the sliding fee schedule. During our testing of sliding fee discount, we noted the following:  Three (3) out of 60 patients selected were given a sliding fee discount that was improperly calculated, resulting in overstatement of the sliding fee discount by $420.  Twenty-seven (27) out of 60 selections were missing either updated proof of income or complete requested support. Therefore not able to confirm that sliding fee adjustment were applicable to these patients.  Context: The audit findings represent a systematic problem, see condition above. Questioned Costs: $420 of the $8,717 patient charges sampled. Effect: Patients were improperly categorized on the Organization’s sliding fee scale and were given an improper sliding fee discount. Cause: The inaccuracies in the application of the sliding fee program discounts were due to human error and inadequate oversight and review. Recommendation: We recommend that the Organization’s procedures be strengthened to ensure 1) income is properly verified and adequately documented and 2) the sliding fee discount is properly determined and applied. The Organization should strengthen processes surrounding monitoring of the program to ensure the Organization’s policies are consistently and properly applied. Repeat finding: This is a repeat finding to 2024-04 and 2023-002. Views of responsible officials and planned corrective actions: While staff training is ongoing to ensure the sliding fee program is applied correctly, Management is concurrently exploring strategies to strengthen the program overall. This includes reviewing current materials and processes, enhancing staff competencies, provide additional tools to support staff, and developing clearer workflows to support consistent and accurate application.