Audit 408148

U.S. Department of Health and Human Services Assistance Listing Number 93.224 and 93.527 Health Center Program Cluster Program Year 2025-2026 Criteria or specific requirement – Special Tests and Provisions: Sliding Fee Discounts Per 42 U.S.C. § 254b(k)(3)(G)(i), Federally Qualified Health Centers (FQHCs) must prepare a schedule of fees or payments and a corresponding schedule of discounts adjusted on the basis of the patient's ability to pay. Implementing regulations at 42 CFR § 51c.303(f) and 42 CFR § 56.303(f) require health centers to establish a schedule of discounts adjusted on the basis of patients' ability to pay, with nominal charges for individuals and families with annual incomes at or below 100% of the Federal Poverty Level (FPL), and discounts for those with incomes between 100% and 200% of FPL. Additionally, 42 U.S.C. § 254b(k)(3)(F) and 42 CFR §§ 51c.303(e) and 56.303(e) prohibit denying services to any patient due to inability to pay. Condition – During our testing of patient encounters, we identified instances where patients did not receive sliding fee discount adjustments in accordance with the Organization's sliding fee schedule and the requirements of 42 CFR §§ 51c.303(f) and 56.303(f). Specifically, three (3) of forty (40) patient encounters tested did not reflect the appropriate sliding fee discount based on the patient's documented income and family size relative to Federal Poverty Level guidelines. Cause – The Organization's internal controls over the application of sliding fee discounts were not operating effectively to ensure compliance with its sliding fee policy Effect or potential effect – Patients may have been charged amounts inconsistent with their eligibility for sliding fee discounts. Questioned costs – None Context – A sample of 40 patients was tested out of the total population of 4,525 encounters. Three patients did not receive the proper sliding fee adjustments. The sampling methodology used is not and is not intended to be statistically valid. Identification as a repeat finding – Yes Recommendation – We recommend management ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure eligible patients receive discounts in accordance with the sliding fee scale. Views of responsible officials and planned corrective actions – The Organization concurs with the finding, and management has continued to implement procedures to ensure that eligible patients receive discounts in accordance with the sliding fee scale. Coordination with Revenue Cycle Management has occurred to ensure awareness across teams. Office Managers review all new sliding fee applications on a monthly basis to ensure accuracy, and the Billing Manager conducts quarterly audits of sliding fee claims to ensure adjustments are entered correctly by the billing department. The Organization also continues to provide staff training for all individuals involved in the sliding fee application process. Management has instructed all outsourced billers not to modify sliding fee adjustments; any required changes must be handled by in-house billing staff. Additionally, sliding fee adjustments auto posted in error will be removed. Management is also working with IT to restrict system access for outsourced users to prevent unauthorized adjustments. Additionally, IT will implement a scheduled monthly audit report to identify improper adjustments and monitor user activity.