Audit 48497

CRITERIA: Providers of health care services who receive funding under this program are required to apply a sliding scale fee discount to all individuals and families based on annual income and household size. CONDITION: During our sliding scale fee discount testing procedures, we selected 18 transactions to test that the patient met the criteria for the sliding fee scale discount and that the discount was properly applied. We identified three instances in our sample where the sliding fee discount applied to the patient was incorrect, resulting in the patient paying a higher rate for services than they were otherwise entitled to. We also noted salary amounts were not consistently documented, resulting in errors in the determination of the appropriate sliding scale fee discount. CAUSE and CONTEXT: Based on discussions with clinic management, it appears there is no consistent process used to inform patients of their right to receive a fee discount based on their income and household size. It also appears patient intake forms are not being consistently reviewed to ensure accurate demographic information is entered into the patient billing system in order for the appropriate sliding fee scale discount to be applied. POSSIBLE EFFECT: In our judgment, without accurate demographic information, patients at the clinic may not receive the appropriate sliding scale fee discount. RECOMMENDATION: We recommend the Organization develop formal procedures to ensure patients are given the opportunity to provide demographic information, and that this information is reviewed for accuracy when input into the patient billing system. Such procedures could include placing a placard in the main area of the clinic and in the treatment rooms informing patients of their right to receive a discount to encourage patients to provide the required information, and implementation of a periodic review process to ensure accuracy of data input and the application of sliding scale discounts. VIEWS of RESPONSIBLE OFFICIALS and PLANNED CORRECTIVE ACTIONS: We agree. CAP has embarked on a process to improve our formal procedures to ensure patients are given the opportunity to provide demographic information, and that this information is reviewed for accuracy when input into the patient billing system. Though patients are informed of the opportunity and their rights through existing visible signage, patient enrollment information, and via our website, these communications will be expanded and improved. The waiting room placard will be included in all exam rooms, patient application clarity will be improved and all applications reviewed in a 2-person verification process. Data entry procedures will be improved through a Plan-Do-Study-Act (PDSA) process. We have identified four key areas to improving the collection of accurate income and household size: staff and patient discomfort, the electronic health record (EHR), in-person versus telemedicine visits, and staff pre-appointment data scrubbing processes. The Prism team is activating plans on these four identified needs.

CRITERIA: Projects funded under this program are required to follow HRSA American Rescue Plan Act Emergency Action Section 106, Project Review Process, prior to submitting claims for reimbursement of costs for alteration or renovation projects. CONDITION: The Organization applied to the State Historic Preservation Office (SHPO) as required for approval of a roof restoration and emergency generator installation on the Prism Clinic structure in October 2021. The finance department drew down federal funds to reimburse costs after the project was completed, but before approval had been received from the SHPO. CAUSE and CONTEXT: The Organization had several communications with the SHPO during the course of the project regarding changes in scope and additional information requested by the SHPO. During the process, the individual managing the project went on leave and subsequently resigned from the Organization. The finance department followed procedures to draw down federal funds after costs had been incurred, but were not aware of the requirement for SHPO approval prior to submitting the claim. The lack of communication appears to be due to the unexpected leave taken by the project manager. EFFECT: The funder notified the Organization in September 2022 that the funds drawn down for the roof restoration and generator installation needed to be returned. Funds were returned to HRSA in October 2022. QUESTIONED COSTS: $50,284 in total. RECOMMENDATION: We recommend the Organization implement a more robust grant review process to ensure that personnel involved in managing grant funds and requests for reimbursement are aware of any special tests or provisions prior to submitting applications for reimbursement under federal programs. VIEWS of RESPONSIBLE OFFICIALS and PLANNED CORRECTIVE ACTIONS: We agree. CAP is implementing a more robust grant review process to ensure that all personnel involved in managing grant funds and requests for reimbursements are aware of special tests or provisions prior to submitting applications for reimbursements. This process includes circulating grant agreements and contracts to all those involved in management and reimbursement prior to the beginning of a grant as well as a multi-step reimbursement approvement process.

CRITERIA: Providers of health care services who receive funding under this program are required to apply a sliding scale fee discount to all individuals and families based on annual income and household size. CONDITION: During our sliding scale fee discount testing procedures, we selected 18 transactions to test that the patient met the criteria for the sliding fee scale discount and that the discount was properly applied. We identified three instances in our sample where the sliding fee discount applied to the patient was incorrect, resulting in the patient paying a higher rate for services than they were otherwise entitled to. We also noted salary amounts were not consistently documented, resulting in errors in the determination of the appropriate sliding scale fee discount. CAUSE and CONTEXT: Based on discussions with clinic management, it appears there is no consistent process used to inform patients of their right to receive a fee discount based on their income and household size. It also appears patient intake forms are not being consistently reviewed to ensure accurate demographic information is entered into the patient billing system in order for the appropriate sliding fee scale discount to be applied. POSSIBLE EFFECT: In our judgment, without accurate demographic information, patients at the clinic may not receive the appropriate sliding scale fee discount. RECOMMENDATION: We recommend the Organization develop formal procedures to ensure patients are given the opportunity to provide demographic information, and that this information is reviewed for accuracy when input into the patient billing system. Such procedures could include placing a placard in the main area of the clinic and in the treatment rooms informing patients of their right to receive a discount to encourage patients to provide the required information, and implementation of a periodic review process to ensure accuracy of data input and the application of sliding scale discounts. VIEWS of RESPONSIBLE OFFICIALS and PLANNED CORRECTIVE ACTIONS: We agree. CAP has embarked on a process to improve our formal procedures to ensure patients are given the opportunity to provide demographic information, and that this information is reviewed for accuracy when input into the patient billing system. Though patients are informed of the opportunity and their rights through existing visible signage, patient enrollment information, and via our website, these communications will be expanded and improved. The waiting room placard will be included in all exam rooms, patient application clarity will be improved and all applications reviewed in a 2-person verification process. Data entry procedures will be improved through a Plan-Do-Study-Act (PDSA) process. We have identified four key areas to improving the collection of accurate income and household size: staff and patient discomfort, the electronic health record (EHR), in-person versus telemedicine visits, and staff pre-appointment data scrubbing processes. The Prism team is activating plans on these four identified needs.

CRITERIA: Projects funded under this program are required to follow HRSA American Rescue Plan Act Emergency Action Section 106, Project Review Process, prior to submitting claims for reimbursement of costs for alteration or renovation projects. CONDITION: The Organization applied to the State Historic Preservation Office (SHPO) as required for approval of a roof restoration and emergency generator installation on the Prism Clinic structure in October 2021. The finance department drew down federal funds to reimburse costs after the project was completed, but before approval had been received from the SHPO. CAUSE and CONTEXT: The Organization had several communications with the SHPO during the course of the project regarding changes in scope and additional information requested by the SHPO. During the process, the individual managing the project went on leave and subsequently resigned from the Organization. The finance department followed procedures to draw down federal funds after costs had been incurred, but were not aware of the requirement for SHPO approval prior to submitting the claim. The lack of communication appears to be due to the unexpected leave taken by the project manager. EFFECT: The funder notified the Organization in September 2022 that the funds drawn down for the roof restoration and generator installation needed to be returned. Funds were returned to HRSA in October 2022. QUESTIONED COSTS: $50,284 in total. RECOMMENDATION: We recommend the Organization implement a more robust grant review process to ensure that personnel involved in managing grant funds and requests for reimbursement are aware of any special tests or provisions prior to submitting applications for reimbursement under federal programs. VIEWS of RESPONSIBLE OFFICIALS and PLANNED CORRECTIVE ACTIONS: We agree. CAP is implementing a more robust grant review process to ensure that all personnel involved in managing grant funds and requests for reimbursements are aware of special tests or provisions prior to submitting applications for reimbursements. This process includes circulating grant agreements and contracts to all those involved in management and reimbursement prior to the beginning of a grant as well as a multi-step reimbursement approvement process.