Summary of finding: Five out of 40 charts reviewed by the auditors’ showed exceptions to the Sliding Fee Discount Schedule (SFDS) that are not supported by policy or documentation. Findings were identified in three primary categories: inconsistent collection and scanning of documents at registration...
Summary of finding: Five out of 40 charts reviewed by the auditors’ showed exceptions to the Sliding Fee Discount Schedule (SFDS) that are not supported by policy or documentation. Findings were identified in three primary categories: inconsistent collection and scanning of documents at registration, Electronic Health Records (EHR) not operating as expected for one line of the SFDS and error not caught and corrected, and a significant process change from percentage to fixed fee SFDS causing inconsistent application during transition and training period. Planned corrective action: System Configuration: Leaders for all service lines and Billing Department will work with EHR Support Team and vendor to review and test all possible SFDS options to verify rules are functioning as expected and as outlined in the SFDS policy. Annual review and testing of EHR rules governing SFDS to validate ongoing compliance. Contact person: Jennifer Velez, Revenue Cycle Director Completion date for action: 10/31/2025 Staff Training and Documentation: All staff responsible for registration and income verification in all service lines, programs, and sites will receive a review of income eligibility assessment, documentation, and application. Registration Program Manager and EHR Trainers will work with Learning and Development Department to develop competency standard for income eligibility assessment, documentation, and application for all staff responsible for registration and income verification in all service lines, programs, and sites. All identified staff will be required to demonstrate competence annually using the Learning Management System (LMS). The Center will audit 5 patient records for FPL (Federal Poverty Level) documentation per site or program two times annually during C-Qual (the Center’s internal audit process). This will result in 180 charts each year. Site Managers or Department Administrators will review front office dashboard in monthly management meetings and develop site specific action plans if exceptions are identified. This was added to the standing agenda for the Primary Care Clinic Managers (PCCM) meeting in September 2025. Contact person: Angela Hurley, Director of Operations Completion date for action: 12/31/2025 Implementation Controls: Update SFDS policy to include review and verification of EHR alignment with fee schedule following any update or change approved by the Board of Directors. Develop checklist for roll-out of changes in SFDS that prompts change management and training team to review readiness and validation procedures before going live with changes. Contact person: Angela Hurley, Director of Operations Completion date for action: 9/30/2025