Finding 1057411 (2023-002)

2023-002 – Sliding Fee Discounts Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Program Cluster CFDA Number: 93.224 / 93.527 Federal Award Number: 5 H80CS10748-16-00 Internal Control: Significant Deficiency Compliance: Special Tests and Provisions Criteria: Health centers must prepare and apply a sliding fee discount schedule and policy so that the amounts owed for health center services by eligible patients are adjusted based on the patient’s ability to pay (42 USC 254(k)(3)(E), (F), and (G); 42 CFR sections 51c.303(e), (f), and (g); and 42 CFR sections 56.303(e), (f), and (g)). Condition: San Ysidro Health lacked adequate controls over its sliding fee discount program to ensure that patients received the correct discount. The following shows the results of our test of program income payments to determine whether San Ysidro Health complies with the Board-approved sliding fee payment schedule. • 3 out of 40 patients sampled were charged with medical fees that did not agree with the stated fee according to the 2023 sliding fee schedules. • 11 out of 40 patients sampled were charged with dental fees that did not agree with the stated fee according to the 2023 sliding fee schedules. Questioned Costs: None Cause: The possible causes for the above errors are as follows: • Growth in patient volumes, clinic site locations and front desk staffing without sufficient expansion of ongoing compliance sampling, testing and subsequent staff training to address instances of non-compliance • Error by staff in determining the patient’s ability to pay • Implementation of new sliding fees in 2023 for dental crowns and dentures without sufficient training for front desk staff Effect: As a result, the sliding fee discounts were applied incorrectly and not in accordance with San Ysidro Health’s policy, resulting in San Ysidro Health over/under billing its lower income patients. Recommendation: It is recommended to develop and maintain proper controls around applying San Ysidro Health's sliding fee discount. Certain procedures should be strengthened to ensure that income is properly verified and adequately documented, and the sliding fee discount is properly determined, reviewed, and applied. This will ensure San Ysidro Health can apply the sliding fee discount in accordance with written polices and comply with federal compliance requirements. San Ysidro Health should provide additional training to staff involved with the sliding fee process to ensure appropriate individuals are properly monitoring and reviewing San Ysidro Health’s compliance with program requirements. Views of Responsible Official: Management acknowledges the finding of the auditors and recognizes the need for improving its Sliding Fee Discount Program systems, processes, and monitoring. In the latter half of 2024, the Billing Department leadership and front desk training team will renew its staff training and oversight efforts to improve compliance. Training on San Ysidro Health’s Sliding Fee Discount Program policies and procedures will be planned, scheduled, and provided for all front desk leaders and staff to ensure that the policies and procedures are followed to mitigate the risk of repetitive findings in following years. In addition, the Billing Department will expand the number of sliding fee encounters sampled and tested for compliance monthly. Noncompliance will serve as the basis for additional follow-up training of staff when noted. Monthly compliance reporting will be provided to senior finance and operational leaders to ensure ongoing monitoring of performance and timely resolution of noncompliance.