Finding Text
2023-002 – Significant Deficiency in Internal Control and Noncompliance with Special Tests and Provisions in Application of Organization's Sliding Fee Discounts Policy
Identification of federal program: 93.224 – Health Center Program Cluster
Criteria: Health centers must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay.
Condition: The Organization has approved a SFDS policy that is consistent with requirements based on federal poverty guidelines and which requires eligible patients to pay a nominal fee as outlined in a Sliding Fee Co-Payment schedule. During the year the control that was designed failed to ensure the proper application of slide adjustments to patient accounts, which resulted in some patients paying amounts that were not in accordance with the SFDS.
Cause: There was turnover during the year where individuals processing the adjustments may not have understood the policy and did not properly apply it to the patient. Additionally, the Organization changed billing systems during the year and did not properly monitor and test to ensure that correct rates were being applied.
Effect or potential effect: The Organization was not in compliance with special tests and provisions during the year. Misapplication of the policy could result in eligible patients being charged in excess of what is permitted by the SFDS, and conversely, excess discounts of patient balances over the adopted policy could result in financial losses to the Organization.
Questioned Costs: N/A
Context: During review of the SFDS and the eligibility application utilized by the Organization as a part of their process of determining and documenting the discounts applicable, the auditor reviewed the application completed for 40 patient accounts, in which it was noted:
• One instance where an approved eligibility application was not filed and retained but the discount was still applied.
• Two instances where staff review and approval of the application was not documented in the “For Office Use Only” section but the discount was still applied.
• Four instances where the application contained inaccurate eligibility dates but the discount was still applied.
• Fourteen instances where the amount charged to the patient was not in accordance with the SFDS co-payment fee schedule.
Identification of Repeat Finding: Repeat of finding 2022-001.
Recommendation: We recommend the Organization improve processes to ensure that the patient’s application is appropriately reviewed and documented approval on the form by trained staff personnel, and that all documentation be retained. Additionally, ensure that the staff processing patient billings and slide adjustments understand the policy and the system application to patient accounts to ensure accuracy and that correct rates and discounts are being used in accordance with the approved copayment fee schedule.
Views of Responsible Officials: See Corrective Action Plan.