Finding Text
Criteria
Pursuant to 42 CFR section 56.303(g)(2), health centers must make every reasonable effort, including the establishment of systems for eligibility determination, billing, and collection, to secure from patients, payments for services in accordance with the schedule of fees and discounts.
Condition
During our testing of special tests and provisions, we noted instances of noncompliance relating to the health center’s application of sliding fee discounts to patient charges; 6 out of 53 patient records sampled showed instances where patient charges were not appropriately adjusted to be consistent with the sliding fee discount schedule.
Cause
Personnel were not following CAMcare’s Financial Sliding Fee Scale Policies and Procedures, which comply with 42 CFR section 56.303(g)(2). Additionally, a revised sliding fee scale was implemented as of 10/1/2023 with updated scale ratings, there was a delay in applying the revised scales to the billing system, and not all personnel were notified of the scale revisions prior to applying the discounts to patient charges. At the time of registration, some applications were not updated to indicate the correct rating, and the system was not updated with the correct payment information.
Effect
Possibility of draw down restriction being placed on Payment Management System (PMS) account or denial of future funding.
Questioned Costs
None
Perspective Information
We tested a statistically valid sample of 53 patient encounters out of a total population of 11,961 uncompensated care program encounters and determined that the audit finding represented a systemic problem.
Repeat Finding
This is a repeat of Finding # 2022-005.
Recommendation
We recommend that management review financial sliding fee scale policies and procedures in place and closely monitor the patient billing process to ensure CAMcare is in compliance with the compliance requirements of 42 CFR section 56.303(g)(2). Prior to registering patient visits, front desk personnel (i.e., Intake) should review patient application information to ensure the information agrees to the registration system. Any information that does not reconcile should be reviewed and corrected by the financial screening team promptly, and prior to applying the sliding fee discount to patient billing records.
Additionally, any time CAMcare revises/updates their sliding fee discount schedule, all necessary personnel should be notified of the revisions, and the financial screening team should review and update patient applications accordingly. Such revisions/updates to the scale should be reflected in the billing system promptly upon implementation of the revised scale.
Views of Responsible Officials
Management recognizes the deficiency; on December 10, 2024, CAMcare’s Interim CFO, Jim Cucinotta agreed with this finding, and explained that CAMcare made significant changes to the patient payment collection process and other policies, and the new EMR system allows for individual Patient Service Representatives (front desk personnel) to monitor management’s adherence to collection efforts.