Finding 1151755 (2024-001)

Significant Deficiency
Requirement
N
Questioned Costs
-
Year
2024
Accepted
2025-09-02

AI Summary

  • Core Issue: A significant internal control deficiency was found in how sliding fee discounts were applied to patient accounts, leading to incorrect discount amounts.
  • Impacted Requirements: Compliance with Title 42 Chapter 1 Subchapter D Section 51c303(f) regarding proper fee schedules and discounts based on patients' ability to pay.
  • Recommended Follow-Up: Investigate the error's cause, provide training for staff, and implement a review process to ensure discounts are applied correctly.

Finding Text

2024 – 001 Federal Agency: U.S Department of Health and Human Services Federal Program Title: Consolidated Health Centers Assistance Listing Numbers: 93.224/93.527 Award Period: 3/1/23 – 2/28/24 and 3/1/24 – 2/28/25 Type of Finding: • Significant Deficiency in Internal Control over Compliance Criteria or Specific Requirement: Per Title 42 Chapter 1 Subchapter D Section 51c303(f), “Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted on the basis of the patient’s ability to pay.” Condition: During our testing of sliding fee discounts for health center patients qualifying for reduced charge visits, we identified one encounter where the sliding fee discount was calculated properly on the sliding fee application, but applied incorrectly to the patient account. Questioned costs: None. Context: The patient intake process occurred according to policy and a 20% adjustment was determined based on family size and income level. When the discount was applied to the patient's accounts, a manual error was made and the discount was applied at 100%. Cause: Manual error entering the patient discount in the electronic medical record system. Effect: Individual received a larger discount than should have been provided according to policy. In addition, without sufficient internal control and review processes in place, there is a greater risk of additional errors occurring. Recommendation: We recommend the Organization investigate the underlying cause of the error, and provide education or incorporate some sort of reconciliation or review process to ensure sliding fee adjustments applied match the original determination. View of responsible officials: No disagreement with the finding. Management will provide training to individuals involved with entering sliding fee discounts into EMR and will investigate other review or reconciliation procedures that could be incorporated to reduce risk.

Categories

Significant Deficiency Internal Control / Segregation of Duties

Other Findings in this Audit

  • 575313 2024-001
    Significant Deficiency
  • 575314 2024-001
    Significant Deficiency
  • 1151756 2024-001
    Significant Deficiency

Programs in Audit

ALN Program Name Expenditures
93.224 Health Center Program (community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) $1.50M
93.527 Grants for New and Expanded Services Under the Health Center Program $212,309
93.525 State Planning and Establishment Grants for the Affordable Care Act (aca)’s Exchanges $155,448
93.898 Cancer Prevention and Control Programs for State, Territorial and Tribal Organizations $64,918
93.268 Immunization Cooperative Agreements $60,140
14.218 Community Development Block Grants/entitlement Grants $40,500
93.526 Grants for Capital Development in Health Centers $39,112