Finding 1159439 (2024-001)

Finding 2024-001 – N: Special Tests and Provisions Information on the Federal Program: Grantor: United States Department of Health and Human Services Program Name: Health Centers Cluster Assistance Listing Numbers: 93.224 – Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care); 93.527 – Grants for New and Expanded Services under the Health Center Program Criteria or Specific Requirement: Title 2 U.S. Code of Federal Regulations (CFR), Part 200.303 of the Uniform Guidance states the following regarding internal control, “The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Per 42 CFR sections 51c.303(e), (f), and (g) and 42 CFR sections 56.303(e), (f), and (g), 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 as defined by these subsections. Condition: Montefiore Health System, Inc. (the Health System) has an established policy for the Bronx Health Collective that includes a SFDS that complies with federal regulations. Per the policy, eligibility for application of the SFDS should be evaluated once a year. In our review of a sample of financial records for patients treated during the audit period, it was noted that for 14 out of 40 patient files selected for review, the Health System was unable to demonstrate that internal controls were operating effectively to ensure proper application of the Health System’s policy relating to the SFDS. Specifically, documentation supporting the application of the SFDS was not obtained within a year of the visit in line with the Health System’s policy. Cause: The deficiency appears to be due to inconsistent documentation and monitoring practices in the patient intake process. Effect or Potential Effect: Without adequate documentation and effective internal controls, the auditee may improperly apply its SFDS policy. This could result in eligible patients being incorrectly charged for services, which may limit access to care and jeopardize compliance with program requirements. Questioned Costs: Not applicable. Context: As part of our control testing over the compliance requirement, we reviewed a random sample of 40 patient financial records to assess the application of the Health System’s SFDS policy. The sample was designed to provide sufficient coverage of the population and identify potential control deficiencies. In 14 of the 40 patient files selected for review, the Health System was unable to demonstrate that internal controls were operating effectively to ensure proper application of the Health System’s policy relating to the SFDS. Specifically, documentation supporting the application of the SFDS was not obtained or tracked within the patient’s electronic medical record within a year of the visit in line with the Health System’s policy. In each of the instances where documentation was not available, there were no out-of-pocket costs charged to the patient. Identification as a repeat finding: This finding is not a repeat finding from the prior year. Recommendation: The Health System should improve its process by implementing standardized procedures for documenting income and family size, conducting regular staff training on eligibility determination and documentation requirements, and performing periodic internal reviews to ensure compliance with the SFDS policy including retention of evidence supporting the performance of the control. View of responsible officials: Management concurred with the audit finding and implemented standardized procedures to enhance screening and enrollment of patients. Additional controls are in place to ensure timely documentation of income and family size. In order to ensure compliance with the SFDS policy including documentation and retention, a policy was adopted requiring reviews on the day before visit, during visit and day after visit, as well as periodic retrospective reviews. There will be regular staff training on eligibility, determination and documentation requirements.