Finding 1162763 (2024-004)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2024
Accepted
2025-11-20
Audit: 372390
Organization: Northshore Health Centers, INC (IN)

AI Summary

  • Core Issue: Incorrect sliding fee discounts were applied to patient encounters due to errors in family size and income assessments.
  • Impacted Requirements: Health centers must ensure discounts reflect patients' ability to pay, adhering to the correct fee schedule.
  • Recommended Follow-Up: Management should review and simplify sliding fee policies, enhance training for the revenue cycle team, and implement regular accuracy checks on discounts.

Finding Text

2024-004 Information on the Federal Program: Assistance Listing Number 93.224/93.527; Health Center Program Cluster; Department of Health and Human Services Criteria Or Specific Requirement: Special Tests and Provisions – Sliding Fee Discounts: Health centers must prepare and apply a sliding fee discount schedule, so the amounts owed for health center services by eligible patients are discounted based on patient’s ability to pay. Condition: The Center had incorrect slide discounts applied to patient encounters based on family size and income on initial intake of information. Also, there were multiple billing codes that received discounts based on commercial insurance allowed costs rather than the center’s fee schedule, which is not allowed. Cause: The intake personnel filed the incorrect slides based on family size and income that eventually got applied to the electronic health records system. There was also incorrect discount methodologies coded to the electronic health records system that resulted in unallowed applied discounts. Effect or Potential Effect: Inaccurate discounts provided to patients based on their ability to pay which could result in over or under payment. Questioned Costs: None. Context: There were 25 patient encounters tested and there were improper discounts applied to 6 during the year. The sample was not statistically valid. Identification as a Repeat Finding, if Applicable: Not a repeat finding. Recommendation: We recommend management review their sliding fee policies and schedules for complexity and increase training provided to their full revenue cycle team. Views of Responsible Officials and Planned Corrective Actions: Management acknowledged the sliding fee adjustment errors resulted from incorrect calculation of sliding fee discount. Management will add an additional layer of review over the application of the sliding fee scale. Further, the Center will implement a process to periodically review sliding fee adjustments throughout the year for accuracy.

Corrective Action Plan

Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-004: • NorthShore Health Centers, Inc. acknowledged the sliding fee adjustment errors resulted from incorrect calculation of sliding fee discount. Management will add an additional layer of review over the application of the sliding fee scale. Further, the Center will implement a process to periodically review sliding fee adjustments throughout the year for accuracy. • Management expects full implementation as of December 31, 2025

Categories

Special Tests & Provisions

Other Findings in this Audit

  • 1162758 2024-003
    Material Weakness Repeat
  • 1162759 2024-003
    Material Weakness Repeat
  • 1162760 2024-003
    Material Weakness Repeat
  • 1162761 2024-004
    Material Weakness Repeat
  • 1162762 2024-004
    Material Weakness Repeat

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) $5.68M
21.027 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS $158,578
93.527 GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $149,714
14.218 COMMUNITY DEVELOPMENT BLOCK GRANTS/ENTITLEMENT GRANTS $75,000
93.426 THE NATIONAL CARDIOVASCULAR HEALTH PROGRAM $55,000