Finding 1164574 (2025-001)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2025
Accepted
2025-12-11
Audit: 374174
Organization: Axis Health System (CO)

AI Summary

  • Core Issue: Patients received sliding fee discounts that did not match the Organization’s policy.
  • Impacted Requirements: Compliance with sliding fee discount categories as outlined in federal regulations.
  • Recommended Follow-Up: Ensure staff fully understand and follow the sliding fee scale policy; implement procedures for accurate discount application.

Finding Text

U.S. Department of Health and Human Services Criteria: Special Tests and Provision: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g); and 42 CFR sections 56.303 (f)) Condition: Patients received a sliding fee discount that was inconsistent with the stated sliding fee discount categories under the Organization’s policy. Questioned Costs: None Context: A sample of 25 encounters out of a population of 6,030 encounters were tested and two errors were noted where patients received an incorrect sliding fee adjustment. The sampling methodology used is not and is not intended to be statistically valid. Two patients received a sliding fee adjustment that was inconsistent with the approved policy for the proper sliding fee adjustments based on their income documentation. Effect: Sliding fee discounts were given to patients that were inconsistent with the Organization’s sliding fee discount policy. Cause: The Organization did not comply with their sliding fee policy. Identification as a repeat finding: Not a repeat finding Recommendation: We recommend management continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale. Views of responsible officials: The Organization agrees with the finding. See separate report for planned corrective actions.

Corrective Action Plan

Federal Assistance Listing No. 93.224 Health Center Program Cluster Award #: H80CS26510, Award year: March 1, 2023 – February 29, 2025, extended to February 28, 2026 U.S. Department of Health and Human Services Criteria: Special Tests and Provision: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g); and 42 CFR sections 56.303 (f)) Condition: Patients received a sliding fee discount that was inconsistent with the stated sliding fee discount categories under the Organization’s policy. Questioned Costs: None Context: A sample of 25 encounters out of a population of 6,030 encounters were tested and 2 errors were noted where patients received an incorrect sliding fee adjustment. The sampling methodology used is not and is not intended to be statistically valid. Two patients received a sliding fee adjustment that was inconsistent with the approved policy for the proper sliding fee adjustments based on their income documentation. Effect: Sliding fee discounts were given to patients that were inconsistent with the Organization’s sliding fee discount policy. Cause: The Organization did not comply with their sliding fee policy. Identification as a repeat finding: Not a repeat finding. Recommendation: We recommend management continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale. CLIENT PLANNED ACTION: A new integrated EHR was implemented and will standardize and improve the accuracy and consistency of Sliding Fee Discount data entry, streamline training, auditing and compliance activities related to the Sliding Fee Discount Program going forward. In direct response to this finding related to the dental program, supplemental training has been developed to enhance existing programs. Dental front desk and billing staff will complete this required training by end of January 2026. Quarterly internal audits of the Sliding Fee Discount Program are conducted in the new EHR by the Director of Reimbursement, sampling all CHC locations with dental encounters included each time. Results are used to track compliance trends and trigger targeted training or oversight for locations or staff to ensure eligible patients receive appropriate income-based discounts. CLIENT RESPONSIBLE PARTY: JC Carrica III, Chief Administrative Officer (CAO) COMPLETION DATE: • Sliding Fee Discount Program quarterly audits – ongoing. • Identified staff will complete the specialized training session by January 31, 2026.

Categories

Special Tests & Provisions

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) $4.18M
93.696 CERTIFIED COMMUNITY BEHAVIORAL HEALTH CLINIC EXPANSION GRANTS $761,780
93.959 BLOCK GRANTS FOR PREVENTION AND TREATMENT OF SUBSTANCE ABUSE $396,850
93.958 BLOCK GRANTS FOR COMMUNITY MENTAL HEALTH SERVICES $184,511
84.126 REHABILITATION SERVICES VOCATIONAL REHABILITATION GRANTS TO STATES $134,636
93.788 OPIOID STR $78,795
21.027 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS $75,880
93.493 CONGRESSIONAL DIRECTIVES $54,166
93.069 PUBLIC HEALTH EMERGENCY PREPAREDNESS $43,000
93.217 FAMILY PLANNING SERVICES $36,836
93.575 CHILD CARE AND DEVELOPMENT BLOCK GRANT $25,144