Finding 1166709 (2025-004)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2025
Accepted
2025-12-29

AI Summary

  • Core Issue: Inaccuracies in sliding fee adjustments were found, including incorrect fees charged and lack of income verification for patients.
  • Impacted Requirements: The Center's sliding fee policy was not consistently followed, risking noncompliance with federal funding regulations.
  • Recommended Follow-Up: Strengthen internal controls, provide additional training for staff, and ensure independent oversight of the sliding fee application process.

Finding Text

Criteria: This award requires that health centers provide sliding fee discounts for services provided based on the patient’s ability to pay, in accordance with the Center’s sliding fee policy. The patient’s ability to pay is based on the type of services provided, patient’s annual income, and household size, in accordance with the Center’s sliding fee policy. Condition and Context: During our audit of a sample of 40 patients who received sliding fee adjustments, we noted the following: • For 4 of 40 patients tested, the fee charged for the service(s) provided did not agree to the fee schedule. It is further noted that this would not have had any bearing on the correct slide being charged. However, charging an incorrect fee could lead to an incorrect amount being written off as a sliding fee adjustment. • For 1 of 40 patients tested, documentation noted that the patient originally self-declared no income but then was seen for multiple visits thereafter with no income verification. Ultimately no slide was applied and the entire balance was written off. Per the Center’s policy, a patient may only self-declare income once. Future visits should have required income verification to determine the proper discount to apply. • For 1 of 40 patients tested, the income support provided supports a higher annual income than what was calculated on the application. As a result, the patient should not have qualified for a sliding fee discount based on the behavioral health sliding fee scale. While the correct sliding fee discount was charged based on the annual income as noted on the application, the error in annual income calculation did not support the patient being eligible for any sliding fee discount. Effect: While there are no material questioned costs associated with these findings, the effect of the breakdown in internal controls over the sliding fee application process allows for potential noncompliance related to the use of federal funds. Cause: The cause of these findings was due to insufficient review and oversight of the sliding fee application process. Recommendation: We recommend the entity strengthen its internal controls over the sliding fee application and administration process, to include further training of individuals with responsibility for approving sliding fee applications, and enhanced oversight by an independent person to ensure the correct fees are charged for services provided, and the income verification supports the correct sliding fee discount based on the sliding fee scales in effect at time of service. We further recommend enhancements to internal controls to ensure that patients who self-declare no income are providing income verification at subsequent visits.

Corrective Action Plan

HHC has reviewed our process for reporting appropriate charges for each CPT code on bills to all third-party payors and found that in isolated cases, the EPIC system was reporting the Sliding Fee Discount Fee on the bill and not the charge from our Fee Schedule for selected CPT codes. HC will collaborate with our EPIC partner- UPMC- to identify why the bills are not appropriately reflecting the CPT code fees from our Fee Schedule instead of the Sliding Fee Discount Fee. HHC has implemented a quarterly internal review process for compliance with all Sliding Fee Discount program requirements. HHC has reviewed our Sliding Fee Discount Policy and determined that there are areas that require revision. There should not be any patients that are given a sliding fee discount based on their self-declaration of income and then continue to receive care without the provision of income verification. HHC is in the process of a total review of our Sliding Fee Discount Policy/Process/Application and will make appropriate adjustments to ensure compliance with the HRSA Sliding Fee Discount Requirements. HHC will replace our One-Time Sliding Fee process with a more compliant approach that will involve: Self-Declaration of Income, whereby the patient will provide us with the income and family size without the required supporting documentation and the appropriate sliding fee will be applied for that visit only, and all future visits will be considered a full fee patient until the patient provides the appropriate support for income and family size; All patients will be requested to provide their income and family size. HHC has implemented a quarterly internal review process for compliance with all Sliding Fee Discount program requirements. HHC has reviewed the claim in question and has no explanation as to why the income reported for a patient was different than the supporting income documents provided by the patient. HHC recognizes that this occurred in only one of forty patient samples. HHC will ensure that all employees that are involved with the Sliding Fee Discount program are re-trained on the importance of accurately reporting the patient’s income based on the supporting documentation provided by the patient. HHC has implemented a quarterly internal review process for compliance with all Sliding Fee Discount program requirements.

Categories

Internal Control / Segregation of Duties

Other Findings in this Audit

  • 1166704 2025-002
    Material Weakness Repeat
  • 1166705 2025-004
    Material Weakness Repeat
  • 1166706 2025-002
    Material Weakness Repeat
  • 1166707 2025-004
    Material Weakness Repeat
  • 1166708 2025-002
    Material Weakness Repeat
  • 1166710 2025-003
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
10.557 WIC SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN $1.34M
93.926 HEALTHY START INITIATIVE $1.23M
93.526 GRANTS FOR CAPITAL DEVELOPMENT IN HEALTH CENTERS $455,411
93.217 FAMILY PLANNING SERVICES $355,000
93.918 GRANTS TO PROVIDE OUTPATIENT EARLY INTERVENTION SERVICES WITH RESPECT TO HIV DISEASE $216,839
93.224 HEALTH CENTER PROGRAM (COMMUNITY HEALTH CENTERS, MIGRANT HEALTH CENTERS, HEALTH CARE FOR THE HOMELESS, AND PUBLIC HOUSING PRIMARY CARE) $140,992
93.297 TEENAGE PREGNANCY PREVENTION PROGRAM $120,015
93.566 REFUGEE AND ENTRANT ASSISTANCE STATE/REPLACEMENT DESIGNEE ADMINISTERED PROGRAMS $119,754
93.268 IMMUNIZATION COOPERATIVE AGREEMENTS $118,528
93.959 BLOCK GRANTS FOR PREVENTION AND TREATMENT OF SUBSTANCE ABUSE $103,494
93.994 MATERNAL AND CHILD HEALTH SERVICES BLOCK GRANT TO THE STATES $68,757
93.527 GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $46,115
93.092 AFFORDABLE CARE ACT (ACA) PERSONAL RESPONSIBILITY EDUCATION PROGRAM $24,916
10.572 WIC FARMERS' MARKET NUTRITION PROGRAM (FMNP) $18,134