Finding 1168207 (2024-005)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2024
Accepted
2026-01-07

AI Summary

  • Core Issue: Deficiencies in the sliding fee discount program documentation led to noncompliance with federal requirements.
  • Impacted Requirements: Failure to maintain necessary documentation for income, family size, and registration forms affects eligibility determinations.
  • Recommended Follow-Up: Implement a review process to ensure all patient files contain complete documentation to support sliding fee eligibility.

Finding Text

Criteria – The HRSA Compliance Manual requires federally qualified health centers (FQHCs) to establish and maintain a sliding fee discount program to ensure that services are accessible to patients regardless of their ability to pay. Eligibility must be based solely on income and family size, supported by appropriate documentation. Under Uniform Guidance (2 CFR §200.303), non-federal entities must establish and maintain effective internal controls over compliance with federal statutes, regulations, and program requirements. The OMB Compliance Supplement (Part 4, Health Center Program Cluster) further emphasizes that health centers must document income and family size to properly apply sliding fee discounts and must consistently implement the approved discount schedule. Condition and Description – During our testing of compliance with the sliding fee discount program, we identified deficiencies in the application and documentation of the sliding fee discount schedule. Of 10 patient encounters selected for review, 6 patient files did not contain a registration form to support determination of sliding fee eligibility. In addition, although the Organization’s policy requires retention of two paystubs for each patient to verify income, only one paystub was maintained in several patient records. Further, 4 patient files reviewed did not contain documentation of household member information, which is required to calculate family size for eligibility determination. These deficiencies reflect noncompliance with the Organization’s policies and federal program requirements and may result in patients not being charged in accordance with their ability to pay. Questioned Costs – Unknown. Cause/Effect –. The Organization did not obtain or retain adequate documentation of patient income, family size, and registration forms to support eligibility determinations. Without this information, compliance with the sliding fee discount requirements could not be demonstrated, creating the risk that discounts were not applied appropriately and federal program requirements were not met

Corrective Action Plan

AHC has revised its patient intake procedures to ensure that all required documentation is collected and verified at the point of service. An electronic eligibility checklist has been integrated into the EHR, and staff have been trained to collect alternative income documentation where appropriate. Monthly audits of ten patient files per site are conducted, and exceptions are logged and resolved within ten business days. Policies and procedures have been updated to reflect documentation and compliance standards. Ongoing monitoring and periodic staff retraining continue to support program integrity and compliance with federal requirements. Moving forward, responsibility for managing the sliding fee discount process will transition from front-desk personnel to the Revenue Cycle department to ensure stronger oversight and accountability.

Categories

Eligibility HUD Housing Programs Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Other Findings in this Audit

  • 1168195 2024-002
    Material Weakness Repeat
  • 1168196 2024-002
    Material Weakness Repeat
  • 1168197 2024-002
    Material Weakness Repeat
  • 1168198 2024-003
    Material Weakness Repeat
  • 1168199 2024-003
    Material Weakness Repeat
  • 1168200 2024-003
    Material Weakness Repeat
  • 1168201 2024-003
    Material Weakness Repeat
  • 1168202 2024-003
    Material Weakness Repeat
  • 1168203 2024-003
    Material Weakness Repeat
  • 1168204 2024-004
    Material Weakness Repeat
  • 1168205 2024-004
    Material Weakness Repeat
  • 1168206 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) $5.00M
93.898 CANCER PREVENTION AND CONTROL PROGRAMS FOR STATE, TERRITORIAL AND TRIBAL ORGANIZATIONS $52,769
93.800 ORGANIZED APPROACHES TO INCREASE COLORECTAL CANCER SCREENING $42,000
93.527 GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $14,425