Finding 1168356 (2025-002)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2025
Accepted
2026-01-08

AI Summary

  • Core Issue: LBUCC failed to accurately determine sliding fee discounts for eligible patients, leading to incorrect charges.
  • Impacted Requirements: Compliance with US Code Title 42, which mandates proper sliding fee discount schedules based on patient income.
  • Recommended Follow-Up: Implement training for staff on discount determination and ensure proper documentation of patient eligibility.

Finding Text

Item 2025-002 - Special Tests and Provisions - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 H80CS00505-23-04, 6 H2ECS45602-02-04, 1 H8LCS50772-01-00 and 6 H8HCS46163-03-01 - (Material Weakness) Criteria: US Code Title 42, The Public Health and Welfare Act, Section 254b requires health centers to prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted or discounted based on the patient's ability to pay. LBUCC’s policy requires that sliding fee discount be modified on an annual basis based on the federal poverty level after the board's approval. Statement of Condition: During our audit, we noted that LBUCC did not properly determine the sliding fee discount provided to certain eligible patients based on information provided during the patient registration process. Additionally, we could not ascertain if the sliding fee discount provided to certain eligible patients were correct as LBUCC did not maintain documentation of the proof of income of those eligible patients. Cause: Lack of proper documentation of eligibility requirements and lack of review process for the determination of sliding fee discount for eligible patients. Effect: Failure to properly apply the sliding fee discount resulted in certain patients being charged incorrect amounts. Questioned Costs: None Context: Out of sixty samples tested, one sample’s family income was incorrectly encoded to the system which resulted in the patient being improperly slid and nine patients had no proof of income on file. Identification as a Repeat Finding: This is not a repeat finding. Recommendation: We recommend that LBUCC conduct training of all of its personnel who are involved in determining and applying the sliding fee scale of patients. We also recommend LBUCC to maintain complete and auditable documentation supporting each patient’s eligibility for sliding fee discount. Management Response: Management agrees with the finding and will implement these measures to ensure equitable access to care, maintain compliance with federal program standards and support accurate reporting and reimbursement

Corrective Action Plan

Material Weakness Item 2025-002 - Special Tests and Provisions - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 H80CS00505-23-04, 6 H2ECS45602-02-04, 1 H8LCS50772-01-00 and 6 H8HCS46163-03-01 During our audit, we noted that LBUCC did not properly determine the sliding fee discount provided to certain eligible patients based on information provided during the patient registration process. Additionally, we could not ascertain if the sliding fee discount provided to certain eligible patients were correct as LBUCC did not maintain documentation of the proof of income of those eligible patients. Recommendation: We recommend that LBUCC conduct training of all of its personnel who are involved in determining and applying the sliding fee scale of patients. We also recommend LBUCC to maintain complete and auditable documentation supporting each patient's eligibility for sliding fee discount. Action Taken: Eligibility was provided additional training which included training on a tool to assist them in determining the proper sliding fee discount. Effectivity Date: Training was held on October 28, 2025, and the tool to assist them was reviewed and provided at that time and implemented immediately thereafter.

Categories

Special Tests & Provisions Cash Management Eligibility Material Weakness Reporting Internal Control / Segregation of Duties

Other Findings in this Audit

  • 1168351 2025-001
    Material Weakness Repeat
  • 1168352 2025-001
    Material Weakness Repeat
  • 1168353 2025-001
    Material Weakness Repeat
  • 1168354 2025-002
    Material Weakness Repeat
  • 1168355 2025-002
    Material Weakness Repeat
  • 1168357 2025-003
    Material Weakness Repeat
  • 1168358 2025-003
    Material Weakness Repeat
  • 1168359 2025-003
    Material Weakness Repeat
  • 1168360 2025-004
    Material Weakness Repeat
  • 1168361 2025-004
    Material Weakness Repeat
  • 1168362 2025-004
    Material Weakness Repeat
  • 1168363 2025-005
    Material Weakness Repeat
  • 1168364 2025-005
    Material Weakness Repeat
  • 1168365 2025-005
    Material Weakness Repeat
  • 1168366 2025-006
    Material Weakness Repeat
  • 1168367 2025-006
    Material Weakness Repeat
  • 1168368 2025-006
    Material Weakness Repeat
  • 1168369 2025-007
    Material Weakness Repeat
  • 1168370 2025-007
    Material Weakness Repeat
  • 1168371 2025-007
    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) $6.32M
10.557 WIC SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN $993,718
93.332 COOPERATIVE AGREEMENT TO SUPPORT NAVIGATORS IN FEDERALLY-FACILITATED EXCHANGES $690,594
93.526 GRANTS FOR CAPITAL DEVELOPMENT IN HEALTH CENTERS $626,094
93.527 GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $62,444
32.006 COVID-19 TELEHEALTH PROGRAM $309