Finding 1170625 (2025-001)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2025
Accepted
2026-01-26
Audit: 383865
Organization: Primary Health Care, Inc. (IA)

AI Summary

  • Core Issue: Patients received sliding fee discounts that did not match the organization's policy categories.
  • Impacted Requirements: Compliance with sliding fee discount policies as outlined in federal regulations (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g) and 56.303(f)).
  • Recommended Follow-Up: Management should ensure staff understand the sliding fee policy, implement procedures for accurate discounts, and audit the EPIC system for compliance by November 2025.

Finding Text

Health Center Program Assistance Listing Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 2 H80CS00715-23-00 Program Year 24 Criteria or specific requirement – Special Tests and Provisions: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g); and 42CFR 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. Cause – The Organization did not comply with their sliding fee policy. Effect or potential effect – Sliding fee discounts were given to patients that were inconsistent with the Organization’s sliding fee discount policy. Questioned costs – None Context – A sample of 25 patients were tested out of the total population of 144,957 encounters. The sampling methodology used is not and is not intended to be statistically valid. Four patients received a sliding fee adjustment that was inconsistent with the approved policy based on their income documentation. 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 and the Health Center Program Compliance Manual. Views of Responsible Officials and Planned Corrective Actions – Management's action plan to improve compliance includes an audit of EPIC to assure that the slide fee categories are loaded and functioning in accordance with the Primary Health Care Sliding Fee Discount Policies, modify EPIC accordingly and correct the system generated “auto-slide” issue, to be led by Beth Frantum, Chief Financial Officer to be completed in November 2025. Beth will then update resource materials and distribute them to the necessary staff. Beth will develop and implement an internal review process to provide reasonable assurance that slide fee category calculations are accurate and EPIC reflects the correct amount expected for services.

Corrective Action Plan

Primary Health Care Corrective Action Plan – Sliding Fee Finding: During the External Financial Audit for FY 2025, it was determined that certain patients had received sliding fee discounts that were not consistent with the stated sliding fee discount categories under PHC’s policy. Action Step Lead Support Due Date Update resource materials associated with sliding fee discounts and distribute to necessary staff. Provide training to necessary staff on sliding fee discount policy and any changes to discounts. Beth Frantum, CFO Revenue Cycle Director Patient Services Director March 2026 Develop and implement an internal review process to provide reasonable assurance that Slide calculations are accurate and EPIC reflects the correct amount expected for services. Beth Frantum, CFO Revenue Cycle Director Patient Services Director John Shaw, Director of Clinics April 2026

Categories

Special Tests & Provisions Matching / Level of Effort / Earmarking

Other Findings in this Audit

  • 1170623 2025-001
    Material Weakness Repeat
  • 1170624 2025-001
    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) $7.31M
21.023 EMERGENCY RENTAL ASSISTANCE PROGRAM $1.70M
64.033 VA SUPPORTIVE SERVICES FOR VETERAN FAMILIES PROGRAM $1.62M
14.267 CONTINUUM OF CARE PROGRAM $599,702
21.027 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS $445,341
14.241 HOUSING OPPORTUNITIES FOR PERSONS WITH AIDS $363,028
93.918 GRANTS TO PROVIDE OUTPATIENT EARLY INTERVENTION SERVICES WITH RESPECT TO HIV DISEASE $359,877
93.917 HIV CARE FORMULA GRANTS $246,867
93.243 SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES PROJECTS OF REGIONAL AND NATIONAL SIGNIFICANCE $228,900
93.217 FAMILY PLANNING SERVICES $209,529
93.527 GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $73,061
14.239 HOME INVESTMENT PARTNERSHIPS PROGRAM $63,748
14.231 EMERGENCY SOLUTIONS GRANT PROGRAM $55,294
93.800 ORGANIZED APPROACHES TO INCREASE COLORECTAL CANCER SCREENING $38,000
93.940 HIV PREVENTION ACTIVITIES HEALTH DEPARTMENT BASED $6,353
93.270 VIRAL HEPATITIS PREVENTION AND CONTROL $1,730