Finding 1175771 (2025-007)

Material Weakness Repeat Finding
Requirement
E
Questioned Costs
-
Year
2025
Accepted
2026-02-28

AI Summary

  • Core Issue: Medication assistance was incorrectly provided to a patient with active insurance coverage, violating eligibility requirements.
  • Impacted Requirements: Lack of a formal policy and inconsistent procedures for determining eligibility led to inappropriate assistance, resulting in questioned costs of $2,079.
  • Recommended Follow-Up: Implement a formal policy for eligibility determinations, requiring secondary reviews and clear communication with the Finance Department to ensure compliance with grant requirements.

Finding Text

Rural Healthcare Services Programs Assistance Listing Number 93.912 U.S. Department of Health and Human Services Award No. 6 HB1RH47071-02-02, September 30, 2023 – August 31, 2024 Award No. 4 HB1RH47071-03-02, September 1, 2024 – August 31, 2026 Criteria or specific requirement – Eligibility Condition – Medication assistance was provided to a patient who was not eligible to receive assistance on the date of service due to active insurance coverage for the prescription. Questioned costs – $2,079. Questioned costs were determined to be the actual amount the Organization paid in medication assistance benefits. Context – A sample of 25 medication assistance benefits totaling $7,622 was tested from a population of 707 instances of medication assistance totaling $344,631 during the fiscal year. Samples were not, and were not intended to be, statistically valid. For one instance of medication assistance in the sample, medication assistance benefits of $2,079 were provided for a patient and prescription who did not meet the eligibility requirements at the time assistance was provided. Effect – Medication assistance benefits was provided for a prescription allowed under the patient’s insurance benefits. Cause – The Organization’s eligibility procedures are not supported by a formal policy or consistently followed as written. Additionally, the Procedure for Medication Financial Assistance provides Community Health Workers and other staff significant discretion in making eligibility determinations. This flexibility and subjective process, while intended to reduce barriers to patients obtaining opioid use disorder treatments, increases the risk for inconsistent and inappropriate eligibility determinations. Identification as a repeat finding, if applicable – Not a repeat finding. Recommendation – The Organization should implement a formal policy for medication assistance eligibility determinations. The formal policy should clearly identify grant requirements, such as the grant being the payor-of-last-resort, from operational preferences and require a secondary review of all eligibility determinations. Views of responsible officials and planned corrective actions – Issues identified during the audit were indicative of an overall lack of controls and processes by grant directors and Finance Department staff. The Organization has reviewed the processes and has developed a formalized policy for medication assistance eligibility determinations, clearly identifying grant requirements for eligibility. Additionally, the procedure associated with the policy identifies the need for secondary review of eligibility determinations and clear communication to the Finance Department along with adequate record keeping. The Organization’s CEO, a former CFO of the organization, will continue to provide oversight for the Finance Department to ensure controls and processes are implemented.

Corrective Action Plan

2025-007: Medication assistance was provided to a patient who was not eligible to receive assistance on the date of service due to active insurance coverage for the prescription. The Organization’s eligibility procedures were not supported by a formal policy or consistently followed as written. Additionally, the Procedure for Medication Financial Assistance provides Community Health Workers and other staff significant discretion in making eligibility determinations. This flexibility and subjective process, while intended to reduce barriers to patients obtaining opioid use disorder treatments, increases the risk for inconsistent and inappropriate eligibility determinations. Responsible Persons: Karen R. White, CPA, Chief Executive Officer and Matthew Derryberry, Chief Financial Officer Completion Date: May 2026 Views of responsible officials and planned corrective actions: Issues identified during the audit were indicative of an overall lack of controls and processes by grant directors and Finance Department staff. The Organization has reviewed the processes and has developed a formalized policy for medication assistance eligibility determinations, clearly identifying grant requirements for eligibility. Additionally, the procedure associated with the policy identifies the need for secondary review of eligibility determinations and clear communication to the Finance Department along with adequate record keeping. The Organization’s CEO, a former CFO of the organization, will continue to provide oversight for the Finance Department to ensure controls and processes are implemented.

Categories

Eligibility Internal Control / Segregation of Duties

Other Findings in this Audit

  • 1175767 2025-003
    Material Weakness Repeat
  • 1175768 2025-004
    Material Weakness Repeat
  • 1175769 2025-005
    Material Weakness Repeat
  • 1175770 2025-006
    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) $5.11M
93.912 RURAL HEALTH CARE SERVICES OUTREACH, RURAL HEALTH NETWORK DEVELOPMENT AND SMALL HEALTH CARE PROVIDER QUALITY IMPROVEMENT $3.73M
10.768 BUSINESS AND INDUSTRY GUARANTEED LOANS $1.48M
93.526 GRANTS FOR CAPITAL DEVELOPMENT IN HEALTH CENTERS $453,418
93.268 IMMUNIZATION COOPERATIVE AGREEMENTS $223,443
93.778 MEDICAL ASSISTANCE PROGRAM $135,220
93.332 COOPERATIVE AGREEMENT TO SUPPORT NAVIGATORS IN FEDERALLY-FACILITATED EXCHANGES $102,152
21.027 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS $56,916
93.527 GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $42,852
93.323 EPIDEMIOLOGY AND LABORATORY CAPACITY FOR INFECTIOUS DISEASES (ELC) $34,666
93.898 CANCER PREVENTION AND CONTROL PROGRAMS FOR STATE, TERRITORIAL AND TRIBAL ORGANIZATIONS $8,710