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.