Finding 1176634 (2025-001)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2025
Accepted
2026-03-05
Audit: 390491
Organization: University of Kentucky (KY)

AI Summary

  • Core Issue: Unapproved sliding fee discounts were applied due to the IT system allowing unverified income information.
  • Impacted Requirements: Compliance with federal regulations regarding eligibility and allowability for sliding fee discounts was not met.
  • Recommended Follow-Up: Update the IT system to block unapproved income entries and establish a review process for discount approvals.

Finding Text

Federal Program: U.S. Department of Health and Human Services Health Center Program Cluster: Grants for New and Expanded Services Under the Health Center Program, Assistance Listing 93.527 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), Assistance Listing 93.224 Criteria: The Health Center must comply with 42 USC 254b(k)(E), (F) and (G); 42 CFR sections 51c.303(e); (f) and (g), and 42 CFR sections 56.303(e), (f), and (g). Condition: During testing of the sliding fee discount, we selected a sample of 25 charges that a sliding scale fee was applied. In one instance, a patient qualified for an 80% sliding fee discount, which was approved on November 25, 2024. However, on November 26, 2024, income information was entered into the Informational Technology (IT) system indicating the patient qualified for a 100% discount. This updated income information was not approved and no supporting documentation was maintained. The entity's system relies on the most recent income information, regardless of approval status. We tested an additional 15 samples and did not find any additional errors. Cause: The Health Center's IT system is not configured to restrict the application of unapproved income or sliding fee discount information. Effect: Unapproved sliding fee discounts were applied to the patient's charges that were not allowable. Continued use of the current system configuration increases the risk that costs charged to the federal award may not comply with federal eligibility and allowability requirements. Questioned Costs: Total questioned costs related to this finding were $8 for the total encounter. Recommendation: We recommend that management modify their IT system to prevent unapproved income information or sliding fee applications from being applied to patients accounts and implement a documented review process to ensure sliding fee discounts are applied only after approval.

Corrective Action Plan

On November 4, 2025, UK HealthCare (UKHC) Information Technology implemented a system configuration change within Epic related to the NFV Sliding Scale settings. This change restricts the application of Federal Poverty Level (FPL) discounts to accounts with a status of “Approved for Financial Assistance,” thereby preventing discounts from being applied to accounts that have not been formally approved. In addition, on December 8, 2025, a new status option— “Did Not Apply for FA”—was added to the status field within the FPL table in Epic. This option is to be selected when patients do not apply for financial assistance, ensuring that status fields are never left incomplete or blank. NFVCHC staff were notified of this update and instructed to consistently complete this step. Planned Process Improvements:NFVCH leadership will conduct a comprehensive review of the NFV and JB clinic policies and procedures related to Financial Assistance Program (FAP) eligibility determination and reevaluation. This review will ensure that: FAP documentation does not include overlapping coverage periods Effective and termination dates are properly validated Internal processes align with system requirements and safeguard against data inconsistencies Ongoing Monitoring / Sustainability Plan: To strengthen oversight and ensure longterm control effectiveness, UKHC Enterprise Revenue Cycle will incorporate into its monthly audit procedures the following reviews: A report identifying accounts with blank or incomplete status entries on the Federal Poverty Level table A review of overlapping FPL coverage dates Monitoring for patients who have both UK and NFV Charity Care, ensuring the correct NFV FPL table is applied for NFVCH accounts This continuous monitoring will ensure system controls operate as designed and that corrective actions remain effective over time. Responsible Party: Larry Quillen – Executive Director, NFVCH Anne Wray - ERC Revenue Assurance Director/UKHC Target Completion Date: Completed on November 4, 2025, with additional enhancements on December 9, 2025

Categories

Eligibility HUD Housing Programs

Other Findings in this Audit

  • 1176631 2025-001
    Material Weakness Repeat
  • 1176632 2025-001
    Material Weakness Repeat
  • 1176633 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) $2.64M
93.884 PRIMARY CARE TRAINING AND ENHANCEMENT $298,456
93.526 GRANTS FOR CAPITAL DEVELOPMENT IN HEALTH CENTERS $112,142
93.527 GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $-72