Finding 119 (2023-002)

Significant Deficiency Repeat Finding
Requirement
N
Questioned Costs
-
Year
2023
Accepted
2023-10-11
Audit: 152
Organization: Health Services, Inc. (AL)

AI Summary

  • Core Issue: There are significant deficiencies in applying the sliding fee scale discounts, leading to incorrect patient charges.
  • Impacted Requirements: Compliance with 42 CFR Sections 51c.303(d) and (f) regarding fee schedules and income documentation is not being met.
  • Recommended Follow-Up: Strengthen policies and procedures for the sliding fee scale to ensure proper compliance and documentation.

Finding Text

Finding 2023-002 – Special Tests and Provisions – Sliding Fee (significant deficiency and noncompliance) Information on the federal program: U.S. Department of Health and Human Services, CFDA No. 93.224 and 93.527 Health Center Program Cluster Criteria: 42 CFR Section 51c.303(d) defines required project elements to include developing a sound control system to ensure compliance with the regulations and terms and conditions of the grant. 42 CFR Section 51c.303(f) establishes the requirement to have a schedule of fees or payments for the provision of its services designed to cover its reasonable costs of operation and a corresponding schedule of discounts adjusted on the basis of the patient's ability to pay. Such schedule of discounts shall provide for a full discount to individuals and families with annual incomes at or below those set forth in the most recent CSA Poverty Income Guidelines and for no discount to individuals and families with annual incomes greater than twice those set forth in such guidelines, except that nominal fees for services may be collected from individuals with annual incomes at or below such levels where imposition of such fees is consistent with project goals. Condition: We tested the controls over the application of the sliding scale fee discount for 40 patient visits during the year. Out of the 40 tested, we noted 11 patients with one or more exceptions. We noted 11 instances in which the sliding fee discount was not properly applied and 11 instances in which the income documentation was not provided by the patient to determine the discount. In addition, we noted that documentation of review of the patient files was not properly documented. Cause: Eligibility documentation obtained by the Organization for each patient is accumulated using an intake form and income verification source documents. Per the Organization, the control system over the sliding fee program includes periodic review of patient files for accuracy and completeness. These file reviews were not properly documented and therefore could not be verified as performed. For the exceptions noted by testing compliance, the income source documentation was not provided by the patient to support the amounts on file and these patients were given the 100% discount. Effect: Sliding fee discounts were not appropriately applied and patients were charged the incorrect amounts. Recommendation: We recommend the Organization strengthen its policies and procedures surrounding the sliding fee scale to ensure compliance with the special tests and provision requirements. Views of Responsible Officials and Planned Corrective Action: See Management’s View and Corrective Action Plan included at the end of the report.

Corrective Action Plan

The area of compliance evaluated relates to the area of organizational workflow that includes patient intake. Due to the severity of this issue, management has implemented the following as a corrective action: Contact granting organization for technical assistance with implementing and maintaining compliance during a period of increased staffing shortages and turnovers  Redesigned current workflow and office procedures to include the following changes: o Entry Level intake will only involve information gathering and collection of copays o 1st Level Supervision will review data and determine eligibility of sliding fee and application o 2nd Level Supervision will perform random chart audits Monthly o 3rd Level Supervisor will perform random chart audits Quarterly  All patient intake staff will receive one-on-one training on Sliding Fee and the importance of documentation.

Categories

Special Tests & Provisions Eligibility Significant Deficiency

Other Findings in this Audit

  • 120 2023-002
    Significant Deficiency Repeat
  • 121 2023-002
    Significant Deficiency Repeat
  • 576561 2023-002
    Significant Deficiency Repeat
  • 576562 2023-002
    Significant Deficiency Repeat
  • 576563 2023-002
    Significant Deficiency Repeat

Programs in Audit

ALN Program Name Expenditures
93.224 Consolidated Health Center Program $8.22M
93.224 Covid-19 Consolidated Health Center Program $2.17M
93.527 Consolidated Health Center Program $185,000
32.006 Covid-19 Telehealth Program Commitment $114,046
10.557 Special Supplemental Nutrition Program for Women, Infants and Children $77,420
93.738 Racial and Ethnic Approaches to Community Health Programs $17,600