Finding 1190736 (2025-001)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2025
Accepted
2026-03-26

AI Summary

  • Core Issue: There were errors in applying sliding fee discounts to eligible patients, leading to incorrect billing.
  • Impacted Requirements: Compliance with 42 CFR regulations regarding fee schedules and patient eligibility determination was not met.
  • Recommended Follow-Up: Implement an independent review process for discount eligibility and enhance staff training and system controls.

Finding Text

2025-001 – Significant Deficiency in Internal Control Over Compliance - Sliding Fee Discount Determination Condition: The Health Center determines patient's sliding fee discount levels based on eligibility. During our testing, we noted instances in which encounters eligible for sliding fee adjustments were not discounted in accordance with the approved sliding fee discount levels. Criteria: Special Tests and Provisions — 42 CFR Part 254b(k)(3)(F), and (G) and 51c.303(f), and (g) requires Health Centers receiving funds under the Health Center Program Cluster to prepare and maintain a fee schedule designed to recover reasonable operating costs, implement a corresponding sliding fee discount schedule based on patient's ability to pay, and maintain systems for eligibility determination, billing, and collection to ensure that patient payments for services are collected in accordance with the schedules of fees and discounts. Context: During our testing of sliding fee discounts for Health Center patients qualifying for reduced-charge visits, we identified three visits out of a sample of fifteen that received an incorrect sliding fee discount. Based on these findings, additional testing was not conducted. Cause: Internal control processes and procedures were not followed, resulting in discounts applied in the billing system that did not align with the sliding fee determinations approved per the patient applications. Effect: Sliding fee discounts were given to patients that were inconsistent with the RRHC's sliding fee discount policy. Auditor's Recommendation: We recommend that management implement a second-level, independent review of demographic and income verification information entered into the patient billing system. This review should ensure that sliding fee discounts are correctly applied in accordance with approved patient eligibility levels. Additionally, staff training and system controls should be strengthened to prevent recurrence.

Corrective Action Plan

Management's Response: Management has created the following Corrective Action Plan: 1. Redwoods Rural Health Center (RRHC) will implement a monthly quality review process, to determine that only patients who correctly complete a SFDP application and provide supporting documentation receive any eligible discounts. 2. Additionally, on a quarterly basis, a sample of Sliding Fee Discount Applications will be selected and reviewed for accuracy of the SFDP calculation. 3. Reviews will be performed by Revenue Cycle department staff and submitted to Patient Intake and Eligibility Staff as an on-going training agenda item. Reviews will be performed utilizing the Income Detail/Sliding Fee Schedule report which pulls data from the information entered within the specified timeframe. See related Board approved Sliding Fee Discount Policy. Responsible Party: Billing Manager, Front Desk Supervisor, Medical Operations Manager Completion Date: This plan has been created as of December 16th, 2025, and implementation will begin effective immediately.

Categories

Special Tests & Provisions Eligibility Significant Deficiency Internal Control / Segregation of Duties

Other Findings in this Audit

  • 1190734 2025-001
    Material Weakness Repeat
  • 1190735 2025-001
    Material Weakness Repeat
  • 1190737 2025-002
    Material Weakness Repeat
  • 1190738 2025-002
    Material Weakness Repeat
  • 1190739 2025-002
    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) $231,120
93.526 GRANTS FOR CAPITAL DEVELOPMENT IN HEALTH CENTERS $149,631
93.493 CONGRESSIONAL DIRECTIVES $83,150