Finding 1201144 (2025-001)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2025
Accepted
2026-03-30
Audit: 395842
Organization: Tca Health, Inc. (IL)

AI Summary

  • Core Issue: The Organization failed to document patient eligibility for sliding fee discounts, leading to incorrect fee adjustments.
  • Impacted Requirements: Compliance with federal regulations requiring accurate sliding fee schedules based on patients' ability to pay.
  • Recommended Follow-Up: Enhance training for staff on collecting and entering family size and income data, and improve internal audits to ensure compliance with policies.

Finding Text

Special Provisions Federal Agency: U.S. Department of Health and Human Services Federal Program Title: Health Center Program Cluster Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H80CS00109-24; H80CS00109-25 Award Period: May 1, 2024 – April 30, 2025; May 1, 2025 – April 30, 2026 Criteria or specific requirement: Health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay (42 USC 254(k)(3)(G); 42 CFR sections 51c.303(f), and (g); and 42 CFR sections 56.303(f), and (g)). Condition: The Organization did not maintain documentation to show that patients had been evaluated for eligibility under its sliding fee scale policy and did not apply sliding fee adjustments consistent with the sliding fee scale assigned. Questioned costs: None. Context:  Twelve (12) of sixty (60) encounters had the incorrect sliding fee discount applied based on the family size and income documentation provided.  For three (3) of sixty (60) encounters we could not verify if the family size and income were updated within a year of the patient visit date. Cause: This matter was initially identified during a prior audit and required the Organization to make an update to the electronic medical records software and process for obtaining the necessary sliding fee information. The Organization started its corrective action during the calendar year 2023 upon becoming aware of the matter. Although a prior corrective action plan has been implemented the matter has continued into the current year. Effect: Patients may not be assessed a correct sliding fee discount according to the Organization's sliding fee scale and their ability to pay. Repeat Finding: Yes, prior year finding 2024-002. Recommendation: Management should continue to provide training and education to front desk staff related to the process for collecting family size and income information, along with inputting it into the electronic medical records. We also recommend enhancing any current internal audits of patient visits to determine all required patient information has been obtained in accordance with TCA’s policies. Views of responsible officials: There is no disagreement with this finding.

Corrective Action Plan

Special Tests and Provisions Condition: The Organization did not maintain documentation to show that patients had been evaluated for eligibility under its sliding fee scale policy and did not apply sliding fee adjustments consistent with the sliding fee scale assigned. Recommendation: Management should continue to provide training and education to front desk staff related to the process for collecting family size and income information, along with inputting it into the electronic medical records. We also recommend enhancing any current internal audits of patient visits to determine all required patient information has been obtained in accordance with TCA’s policies. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: TCA Health is strengthening controls over its sliding fee discount program. Effective FY26 (April 11, 2026), Epic will require entry of family size and income and will apply the appropriate discount based on the approved sliding fee schedule, reducing the risk of missing or incorrect discounts. Staff training on sliding fee policies and Epic workflows has been reinforced and will be refreshed at least quarterly. TCA Health will also conduct monthly audits of encounters to confirm required documentation is on file and discounts are applied in accordance with the sliding fee scale, and will use results to drive targeted follow-up and process improvements. We will increase the audit to include the total population vs. a sample when reviewing. Name(s) of the contact person(s) responsible for corrective action: Samantha O. Mitchell Planned completion date for corrective action plan: 9/1/26

Categories

No categories assigned yet.

Other Findings in this Audit

  • 1201140 2025-001
    Material Weakness Repeat
  • 1201141 2025-001
    Material Weakness Repeat
  • 1201142 2025-001
    Material Weakness Repeat
  • 1201143 2025-001
    Material Weakness Repeat
  • 1201145 2025-002
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.558 TEMPORARY ASSISTANCE FOR NEEDY FAMILIES $285,286
10.561 STATE ADMINISTRATIVE MATCHING GRANTS FOR THE SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM $187,157
93.217 FAMILY PLANNING SERVICES $180,920
14.218 COMMUNITY DEVELOPMENT BLOCK GRANTS/ENTITLEMENT GRANTS $180,491
93.224 HEALTH CENTER PROGRAM (COMMUNITY HEALTH CENTERS, MIGRANT HEALTH CENTERS, HEALTH CARE FOR THE HOMELESS, AND PUBLIC HOUSING PRIMARY CARE) $167,779
93.495 COMMUNITY HEALTH WORKERS FOR PUBLIC HEALTH RESPONSE AND RESILIENT $133,733
93.527 GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $114,657
93.332 COOPERATIVE AGREEMENT TO SUPPORT NAVIGATORS IN FEDERALLY-FACILITATED EXCHANGES $62,744
93.323 EPIDEMIOLOGY AND LABORATORY CAPACITY FOR INFECTIOUS DISEASES (ELC) $10,769
10.557 WIC SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN $999