Finding 1204931 (2025-002)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2025
Accepted
2026-03-30
Audit: 396538
Organization: Wellspace Health (CA)

AI Summary

  • Core Issue: The Organization improperly calculated sliding fee discounts for patients, leading to a $420 overstatement.
  • Impacted Requirements: Compliance with 42 CFR 56.303 regarding proper fee schedules and patient income verification was not met.
  • Recommended Follow-Up: Strengthen verification processes and monitoring to ensure accurate application of sliding fee discounts and prevent future errors.

Finding Text

Criteria: In accordance with 42 CFR 56.303, health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted based on the patient’s ability to pay. The patient’s ability to pay is determined based on the official poverty guidelines, as revised annually by U.S. Department of Health and Human Services (HHS). The schedule of discounts must provide for a full discount to individuals and families with annual incomes at or below those set forth in the most recent poverty income guidelines (except that nominal fees for service may be collected from such individuals and families) and for no discount to individuals and families with annual incomes greater than twice those set forth in such Guidelines. Condition: The Organization determines the amount of fees to be charged to the patients based on their annual gross income and household size in conjunction with the sliding fee schedule. During our testing of sliding fee discount, we noted the following:  Three (3) out of 60 patients selected were given a sliding fee discount that was improperly calculated, resulting in overstatement of the sliding fee discount by $420.  Twenty-seven (27) out of 60 selections were missing either updated proof of income or complete requested support. Therefore not able to confirm that sliding fee adjustment were applicable to these patients.  Context: The audit findings represent a systematic problem, see condition above. Questioned Costs: $420 of the $8,717 patient charges sampled. Effect: Patients were improperly categorized on the Organization’s sliding fee scale and were given an improper sliding fee discount. Cause: The inaccuracies in the application of the sliding fee program discounts were due to human error and inadequate oversight and review. Recommendation: We recommend that the Organization’s procedures be strengthened to ensure 1) income is properly verified and adequately documented and 2) the sliding fee discount is properly determined and applied. The Organization should strengthen processes surrounding monitoring of the program to ensure the Organization’s policies are consistently and properly applied. Repeat finding: This is a repeat finding to 2024-04 and 2023-002. Views of responsible officials and planned corrective actions: While staff training is ongoing to ensure the sliding fee program is applied correctly, Management is concurrently exploring strategies to strengthen the program overall. This includes reviewing current materials and processes, enhancing staff competencies, provide additional tools to support staff, and developing clearer workflows to support consistent and accurate application.

Corrective Action Plan

Corrective Action Plan: The organization will continue with its ongoing implementation of several measures to ensure accuracy and compliance in the sliding fee process. Monthly audits will continue to be conducted to review all sliding fee application forms from the previous month for accuracy and verifying information in NextGen. Skills assessments will continue to be conducted in January and July to identify staff needing refresher training. A sliding fee wage training video has been added to Relias and will be required for all staff involved in the process, providing guidance on wage calculation. This training will be distributed twice a year. Additionally, sliding fee monthly audit results will be reported quarterly at QA/QI meetings. To enhance accountability, the organization has implemented an expiration policy for applications lacking supporting documentation within 30 days. The system will automatically expire these applications on day 31, prompting staff to have the patient reapply. Patients who fail to provide the required documentation within the timeframe will receive an invoice or statement for all services rendered during the 30-day period. Estimated completion date: September 30, 2026 Contact person: Jessica Dana, Vice President of Strategy

Categories

Subrecipient Monitoring Internal Control / Segregation of Duties

Other Findings in this Audit

  • 1204929 2025-002
    Material Weakness Repeat
  • 1204930 2025-002
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.778 MEDICAL ASSISTANCE PROGRAM $2.37M
93.696 CERTIFIED COMMUNITY BEHAVIORAL HEALTH CLINIC EXPANSION GRANTS $1.14M
93.977 SEXUALLY TRANSMITTED DISEASES (STD) PREVENTION AND CONTROL GRANTS $335,259
93.959 BLOCK GRANTS FOR PREVENTION AND TREATMENT OF SUBSTANCE ABUSE $193,966
93.686 ENDING THE HIV EPIDEMIC: A PLAN FOR AMERICA — RYAN WHITE HIV/AIDS PROGRAM PARTS A AND B $92,920
93.527 GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $83,651
21.027 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS $42,304
93.556 MARYLEE ALLEN PROMOTING SAFE AND STABLE FAMILIES PROGRAM $34,000
93.224 HEALTH CENTER PROGRAM (COMMUNITY HEALTH CENTERS, MIGRANT HEALTH CENTERS, HEALTH CARE FOR THE HOMELESS, AND PUBLIC HOUSING PRIMARY CARE) $24,503
93.596 CHILD CARE MANDATORY AND MATCHING FUNDS OF THE CHILD CARE AND DEVELOPMENT FUND $20,970
93.604 ASSISTANCE FOR TORTURE VICTIMS $17,204
93.788 OPIOID STR $7,826
93.243 SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES PROJECTS OF REGIONAL AND NATIONAL SIGNIFICANCE $-12,819