Finding 1214940 (2024-005)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2024
Accepted
2026-05-19
Audit: 401709
Auditor: SJT GROUP LLC

AI Summary

  • Core Issue: One medical claim did not match FCCH’s fee schedule due to missed communication about income documentation for a sliding fee discount.
  • Impacted Requirements: Non-compliance with 42 CFR Part 51c.303(f) and FCCH’s own Sliding Fee Discount Policies.
  • Recommended Follow-Up: FCCH should enhance communication protocols, provide staff training on SFDP requirements, and conduct internal reviews of claims to prevent future errors.

Finding Text

2024-005—Special Tests and Provisions—Sliding Fee Discount Program Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Health Center Cluster Assistance Listing Number (ALN): 93.224 Award number and year: H80CS00202 (1/1/2024 – 12/31/2024) Criteria: According to 42 CFR Part 51c.303(f) and FCCH’s Sliding Fee Discount and Related Billing and Collections Program Policies and Procedures, a community health center must have prepared 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, provided that 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 poverty guidelines updated periodically in the Federal Register by the U.S. Department of Health and Human Services under the authority of 42 U.S.C. 9902(2); and for no discount to individuals and families with annual incomes greater than twice those set forth in such guidelines. Condition: For one of 30 medical claims tested, the amount billed did not agree to FCCH’s fee schedule for the procedures performed after applying FCCH’s sliding fee discount from the Sliding Fee Discount Program (SFDP). Questioned Costs: None Context: One of 30 medical claims tested. Cause: At the patient’s initial visit, they did not bring in income documentation to qualify for a sliding fee discount. However, the patient did bring in the income documentation within 30 days of the date of service, but the billing department was not notified of this information so that the sliding fee discount could be applied. Effect: FCCH is not in compliance with 42 CFR Part 51c.303(f). Additionally, FCCH is not in compliance with its Sliding Fee Discount and Related Billing and Collections Program Policies and Procedures. Auditor’s Recommendations: FCCH should implement its established policies and procedures which require adherence to the approved schedule of fees for services and discounts. FCCH should also consider performing its own review of medical claims billed to determine the prevalence of these errors. Management’s Response: Management acknowledges the finding. FCCH agrees that the claim in question did not reflect the appropriate sliding fee discount because the billing department was not notified that the patient submitted income documentation within the 30-day eligibility window. FCCH recognizes the importance of ensuring that all departments consistently follow established Sliding Fee Discount Program (SFDP) procedures. To address this issue, FCCH has implemented the following corrective actions: • Reinforce communication protocols between front desk/eligibility staff and the billing department to ensure that any income documentation received after the date of service is promptly communicated and documented. • Provide refresher training to front desk, eligibility, and billing staff on SFDP requirements, including the 30-day documentation rule and the process for updating patient classifications. • Initiated an internal review of a sample of medical claims to assess whether similar errors occurred and to confirm that corrective measures are effective. FCCH remains committed to full compliance with 42 CFR Part 51c.303(f) and its internal Sliding Fee Discount and Related Billing and Collections Program Policies and Procedures. Management will continue monitoring to ensure ongoing adherence and prevent recurrence.

Corrective Action Plan

2024-005—Special Tests and Provisions—Sliding Fee Discount Program Corrective Action: Management acknowledges the finding. FCCH agrees that the claim in question did not reflect the appropriate sliding fee discount because the billing department was not notified that the patient submitted income documentation within the 30-day eligibility window. FCCH recognizes the importance of ensuring that all departments consistently follow established Sliding Fee Discount Program (SFDP) procedures. To address this issue, FCCH has implemented the following corrective actions: • Reinforce communication protocols between front desk/eligibility staff and the billing department to ensure that any income documentation received after the date of service is promptly communicated and documented. • Provide refresher training to front desk, eligibility, and billing staff on SFDP requirements, including the 30-day documentation rule and the process for updating patient classifications. • Initiated an internal review of a sample of medical claims to assess whether similar errors occurred and to confirm that corrective measures are effective. FCCH remains committed to full compliance with 42 CFR Part 51c.303(f) and its internal Sliding Fee Discount and Related Billing and Collections Program Policies and Procedures. Management will continue monitoring to ensure ongoing adherence and prevent recurrence. Person Responsible: Tammy Collins, Revenue Cycle Director Completion Date: September 30, 2026

Categories

Special Tests & Provisions Subrecipient Monitoring Eligibility

Other Findings in this Audit

  • 1214934 2024-004
    Material Weakness Repeat
  • 1214935 2024-004
    Material Weakness Repeat
  • 1214936 2024-004
    Material Weakness Repeat
  • 1214937 2024-004
    Material Weakness Repeat
  • 1214938 2024-004
    Material Weakness Repeat
  • 1214939 2024-004
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.526 GRANTS FOR CAPITAL DEVELOPMENT IN HEALTH CENTERS $603,824
93.224 HEALTH CENTER PROGRAM $602,464
93.778 GRANTS TO STATES FOR MEDICAID $94,557
93.527 GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $34,337