Finding 1215381 (2025-001)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2025
Accepted
2026-05-21

AI Summary

  • Core Issue: A patient received a sliding fee discount without an active application on file, indicating a gap in the discount process.
  • Impacted Requirements: Compliance with Title 42 regulations requiring health centers to maintain proper fee schedules and discount applications based on patient ability to pay.
  • Recommended Follow-Up: Review and strengthen internal controls for the sliding fee process to ensure accurate application and documentation of discounts.

Finding Text

Special Tests: Application of Sliding Fee Discount Federal Agency: U.S. Department of Health and Human Services Federal Program: Consolidated Health Centers Grant AL Number: 93.224 & 93.527 Award Period: 1/1/25 - 12/31/25 Type of Finding: Significant Deficiency in Internal Control over Compliance and Compliance Criteria or Specific Requirement Per Title 42 Chapter 1 Subchapter D Section 51c303(f), “Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted on the basis of the patient’s ability to pay.” Condition and Context During our testing of forty sliding fee discounts for health center patients qualifying for reduced charge visits, we identified one visit that did not have an active sliding fee discount application on file, but the patient received a discounted visit. Effect Potential that a patient would not receive the appropriate sliding fee discount or may receive a discount when they have not applied for one. Questioned Costs None identified. Cause Clerical error in which the sliding fee rate was improperly applied due to lack of an oversight process in place. Recommendation We recommend the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter and that all documentation supporting the sliding discount provided is retained. Views of Responsible Officials The Organization identified challenges and errors in the prior eligibility workflow after the 2024 audit. Over the course of 2025, the Organization experienced turnover in management and front desk personnel in the dental department. The workflows were modified when the new eligibility manager joined the Organization. Upon hiring a new dental manager and patient access (front desk) manager, workflows and procedures were also modified to ensure the front desk reviews insurance coverage upon check in. The system is set up so the Organization does not need manually adjust all claims, so the claim was auto-posted for the visit identified above. Our corrective action plan is already established, although it was put into place after the date of service of the visit identified above.

Corrective Action Plan

Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter and that all documentation supporting the sliding discount provided is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization identified challenges and errors in the prior eligibility workflow after the 2024 audit. Over the course of 2025, the Organization experienced turnover in management and front desk personnel in the dental department. The workflows were modified when the new eligibility manager joined the Organization. Upon hiring a new dental manager and patient access (front desk) manager, workflows and procedures were also modified to ensure the front desk reviews insurance coverage upon check in. The system is set up so the Organization does not need manually adjust all claims, so the claim was auto-posted for the visit identified above. Our corrective action plan is already established, although it was put into place after the date of service of the visit identified above. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Amanda Craig, CFO, at 970-710-5062.

Categories

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

Other Findings in this Audit

  • 1215379 2025-001
    Material Weakness Repeat
  • 1215380 2025-001
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.224 Consolidated Health Center, Affordable Care Act for New and Expanded Services $1.82M
93.224 Behavioral Health Expansion $460,278
21.027 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS - Community Investment $403,383
93.898 CANCER PREVENTION AND CONTROL PROGRAMS FOR STATE, TERRITORIAL AND TRIBAL ORGANIZATIONS $129,802
93.959 BLOCK GRANTS FOR PREVENTION AND TREATMENT OF SUBSTANCE ABUSE $93,155
93.217 Title X Family Planning Services $84,892
93.436 Improving the Health of Americans through Prevention Across the Nation (WISEWOMAN) $54,584
21.027 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS - BHA Workforce $44,644
93.800 ORGANIZED APPROACHES TO INCREASE COLORECTAL CANCER SCREENING $15,253
93.527 Consolidated Health Center, Affordable Care Act for New and Expanded Services $0