Criteria: Per the 2023 OMB Compliance Supplement, Part 4, Agency Program for ALN 93.224, Section III-N: Special Tests and Provisions – Sliding Fee Discounts, health centers must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay as follows: a. Sliding fee discounts are applied to fees for health center services provided to all individuals and families with annual incomes at or below 200 percent of the Federal Poverty Guidelines (FPG). b. A full discount is applied to fees for health center services provided to individuals and families with annual incomes at or below 100 percent of the FPG, or the health center applies only a nominal charge. c. Fees for health center services are discounted based on gradations in family size and income for individuals and families with incomes above 100 and at or below 200 percent of the FPG. d. No sliding fee discount is applied to fees for health center services provided to individuals and families with annual incomes above 200 percent of the FPG. Conditions: a. The sliding fee discount schedule used by the Republic is the Ministry of Health and Human Service’s Sliding Fee Scale, which is not in accordance with Federal requirements, and has not been updated since January 2006 as shown below. The discounts were applied and determined based on whether the patient is a resident or a nonresident, tourist or non-tourist, with insurance or none, senior citizen, and behavioral health patient. Family Size Ministry of Health and Human Services Sliding Fee Schedule 2023 Federal Poverty Guidelines Percentage of Maximum Charge based on Family Income & Size 20% 30% 40% 50% 60% 70% 100% 200% 1 0-5,700 5,701-10,050 10,051-12,600 12,601-14,100 14,101-17,500 >17,500 $14,580 $29,160 2 0-6,600 6,601-13,500 13,501-16,300 16,301-19,000 19,001-21,800 >21,800 19,720 39,440 3 0-7,400 7,401-17,000 17,001-20,500 20,501-23,900 23,901-27,500 >27,500 24,860 49,720 4 0-8,500 8,501-20,600 20,601-24,800 24,801-28,900 28,901-32,500 >32,500 30,000 60,000 5 0-9,700 9,701-24,200 24,201-29,000 29,001-33,800 33,801-38,700 >38,700 35,140 70,280 6 0-10,700 10,701-27,700 27,701-33,200 33,201-37,500 37,501-43,000 >43,000 40,280 80,560 7 0-11,500 11,501-31,200 31,201-37,400 37,401-43,700 43,701-46,000 >46,000 45,420 90,840 8 0-12,600 12,601-34,700 34,701-41,600 41,601-48,600 48,601-55,600 >55,600 50,560 101,120Family Size Ministry of Health Sliding Fee Schedule 2023 Federal Poverty Guidelines Percentage of Maximum Charge based on Family Income & Size 20% 30% 40% 50% 60% 70% 100% 200% 9 0-14,800 14,801-38,300 38,301-45,900 45,901-53,600 53,601-65,000 >65,000 55,700 111,400 10 0-16,600 16,601-41,800 41,801-50,200 50,201-58,500 58,501-70,000 >70,000 60,840 121,680 11 0-18,900 18,901-45,300 45,301-54,400 54,401-63,400 63,401-75,000 >75,000 65,980 131,960 12 0-23,500 23,501-48,800 48,801-58,600 58,601-68,400 68,401-85,000 >85,000 71,120 142,240 b. For 53 (or 88%) of the 60 invoices tested, $2,123 out of $2,602,954 in total billed amount, patients were not properly billed in accordance with the FPG. A full discount was not applied to fees for health center services provided to individuals and families with annual incomes at or below 100% of the FPG, or a nominal charge. No. Encounter No. Invoice Number Payor Family Size Payor Income Billed Amount Audit Calculation Overbilled 1 787277 764957 1 $ – $ 64 $ 39 $ 25 2 787819 765457 4 – 18 15 3 3 789092 766766 4 – 11 6 5 4 848190 824175 4 12,571 101 89 12 5 793230 770873 3 – 8 6 2 6 796501 774039 1 – 6 6 - 7 797128 774688 4 27,000 21 18 3 8 797721 775240 1 – 57 45 12 9 797818 775349 1 – 103 39 64 10 801261 778707 1 – 9 – 9 11 802290 779671 1 5,426 71 34 37 12 804927 782163 6 18,200 21 - 21 13 806898 784035 1 644 19 10 9 14 807608 784780 2 – 31 – 31 15 813192 790462 6 118 46 – 46 16 814856 791804 1 – 21 12 9 17 815213 792247 4 – 131 – 131 18 815876 792751 2 – 7 6 1 19 818029 794944 2 – 36 34 2 20 818263 795048 1 – 15 – 15 21 820650 797464 1 – 8 – 8 22 820731 797364 1 – 22 5 17 23 821582 798229 1 – 79 10 69 24 822114 798690 1 4,020 22 18 4 25 822216 798815 1 – 136 – 136 26 824758 801180 2 – 41 39 2 No. Encounter No. Invoice Number Payor Family Size Payor Income Bill Charge Audit Calculation Overbilled 27 827135 803468 4 $ 27,000 $ 5 $ – 5 28 808787 786091 3 18,162 121 29 92 29 834360 810455 1 – 68 6 62 30 840094 816261 1 – 55 – 55 31 840363 816597 2 10,654 39 5 34 32 842882 819135 1 – 112 10 102 33 849755 837941 3 252 52 35 17 34 851139 826909 1 14,344 31 5 26 35 856826 832215 3 6,311 19 5 14 36 858240 833919 7 – 18 11 7 37 861380 836621 2 14,657 28 11 17 38 861518 836728 9 – 182 11 171 39 863886 839511 3 – 8 – 8 40 845667 821845 5 16,894 13 – 13 41 829948 806271 2 – 4 – 4 42 794661 772305 2 6,000 5 – 5 43 804242 781544 1 1,974 33 29 4 44 805480 782731 1 – 31 29 2 45 808859 785946 1 – 11 10 1 46 818784 795565 1 – 36 20 16 47 826380 802729 1 11,085 12 5 7 48 850512 826525 2 – 12 – 12 49 851026 826812 1 – 1 – 1 50 791924 769826 2 – 3 – 3 51 857073 833490 5 – 8 – 8 52 857388 832805 3 252 53 44 9 53 859027 834391 2 8,074 61 12 49 Subtotal: $2,125 $708 $1,417 c. For 1 (or 1%) of 60 invoices tested, $13 of $2,602,954 in total billed amount, patients were not properly billed based on the FPG. The fees for health center services were not properly discounted based on gradations in family size and income for this individual with income above 100 and at or below 200% of the FPG. Encounter No. Invoice Number Payor Family Size Payor Income Bill Charge Audit Calculation Overbilled 852731 828622 1 $14,991 $13 $10 $3 d. For 2 (or 3%) of 60 invoices tested, $285 of $2,602,954 in total billed amount, patients were not properly billed based on the FPG. The sliding fee discount was applied to fees for health center services provided to this with annual income above 200% of the FPG. No. Encounter No. Invoice Number Payor Family Size Payor Income Bill Charge Audit Calculation (Underbilled) 1 850308 826165 1 $ 37,920 $ 210 $ 244 $ (34) 2 859829 835191 1 $ 46,675 75 107 (32) Grand Total: $ 285 $ 351 $ (66) Cause: Republic of Palau Public Law (RPPL) 7-13 Section 19, which amends RPPL 5-7, requires Palauan citizens and their spouses to be charged hospital fees at a subsidized rate compared to non-Palauans. Accordingly, the Ministry of Health and Human Services implemented its sliding fee schedule policy in 2006 in accordance with RPPL 7-13. The community health centers program adopted its fee schedule policy based on income and family size. However, this policy cannot be implemented without the support of the Olbiil era Kelulau (National Congress). Effect: The Republic is in noncompliance with applicable special tests and provisions requirements for sliding fee discounts. Reportable questioned cost is $1,354. Identification as a Repeat Finding: Finding 2022-010 Recommendation: We recommend that the Republic implement policies related to the sliding fee discount based on family income and size, in accordance with the aforementioned criteria. Views of Responsible Officials: The Republic’s Corrective Action Plan does not indicate disagreement and provides planned corrective action.