Finding 1217948 (2025-006)

Material Weakness Repeat Finding
Requirement
ABLN
Questioned Costs
-
Year
2025
Accepted
2026-06-18

AI Summary

  • Core Issue: OIC has significant control deficiencies in its revenue cycle, leading to inaccurate reporting of patient service revenue and accounts receivable.
  • Impacted Requirements: Compliance with GAAP and federal financial management standards is compromised, increasing risks of material misstatements and compliance failures.
  • Recommended Follow-Up: Management must develop a comprehensive remediation plan to align revenue recognition and accounts receivable practices with GAAP and ensure effective oversight and reconciliation processes.

Finding Text

Finding 2025-006 Revenue Recognition, Contractual Allowances, Accounts Receivable, and Billing System Reconciliations (Material Weakness) Information on Federal Programs – HHS–HRSA Section 330 Health Center Program, June 30, 2025; U.S. Department of Labor Workforce Development Awards, June 30, 2025 Criteria – Under 2 CFR § 200.302 and § 200.303, non-Federal entities must maintain financial management systems and internal controls that provide reasonable assurance that federal funds are properly managed, financial results are accurately reported, and assets are safeguarded. These controls must align with GAAP and recognized internal control frameworks (COSO). GAAP (ASC 606) requires patient service revenue to be recognized at net realizable value, reflecting contractual allowances, sliding-fee discounts, and implicit price concessions at the time revenue is recorded. Accounts receivable must be evaluated for collectability, supported by an allowance for doubtful accounts, and written off only through documented and approved processes. HRSA Section 330 financial management requirements further require health centers to maintain accurate billing, accounts receivable, and reconciliation processes to support fiscal integrity and compliance with federal award conditions. Condition – OIC’s revenue-cycle processes exhibit multiple, interrelated control deficiencies that collectively impair the accuracy and reliability of patient service revenue and accounts receivable reporting: 1. Revenue Recognition Methodology • Patient revenue recorded in the general ledger is based on an estimated flat per-encounter rate multiplied by total encounters, rather than at net realizable value. • Contractual allowances, payer-specific discounts, and implicit price concessions are not estimated or recognized at the time revenue is initially recorded. 2. Accounts Receivable Valuation and Write-Off Controls • Patient receivables are written off within the EPIC billing system without documented review of collectability, allowance analysis, or documented approval by Executive Management. • Write-offs processed in EPIC do not consistently result in corresponding adjustments to general ledger accounts receivable. 3. Billing System and General Ledger Reconciliations • EPIC and eClinicalWorks billing systems are not integrated with the Sage MIP general ledger. • Patient revenue and accounts receivable balances are recorded through manual journal entries. • Formal, consistent, and documented reconciliations between billing system activity (gross charges, contractual adjustments, collections) and the general ledger are not performed as part of the monthly close. 4. Revenue Cycle Oversight and Monitoring • Patient statements are generated only when a patient balance is due, limiting an independent verification mechanism over gross charges and third-party payment processing. • Given the absence of system integration and reliance on manual processes, compensating oversight controls are insufficient to mitigate the combined risks noted above. Cause – Management has not implemented a comprehensive, GAAP-aligned revenue-cycle control framework that integrates revenue recognition, contractual allowance estimation, accounts receivable management, billing system reconciliation, and write-off governance. System limitations, reliance on historical estimation practices, and incomplete documentation of review and approval controls have contributed to the deficiencies. Effect – The combined effect of these deficiencies is an increased risk that patient service revenue and accounts receivable are materially overstated and not reflective of amounts expected to be collected. This condition: • Impairs the reliability and auditability of financial statements • Weakens internal control over federal program financial reporting • Increases the likelihood that material misstatements could occur and not be prevented or detected timely • Creates elevated compliance risk under Uniform Guidance, HRSA Section 330 financial management standards, and Single Audit reporting requirements Given the materiality of patient service revenue and accounts receivable to the financial statements, this condition constitutes a material weakness in internal control over financial reporting. Perspective – This material weakness reflects pervasive deficiencies across OIC’s revenue cycle that affect the accuracy, integrity, and auditability of patient service revenue and accounts receivable, which represent significant components of the financial statements and federal program reporting. The absence of GAAP-aligned revenue recognition, effective accounts receivable oversight, and reliable reconciliation between billing systems and the general ledger limits management’s and the Board’s ability to rely on reported financial results for decision-making and program oversight. Given the reliance on federal funding, particularly under the HRSA Section 330 Health Center Program, these deficiencies elevate compliance risk under Uniform Guidance and increase exposure to adverse Single Audit outcomes if not timely remediated. The Board and Audit Committee should view this matter as a high-priority governance issue requiring active oversight of management’s remediation efforts, including clear timelines, accountability, and validation that revised controls are designed and operating effectively. Prompt and sustained corrective action is necessary to restore confidence in financial reporting, demonstrate stewardship of federal resources, and reduce the risk of recurring audit findings. Questioned Costs – None identified. Recommendation – Management should implement a coordinated remediation strategy to strengthen the revenue cycle and restore compliance with GAAP and Uniform Guidance requirements. At a minimum, management should: • Discontinue or substantially revise the flat per-encounter revenue estimation methodology. • Record patient revenue at net realizable value at initial recognition, including estimated contractual allowances and implicit price concessions. 1. Accounts Receivable and Write-Off Governance • Perform documented monthly reviews of accounts receivable aging and collectability. • Maintain and review an allowance for doubtful accounts prior to any write-off activity. • Require documented CFO or Executive Management approval for all write-offs impacting the general ledger. • Ensure all billing-system write-offs are fully reconciled to the general ledger. 2. Billing System and General Ledger Reconciliations • Evaluate the feasibility of implementing automated interfaces between EPIC, eClinicalWorks, and the general ledger. • Establish formal, timely, and documented reconciliations between billing system reports and general ledger balances, reviewed by personnel independent of preparation. 3. Oversight and Compensating Controls • Enhance revenue-cycle oversight through expanded management review reports, reconciliation procedures, or other compensating controls that provide visibility into gross charges, adjustments, collections, and zero-balance accounts. 4. Oversight and Compensating Controls • Enhance revenue-cycle oversight through expanded management review reports, reconciliation procedures, or other compensating controls that provide visibility into gross charges, adjustments, collections, and zero-balance accounts. Implementing these actions will improve financial reporting accuracy, strengthen internal control over federal programs, and reduce audit and compliance risk. View of Responsible Officials – Management concurs with the finding. OIC will strengthen revenue cycle controls to improve patient service revenue recognition, accounts receivable valuation, write-off governance, and billing system reconciliations.

Corrective Action Plan

Classification Material Weakness Responsible Official Chief Financial Officer and Chief Health Operations Officer Anticipated Completion Date March 31, 2027 Management Response Management concurs with the finding. OIC will strengthen revenue cycle controls to improve patient service revenue recognition, accounts receivable valuation, write-off governance, and billing system reconciliations. Corrective Action Plan 1. Transition from a flat encounter-based revenue estimate to a net realizable value methodology that incorporates contractual allowances, sliding fee discounts, implicit price concessions, and allowance for doubtful accounts. 2. Perform monthly documented reconciliations between EPIC, eClinicalWorks, Sage MIP, patient receivables, gross charges, adjustments, collections, write-offs, and general ledger balances. 3. Require documented management review and approval of accounts receivable aging, collectability analyses, write-offs impacting the general ledger, and revenue cycle dashboard reporting.

Categories

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness Matching / Level of Effort / Earmarking

Other Findings in this Audit

  • 1217941 2025-003
    Material Weakness Repeat
  • 1217942 2025-003
    Material Weakness Repeat
  • 1217943 2025-003
    Material Weakness Repeat
  • 1217944 2025-006
    Material Weakness Repeat
  • 1217945 2025-006
    Material Weakness Repeat
  • 1217946 2025-006
    Material Weakness Repeat
  • 1217947 2025-006
    Material Weakness Repeat
  • 1217949 2025-007
    Material Weakness Repeat
  • 1217950 2025-007
    Material Weakness Repeat
  • 1217951 2025-007
    Material Weakness Repeat
  • 1217952 2025-007
    Material Weakness Repeat
  • 1217953 2025-007
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
17.258 WIOA ADULT PROGRAM $626,857
17.259 WIOA YOUTH ACTIVITIES $392,534
93.224 HEALTH CENTER PROGRAM $291,318
10.561 STATE ADMINISTRATIVE MATCHING GRANTS FOR THE SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM $221,520
17.277 WIOA NATIONAL DISLOCATED WORKER GRANTS / WIA NATIONAL EMERGENCY GRANTS $197,000
21.027 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS $148,525
93.088 ADVANCING SYSTEM IMPROVEMENTS FOR KEY ISSUES IN WOMEN'S HEALTH $127,565
93.940 HIV PREVENTION AND SURVEILLANCE ACTIVITIES-HEALTH DEPARTMENT BASED $107,262
16.812 SECOND CHANCE ACT REENTRY INITIATIVE $27,975
20.616 NATIONAL PRIORITY SAFETY PROGRAMS $19,475
93.527 GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $19,301
93.399 CANCER CONTROL $15,600
93.837 CARDIOVASCULAR DISEASES RESEARCH $9,040
17.270 REENTRY EMPLOYMENT OPPORTUNITIES $1,250