Finding 1223584 (2025-002)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2025
Accepted
2026-07-13

AI Summary

  • Core Issue: The organization failed to document patient eligibility for sliding fee discounts, leading to potential inaccuracies in fee assessments.
  • Impacted Requirements: Compliance with federal regulations requiring health centers to apply discounts based on patients' ability to pay was not met.
  • Recommended Follow-Up: Provide training for front desk staff on collecting necessary patient information and enhance internal audits to ensure compliance with the sliding fee scale policy.

Finding Text

Special Provisions Federal Agency: U.S. Department of Health and Human Services Federal Program Title: Health Center Program Cluster Assistance Listing Number: 93.224 Federal Award Identification Numbers and Year: 6 H80CS29010; 6 H80CS29011 Award Period: June 1, 2024 – May 31, 2025; June 1, 2025 – May 31, 2026 Criteria or Specific Requirement: Health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay (42 USC 254(k)(3)(G); 42 CFR sections 51c.303(f), and (g); and 42 CFR sections 56.303(f), and (g)). Condition: The Organization did not maintain documentation to show that patients had been evaluated for eligibility under its sliding fee scale policy and did not apply sliding fee adjustments consistent with the sliding fee scale assigned. Questioned Costs: None. Context: Eleven (11) of seventeen (17) encounters tested could not be verified as having received an appropriate sliding fee discount as their family size and income information was missing or outdated. Cause: This matter seems to be caused by a lack of adherence to policy and procedure by the front desk for obtaining all necessary information to appropriately determine the type of sliding fee discount for which a patient is eligible. Additionally, management is still working to identify the extent to which any of these issues are the result of the electronic medical records system's configuration. Effect: Patients may not be assessed a correct sliding fee discount according to their ability to pay and the Organization's sliding fee scale. Repeat Finding: No Recommendation: Management should provide training and education to front desk staff related to the EMR and the process for collecting and retaining family size and income information in addition to inputting it into the electronic medical records. We also recommend enhancing any current internal audits of patient visits to determine all required patient information and has been obtained and charges are appropriately billed in accordance with the Organization's policies. Views of Responsible Officials: There is no disagreement with this finding.

Corrective Action Plan

Health Center Program – Assistance Listing No. 93.224 Recommendation: Management should provide training and education to front desk staff related to the EMR and the process for collecting and retaining family size and income information in addition to inputting it into the electronic medical records. We also recommend enhancing any current internal audits of patient visits to determine all required patient information and has been obtained and charges are appropriately billed in accordance with the Organization's policies. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management concurs with the finding. To address this issue, the Organization will reinforce procedures requiring current incomeand family size documentation prior to determining sliding fee eligibility, provide additionalstaff training, and will review electronic medical record system settings to ensure properdocumentation and application of discounts. Management will conduct periodic reviews tomonitor compliance with sliding fee discount requirements. Name(s) of the contact person(s) responsible for corrective action: Chief Operations Officer or their designee. Planned completion date for corrective action plan: September 1, 2026

Categories

Eligibility Special Tests & Provisions

Other Findings in this Audit

  • 1223583 2025-001
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
10.557 WIC SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN $2.69M
93.224 HEALTH CENTER PROGRAM $1.35M
21.027 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS $408,051
84.425 EDUCATION STABILIZATION FUND $52,975
93.217 FAMILY PLANNING SERVICES $47,636
93.914 HIV EMERGENCY RELIEF PROJECT GRANTS $7,548