Finding 1229171 (2025-002)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2025
Accepted
2026-09-09

AI Summary

  • Core Issue: Errors in applying sliding fee adjustments due to improper setup in the Electronic Health Record System.
  • Impacted Requirements: Compliance with 42 CFR 51c.303e through 56.303g regarding patient fee adjustments based on ability to pay.
  • Recommended Follow-Up: Review and correct the sliding fee calculation setup, and implement regular management reviews of adjustments against the organization’s policies.

Finding Text

Information on the federal program – Assistance Listing Number 93.224/93.527, Health Center Program Cluster from the U.S. Department of Health and Human Services, Federal Award No. 6 H80CS00581 for project period March 1, 2025 through February 28, 2026. Criteria or specific requirement – Health Centers must prepare and apply a sliding fee discount schedule that incorporates the provisions of 42 CFR 51c.303e through 56.303g to ensure that amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Condition – The audit of the major federal program identified errors in the application of sliding fee adjustments. Cause – The sliding fee calculation was improperly set up within the Electronic Health Record System. Effect or potential effect – Inaccurate application of sliding fee adjustments may result in potential noncompliance with program requirements. Questioned costs – Not applicable. Context – Out of a population of 14,158 sliding fee adjustments, a sample of 25 adjustments were tested. Out of the 25 tested, 3 adjustments were incorrectly calculated based on the Organization’s sliding fee scales and the patient’s sliding fee application. A non-statistical sampling methodology was used to select the sample. Identification as a repeat finding, if applicable – Is a repeat finding. Recommendation – We recommend that the Organization perform a review of the calculation of the sliding fee adjustments within the Electronic Health Record system to ensure it is properly set up. Additionally, we recommend that a member of management with an understanding of the Organization’s billing and sliding fee policies regularly review a sample of sliding fee adjustments in comparison to the Organization’s sliding fee policy. Views of responsible officials and planned corrective actions – The sliding fee adjustment errors resulted from an error in the set up of the automated adjustment calculation within the Electronic Health Record system. Management has identified the error with plans to ensure correction within the system. Further, the Organization will implement a process to periodically review sliding fee adjustments throughout the year for accuracy.

Corrective Action Plan

Finding Number: 2025-002 Planned Corrective Action: The sliding fee adjustment errors resulted from an error in the set-up of the automated adjustment calculation within the Electronic Health Record system. Management has identified the error with plans to ensure correction within the system. Further, the Organization will implement a process to review a sample of sliding fee adjustments monthly to assess accuracy, correct any on-going issues, and maintain records as evidence of this review. Anticipated Completion Date: 12/31/2026 Responsible Contact Person: Tyson Bouyack, Chief Financial Officer

Categories

Special Tests & Provisions

Other Findings in this Audit

  • 1229170 2025-002
    Material Weakness Repeat
  • 1229172 2025-003
    Material Weakness Repeat
  • 1229173 2025-003
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.224 HEALTH CENTER PROGRAM $4.21M
93.527 GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $259,498
93.994 MATERNAL AND CHILD HEALTH SERVICES BLOCK GRANT TO THE STATES $196,000