Finding Text
U.S. Department of Health and Human Services Assistance Listing Number 93.224 Health Center Program Cluster Program Year 2025-2026 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts Per 42 U.S.C. § 254b(k)(3)(G)(i), Federally Qualified Health Centers (FQHC) must prepare a schedule of fees or payments and a corresponding schedule of discounts adjusted on the basis of the patient’s ability to pay. Implementing regulations at 42 CFR § 51c.303(f) and 42 CFR § 56.303(f) require health centers to establish a schedule of discounts adjusted on the basis of patients’ ability to pay, with nominal charges for individuals and families with annual incomes at or below 100% of the Federal Poverty Level (FPL), and discounts for those with incomes between 100% and 200% of FPL. Additionally, 42 U.S.C. § 254b(k)(3)(F) and 42 CFR § 51c.303(e) and § 56.303(e) prohibit denying services to any patient due to inability to pay. Condition – During our testing of patient encounters, we identified instances where patients did not receive sliding fee discount adjustments in accordance with the Organization’s sliding fee schedule and the requirements of 42 CFR § 51c.303(f) and §56.303(f). Specifically, three (3) of twenty-five (25) patient encounters tested did not reflect the appropriate sliding fee discount based on the patient’s documented income and family size relative to FPL guidelines. Cause – The Organization’s internal controls over the application of sliding fee discounts were not operating effectively to ensure compliance with its sliding fee policy. Effect or Potential Effect – Patients may have been charged amounts inconsistent with their eligibility for sliding fee discounts. Questioned Costs – None Context – A sample of 25 patients was tested out of the total population of 3,000 encounters. Three patients did not receive the proper sliding fee adjustments. The sampling methodology used is not and is not intended to be statistically valid. Identification as a Repeat Finding – No Recommendation – We recommend management ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure eligible patients receive discounts in accordance with the sliding fee scale. Views of Responsible Officials and Planned Corrective Actions – The Organization concurs with the finding, and management has continued to implement procedures to ensure that eligible patients receive discounts in accordance with the sliding fee scale. Management and all personnel involved will review and determine the appropriate sliding fee discount in order to be in compliance with federal regulations. All patients will be offered an application to participate in the sliding fee discount. Information will be entered into the system as declined or appropriate to arrive at the sliding fee category. The application will then come to Hampton where a billing clerk will review the application for accuracy. The CHC and Insurance tab will reflect the correct sliding fee category. Corrections to the patient account will be made if there are any inaccuracies found. Education will be provided to those making the error and corrective action taken if continued omissions. In the Organization’s PMS, the slide is setup as an insurance, if no other insurance is primary the adjustment is automatically made. The PMS has been checked for accuracy of slide categories, adjustment codes and insurance types. The Organization’s Billing and Collections staff will be re-educated on the entire process of sliding fee; from application to ensuring adjustments are made correctly. Reviews will be made by the CIO on a quarterly basis to assure the correct adjustment has been made.