Finding Text
Federal agency: U.S. Department of Health and Human Services Federal program title: Health Center Program Cluster (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) Assistance Listing Number: 93.224/93.527 Federal Award Identification Number: H8026575, H8N54101 Award Period: March 2023 through February 2026 Type of Finding: Significant Deficiency in Internal Control over Compliance – Special Tests Criteria or specific requirement: The Health Resources and Services Administration (HRSA), as reflected in the OMB Compliance Supplement for the Health Center Program, requires health centers to maintain and consistently apply a sliding fee discount program (SFDP) based on patients’ documented household income and family size. Discounts must be determined using current, complete applications with supporting documentation, and applied in accordance with the approved sliding fee schedule. Patients who do not provide sufficient income information are not eligible for sliding fee discounts. Condition: The Organization applied a sliding fee adjustment incorrectly to 8 of 60 patient accounts tested. Questioned costs: None Context: In a sample of 60, four instances noted where the discount level applied (e.g., Slide A) did not align with the income documentation provided, which supported a different discount eligibility (e.g., Slide B) under the Federal Poverty Guidelines and Sliding Fee Schedule in place at the date the application was signed. Four other instances noted where the information input into the electronic medical records (EcW) to calculate the slide was not accurate based on the completed sliding fee application resulting in the slide calculated to also be inaccurate. Cause: The noncompliance appears to result from inadequate internal controls over the review and approval of sliding fee applications, including: • The SFDS updated in March 2024 for annual FPG adjustments was not entered into the client’s billing software, therefore, the slide calculated by the billing software for a few patients was based on previous FPG instead of the updated FPG adopted by the entity in March 2024. • A patient’s application was received and completed under the guidelines of the 2024 SFDS in place, however, the application information was not entered into billing software until the 2025 SFDS guidelines were in place which resulted in an error in calculating the slide that was appropriate as of the date the application was considered complete. • Inconsistent application of policies by staff responsible for patient eligibility determinations. Sliding Fee opportunity form information input instead of the information obtained from a completed application in accordance with the Organization’s policy. • Controls not in place to review information input into EcW to calculate the slide to make sure applications match and human error identified.Effect: Patients may have received discounts that were not in accordance with HRSA requirements. Repeat Finding: Yes Recommendation: We recommend that management implement a secondary review or approval control to validate that assigned discount levels align with documented income at the time the application is considered complete, periodically test a sample of sliding fee determinations to ensure consistent application of the fee schedule, and provide training to registration and billing staff to reinforce SFDP requirements and documentation standards. Views of responsible officials: There is no disagreement with the audit finding and are currently working on training the intake staff and improving the review process.