Finding 374451 (2022-001)

Significant Deficiency Repeat Finding
Requirement
N
Questioned Costs
$1
Year
2022
Accepted
2024-03-07
Audit: 294123
Organization: Community Medical Centers, Inc. (CA)
Auditor: Moss Adams LLP

AI Summary

  • Core Issue: Patients received improper sliding fee discounts due to lack of documentation and inaccuracies in applying the discount policy.
  • Impacted Requirements: Compliance with HRSA guidelines and 42 CFR 56.303 regarding sliding fee discount schedules based on income and household size.
  • Recommended Follow-up: Strengthen procedures for verifying and documenting income, ensure accurate application of discounts, and enhance monitoring processes for compliance.

Finding Text

Criteria: In accordance with the Health Resources & Services Administration Health Center Program Compliance Manual, Chapter 9: Sliding Fee Discount Program, health centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted based on the patients’ ability to pay. In accordance with 42 CFR 56.303, health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted based on the patient’s ability to pay. The patient’s ability to pay is determined based on the official poverty guidelines, as revised annually by U.S. Department of Health and Human Services (HHS). The schedule of discounts must provide for a full discount to individuals and families with annual incomes at or below those set forth in the most recent poverty income guidelines (except that nominal fee for service may be collected from such individuals and families) and for no discount to individuals and families with annual incomes greater than twice those set forth in such guidelines. Condition: The Organization determines the sliding fee discount charged to the patients based on their annual gross income and household size. During our testing of sliding fee discount, we noted the following: • Three (3) out of 25 encounters selected were given a sliding fee discount and no sliding fee application with gross income and household size was retained resulting in application of the sliding fee discount of $611.79. There was a total of 42,354 encounters and the sample procedures were not statistical. • One (1) out of 25 encounters selected was given a sliding fee discount in an amount that did not match their annual gross income and household size per the sliding fee policy resulting in overcharging the patient $45. Questioned Costs: $566.79 of the $6,239.27 discount amounts sampled. Total likely questioned costs were $48,999. Context: The audit findings represent a systematic problem, see condition above. Effect: Patients were given an improper sliding fee discount without documentation to support that the patient qualified based on their income. Cause: The lack of retaining forms and inaccuracy in the application of the sliding fee program discounts were due to inadequate oversight and review. Indication of Repeat Finding: This is a repeat of the prior year finding 2021-001, which was remedied in March 2022. Recommendation: We recommend that the Organization’s procedures be strengthened to ensure 1) income is properly verified and adequately documented and retained, and 2) the sliding fee discount is properly determined and applied. The Center should strengthen processes surrounding monitoring of the program to ensure the Center’s policies are consistently and properly applied. Views of Responsible Officials and Planned Corrective Actions: The Organization incorporated training on the program to all front office staff and new front office staff to ensure that income is properly verified, adequately documented, and retained, and that the sliding fee discount is properly determined and applied. Additional levels of internal audit and management were also added to the process to ensure program compliance.

Corrective Action Plan

Condition Sliding Fee Discounts. Testing performed on the sliding fee discounts charged to patients based on annual gross income and household size, found sliding fee scales to be inappropriately unsupported. The result was patients were given an improper sliding fee discount without documentation to support that the patient qualified based on their income. In addition, one encounter was given a sliding fee discount tin an amount that did not match their annual gross income and household size resulting in an over charge to the patient. Lack of retaining forms and inaccuracy in the application of the sliding fee program discounts were due to inadequate oversight and review. Corrective actions This is a repeat finding from prior fiscal year financial statements. Corrective actions were taken and implemented by March 2, 2022. Corrective action plan from prior year is stated below. Indication of repeat finding was remedied in March of 2022. Each of the findings noted were in fiscal year 2022, however were prior to the corrective action plan of March 2022. Once corrective action plan was implemented, there were no further findings related to the sliding fee discounts. Internal audit process is still in place and continued training to front office is in place. Corrective Action from prior year finding Training: Retrain staff on sliding fee policy procedures to ensure (1) income is properly verified, adequately documented and retained and (2) the sliding fee discount is properly determined and applied. All new Front Office staff will receive sliding fee program training as part of their 4-day front office training during onboarding. By Feb 28, 2022, the Front Office Trainer will review documentation requirements around sliding fee scale for patients, including checking applications for completion and making sure the sliding fee applied is being correctly calculated by all Front Office Leads, Supervisors and Center Managers. By Mar 2, 2022, the Front Office Trainer will help create a front office compliance checklist to review front office procedures around documentation, insurance, sliding fees and other programs. Sliding Fee Annual Update: The Revenue Cycle Director will notify the Applications Team and Front Office trainer each year when the sliding fee scale has been updated. The Applications Team will update the UDS table and map to the calculator in the EHR. The Front Officer trainer will review sliding fee updates on an annual basis update trainings with front office staff and within thirty days of notification of any sliding fee policy revisions. Internal Audit: An additional level of review will be added to the process to ensure program compliance. The Revenue Cycle Director will create and document a sliding fee scale internal audit process that will be performed monthly. When the audit is performed, findings will be reported to the following: General Cousnel & Compliance Officer, Chief Financial Officer, Chief Operating Officer, Front Officer Trainer, Center Manager, and lead/supervisors. Front Office Trainers will work closely with Center Managers, Leads and Supervisors to ensure that ongoing compliance on sliding fees are met based on internal audit findings. Refresher trainings to staff will be provided based on patterns determined by internal audit findings. This process will be implemented by February 28, 2022. Name of Contact Person(s) Responsible for Corrective Action: Jaime Allen, Chief Financial Officer Anticipated Completion Date: March 2, 2022 Update: All corrective actions were implemented as planned and are monitored by the monthly audit led by the Revenue Cycle Director. Front Office trainings continue on a regular basis to mitigate future reoccurrence.

Categories

Questioned Costs Subrecipient Monitoring Internal Control / Segregation of Duties

Other Findings in this Audit

  • 374452 2022-001
    Significant Deficiency Repeat
  • 374453 2022-001
    Significant Deficiency Repeat
  • 374454 2022-001
    Significant Deficiency Repeat
  • 374455 2022-001
    Significant Deficiency Repeat
  • 374456 2022-001
    Significant Deficiency Repeat
  • 374457 2022-001
    Significant Deficiency Repeat
  • 374458 2022-001
    Significant Deficiency Repeat
  • 374459 2022-001
    Significant Deficiency Repeat
  • 374460 2022-001
    Significant Deficiency Repeat
  • 374461 2022-001
    Significant Deficiency Repeat
  • 950893 2022-001
    Significant Deficiency Repeat
  • 950894 2022-001
    Significant Deficiency Repeat
  • 950895 2022-001
    Significant Deficiency Repeat
  • 950896 2022-001
    Significant Deficiency Repeat
  • 950897 2022-001
    Significant Deficiency Repeat
  • 950898 2022-001
    Significant Deficiency Repeat
  • 950899 2022-001
    Significant Deficiency Repeat
  • 950900 2022-001
    Significant Deficiency Repeat
  • 950901 2022-001
    Significant Deficiency Repeat
  • 950902 2022-001
    Significant Deficiency Repeat
  • 950903 2022-001
    Significant Deficiency Repeat

Programs in Audit

ALN Program Name Expenditures
93.224 Consolidated Health Centers (community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) $7.00M
10.557 Special Supplemental Nutrition Program for Women, Infants, and Children $1.44M
93.498 Provider Relief Fund $591,660
16.320 Services for Trafficking Victims $98,416
93.217 Family Planning_services $40,425
93.527 Affordable Care Act (aca) Grants for New and Expanded Services Under the Health Center Program $36,055
93.501 Affordable Care Act (aca) Grants for School-Based Health Center Capital Expenditures $28,663
93.918 Grants to Provide Outpatient Early Intervention Services with Respect to Hiv Disease $18,802
93.940 Hiv Prevention Activities_health Department Based $18,088