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.