Finding 393703 (2023-002)

Significant Deficiency
Requirement
J
Questioned Costs
-
Year
2023
Accepted
2024-04-18

AI Summary

  • Core Issue: There is a significant deficiency in internal controls regarding the documentation of patient income and household size for sliding fee discounts.
  • Impacted Requirements: Compliance with HHS guidelines requires proper documentation of patient financial information to determine eligibility for discounts based on ability to pay.
  • Recommended Follow-Up: Management should enhance the patient intake process to ensure all necessary documentation is collected, verified, and retained as per program requirements.

Finding Text

Federal Agency: Department of Health and Human ServicesFederal Program: Family Planning Services – Title XFederal Assistance Listing Number(s): 93.217 Award Period: July 1, 2022 to June 30, 2023 Type of Finding: 􀁸 Significant Deficiency in Internal Control over Compliance 􀁸 Compliance – Other Matters Criteria or Specific Requirement: In accordance with the HHS Office of Population Affairs Title X Program Handbook, Chapter 3: Program Expectations, family planning service providers must prepare and apply a sliding fee discount schedule so that amounts owed for family planning services by eligible patients are adjusted based on the patients’ ability to pay. In accordance with 42 CFR 59.5(a), family planning service providers must have a schedule of fees or payments for the provision of their services consistent with locally prevailing rates or charges and designed to cover their reasonable costs of providing services. 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 federal poverty guidelines, as revised annually by U.S. Department of Health and Human Services (HHS), which considers the patient’s annual income and household size. 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 patient files, we noted the 3 out of 40 encounters selected did not have a patient intake form on file that supported the patient’s annual income and household size that was entered into the patient billing system. Of those 3 encounters none of the patients were improperly charged or given a sliding fee discount, as their insurance provider covered the full cost of services in accordance with the program requirements. Context: Patient intake forms are signed by both the patient and clinic personnel. This form is filled out by the patient indicating use or no use of insurance, that they are responsible for the charges, etc. This form also serves as verification of the patient’s annual income and household size which is then entered into the patient billing system to calculate billing/ eligibility for assistance, as applicable. Cause: Due to the lack of retaining the intake forms the patient’s income and household size that was entered into the patient billing system could not be fully supported. This was caused by inadequate oversight and review. Effect: Patients could have been given an improper sliding fee discount without documentation to support that the patient qualified based on their income and household size. Recommendation: We recommend management review its patient intake process to ensure income and household size is properly verified, adequately documented, and retained for each patient in accordance with organizational policies and program requirements. Views of Responsible Official: Management agrees with the finding. Management will review its patient intake policies and procedures.

Corrective Action Plan

Title X – Assistance Listing No. 93.217Recommendation: We recommend management review its patient intake process to ensure income and household size is properly verified, adequately documented, and retained for each patient in accordance with organizational policies and program requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PPNCS has put a process in place to ensure patient income and household size is accurately identified and documented. Patients report their income and household size to the health center staff, who enter the information into the electronic medical record system (NextGen). After the information is entered, a registration form (B209) is printed and given to the patient to review, verify, and sign. Name of the contact person responsible for corrective action: Randy Drager, CFO Planned completion date for corrective action plan: April 15, 2024

Categories

Internal Control / Segregation of Duties Eligibility Significant Deficiency

Other Findings in this Audit

  • 393702 2023-001
    Material Weakness
  • 970144 2023-001
    Material Weakness
  • 970145 2023-002
    Significant Deficiency

Programs in Audit

ALN Program Name Expenditures
93.217 Family Planning_services $698,509
93.092 Affordable Care Act (aca) Personal Responsibility Education Program $236,352
93.332 Cooperative Agreement to Support Navigators in Federally-Facilitated and State Partnership Marketplaces $212,481
93.235 Affordable Care Act (aca) Abstinence Education Program $207,925
93.297 Teenage Pregnancy Prevention Program $109,836
93.558 Temporary Assistance for Needy Families $44,630
93.744 Pphf: Breast and Cervical Cancer Screening Opportunities for States, Tribes and Territories Solely Financed by Prevention and Public Health Funds $10,425