Finding Text
Criteria: Federal grant compliance provisions require that the Organization correctly identify a patient's ability to pay and that the rates for services be adjusted accordingly based on the sliding fee schedule. The Organization is required to follow its sliding fee policy when providing discounts to eligible patients.
Condition: In the sample of 35 tested items, patient information for 19 claims were inadequate to determine the proper sliding fee discount or the patient was given an inappropriate discount based on information provided.
Cause: There was inadequate understanding and inconsistent handling of the documentation requirements of the sliding fee discount program policies and procedures by certain employees who were involved in sliding fee discount determination.
Effect: Lack of strict enforcement of the policy of sliding fee eligibility determination and compliance may have resulted in the Center providing incorrect discounts for services provided.
Questioned Costs: None reported
Context/Sampling: For 3 of 10 over 200% income level patients selected for testing; the accounts had a discount applied improperly. Also, 16 of 25 less than 200% income level patients selected for testing, had various documents missing and could not be completely tested. This sampling was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue.