Finding 43407 (2022-001)

Significant Deficiency
Requirement
N
Questioned Costs
-
Year
2022
Accepted
2023-03-30
Audit: 48497
Organization: Cascade Aids Project (OR)

AI Summary

  • Core Issue: Incorrect application of sliding scale fee discounts led to patients overpaying for services.
  • Impacted Requirements: Inconsistent documentation of salary and demographic information hindered accurate discount determination.
  • Recommended Follow-Up: Establish formal procedures for collecting and verifying patient demographic data to ensure proper discount application.

Finding Text

CRITERIA: Providers of health care services who receive funding under this program are required to apply a sliding scale fee discount to all individuals and families based on annual income and household size. CONDITION: During our sliding scale fee discount testing procedures, we selected 18 transactions to test that the patient met the criteria for the sliding fee scale discount and that the discount was properly applied. We identified three instances in our sample where the sliding fee discount applied to the patient was incorrect, resulting in the patient paying a higher rate for services than they were otherwise entitled to. We also noted salary amounts were not consistently documented, resulting in errors in the determination of the appropriate sliding scale fee discount. CAUSE and CONTEXT: Based on discussions with clinic management, it appears there is no consistent process used to inform patients of their right to receive a fee discount based on their income and household size. It also appears patient intake forms are not being consistently reviewed to ensure accurate demographic information is entered into the patient billing system in order for the appropriate sliding fee scale discount to be applied. POSSIBLE EFFECT: In our judgment, without accurate demographic information, patients at the clinic may not receive the appropriate sliding scale fee discount. RECOMMENDATION: We recommend the Organization develop formal procedures to ensure patients are given the opportunity to provide demographic information, and that this information is reviewed for accuracy when input into the patient billing system. Such procedures could include placing a placard in the main area of the clinic and in the treatment rooms informing patients of their right to receive a discount to encourage patients to provide the required information, and implementation of a periodic review process to ensure accuracy of data input and the application of sliding scale discounts. VIEWS of RESPONSIBLE OFFICIALS and PLANNED CORRECTIVE ACTIONS: We agree. CAP has embarked on a process to improve our formal procedures to ensure patients are given the opportunity to provide demographic information, and that this information is reviewed for accuracy when input into the patient billing system. Though patients are informed of the opportunity and their rights through existing visible signage, patient enrollment information, and via our website, these communications will be expanded and improved. The waiting room placard will be included in all exam rooms, patient application clarity will be improved and all applications reviewed in a 2-person verification process. Data entry procedures will be improved through a Plan-Do-Study-Act (PDSA) process. We have identified four key areas to improving the collection of accurate income and household size: staff and patient discomfort, the electronic health record (EHR), in-person versus telemedicine visits, and staff pre-appointment data scrubbing processes. The Prism team is activating plans on these four identified needs.

Corrective Action Plan

Recommendation: The Organization should develop formal procedures to ensure patients are given the opportunity to provide demographic information, and that this information is reviewed for accuracy when input into the patient billing system. Such procedures could include placing a placard in the main area of the clinic and in the treatment rooms informing patients of their right to receive a discount to encourage patients to provide the required information, and implementing a periodic review process to ensure accuracy of data input and the application of sliding scale discounts. Action Taken: CAP acknowledges the finding and has the following action steps: Prism has a placard posted in the lobby with information about our sliding fee scale, information is provided on our website as well as in the initial paperwork signed by patients when establishing care. All new patients are given and must sign the Prism Health Patient Rights and Responsibilities, Consents, and Financial Agreement form. This form outlines the financial options available to all patients including information about the Sliding Fee Discount Program and assistance in determining eligibility for the Oregon Health Plan if a patient is uninsured. Prism will add placards in all exam rooms in addition to sending out notification to patients annually via email. Mode of patient applications. Completed applications reside in patient registration records. Staff cannot notate their Federal Poverty Level (FPL) calculation or determination of award, or who reviewed the completed form unless the form is printed from the chart, notated, and then rescanned. Therefore, the MyChart version of the Sliding Fee Discount Program application will be removed from MyChart and replaced with a fillable demographic form that explains why Prism Health is required to annually collect patient income and household size, as well as other additional HRSA required data points (I.e., seasonal or migrant farm worker, veteran status, housing status). Unless the patient declines to provide income and household size information, staff will use the information provided to determine FPL and outreach to the patient if their FPL makes them eligible to apply for the Sliding Fee Discount Program. If the patient expresses interest, staff will provide them with the Sliding Fee Discount Program application and the Zero Income Form.A two-person verification system will be implemented to ensure that the discount application is fully completed and signed by the patient, that staff?s calculation of annual income is done accurately, and that staff have completed the Prism Health portion of the application before it is scanned into the patient?s registration record. Additionally, a calculation guide for determining (FPL) will be added to the ?Office Use Only? section of the application to help staff more accurately calculate a patient?s annual income (e.g., if a patient is paid once a week their weekly pay is multiplied by 52 weeks to get an accurate annual income amount). The Prism team has embarked on a PDSA (Plan-Do-Study-Act) cycle to review our data collection procedures, look for opportunities to improve, and check on progress. We have identified four key areas to improving the collection of accurate income and household size: staff and patient discomfort, the electronic health record (EHR), in-person versus telemedicine visits, and staff pre- appointment data scrubbing processes. The Prism team is activating plans on these four identified needs.

Categories

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Other Findings in this Audit

Programs in Audit

ALN Program Name Expenditures
93.939 Hiv Prevention Activities_non-Governmental Organization Based $344,573
93.527 Affordable Care Act (aca) Grants for New and Expanded Services Under the Health Center Program $180,999
14.241 Housing Opportunities for Persons with Aids $122,075
93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (elc) $92,506
93.940 Hiv Prevention Activities_health Department Based $40,370
93.914 Hiv Emergency Relief Project Grants $31,376
14.267 Continuum of Care Program $24,335
93.928 Special Projects of National Significance $9,052
93.924 Ryan White Hiv/aids Dental Reimbursement and Community Based Dental Partnership Grants $2,783