Finding 485382 (2024-001)

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Requirement
N
Questioned Costs
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Year
2024
Accepted
2024-08-28
Audit: 318111
Organization: Valley Family Health Care, Inc. (ID)
Auditor: Harris CPAS

AI Summary

  • Core Issue: Inadequate income verification led to incorrect sliding fee discounts for patients.
  • Impacted Requirements: Discounts must align with federal poverty guidelines for those at or below 100% FPG.
  • Recommended Follow-Up: Update billing procedures to ensure accurate application of sliding fee discounts and enhance oversight.

Finding Text

CRITERIA: SPECIAL TESTS AND PROVISIONS UNDER THE DEPARTMENT OF HEALTH AND HUMAN SERVICES, HEALTH CENTER CLUSTER, REQUIRE THAT A FULL SLIDING FEE DISCOUNT IS APPLIED TO FEES FOR HEALTH CENTER SERVICES PROVIDED TO INDIVIDUALS AND FAMILIES WITH ANNUAL INCOMES AT OR BELOW 100 PERCENT OF THE FPG, OR THE HEALTH CENTER APPLIES ONLY A NOMINAL CHARGE. CONDITION: FIVE INSTANCES WERE NOTED WHERE A PATIENT WAS GIVEN A SLIDING FEE DISCOUNT WITHOUT ADEQUATE INCOME VERIFICATION SUPPORTING THE DISCOUNT PROVIDED. OF THESE FIVE INSTANCES, TWO INSTANCES RESULTED IN THE PATIENT RECEIVING A SLIDING FEE DISCOUNT LOWER THAN THE DISCOUNT ACCORDING TO THEIR FEDERAL POVERTY LEVEL (FPL), AND ONE INSTANCE RESULTED IN THE PATIENT RECEIVING A SLIDING FEE DISCOUNT HIGHER THAN THE DISCOUNT ACCORDING TO THEIR FPL. CAUSE: INCONSISTENT CONTROL ACTIVITIES RELATED TO THE APPLICATION OF SLIDING FEE DISCOUNTS. EFFECT: THE INCORRECT FEE WAS CHARGED TO THREE PATIENTS. RECOMMENDATIONS: WE RECOMMEND THAT THE ORGANIZATION MODIFY EXISTING WRITTEN BILLING PROCEDURES AND CONTROLS TO ENSURE SLIDING FEE DISCOUNTS ARE CONSISTENTLY AND ACCURATELY APPLIED TO ALL ELIGIBLE PATIENTS. VIEWS OF RESPONSIBLE OFFICIALS AND PLANNED CORRECTIVE ACTION PLAN: MANAGEMENT AGREES WITH THE FINDING AND IS IN THE PROCESS OF IMPLEMENTING AND DOCUMENTING PROCEDURES TO PROVIDE ADDITIONAL OVERSIGHT ON THE APPLICATION OF SLIDING FEE DISCOUNTS.

Corrective Action Plan

VALLEY FAMILY HEALTH CARE, INC. (VFHC) BELIEVES THE SIGNIFICANT DEFICIENCIES NOTED IN THE SCHEDULE OF FINDINGS AND QUESTIONED COSTS WERE A COMBINATION OF INSUFFICIENT USER TRAINING ISSUES, SYSTEM (EPIC) ISSUES AND INADEQUATE REVIEW AND INTERNAL AUDITING. TO ADDRESS THE SYSTEM ISSUES, WE HAVE REQUESTED VERIFICATION FROM OUR 3RD PARTY BILLING SYSTEM ON HOW THE EFFECTIVE AND EXPIRATION DATES ENTERED IN THE SYSTEM FOR THE FEDERAL POVERTY LEVEL (FPL) DATA IMPACT THE CALCULATION. IN ADDITION, IN DECEMBER OF 2023, VFHC IMPLEMENTED A NEW FEE SCHEDULE THAT INCREASED THE NUMBER OF SLIDING FEE DISCOUNTS THAT COULD BE AUTOMATICALLY CALCULATED BY THE SYSTEM, TO REMOVE THE OPPORTUNITY FOR USER ERROR. TO ADDRESS USER ERRORS, WE REINSTATED OUR FRONT OFFICE MANAGER POSITION RESPONSIBLE FOR TRAINING FRONT DESK STAFF WHO ASSIST PATIENTS WITH THE COMPLETION OF THE SLIDING FEE DISCOUNT APPLICATION. THE HANDBOOK AND TRAINING MATERIALS HAVE BEEN ENHANCED. IN ADDITION, WE ARE CREATING LOGIC IN THE EPIC SYSTEM TO IDENTIFY MISSING OR INCONSISTENT INFORMATION AND DIRECT THESE ISSUES TO A WORK QUE THAT WILL BE REVIEWED BY STAFF. WE ARE IMPLEMENTING AN INTERNAL AUDIT PROCESS OF THE SLIDING FEE DISCOUNTS. THE FRONT OFFICE MANAGER OR DESIGNEE WILL AUDIT A STATISTICALLY MEANINGFUL RANDOM SAMPLE OF NEW SLIDING FEE DISCOUNT APPLICATIONS FOR COMPLETENESS AND ACCURACY. IN ADDITION, WE WILL AUDIT A STATISTICALLY MEANINGFUL NUMBER OF PATIENT ACCOUNTS WHERE A SLIDING FEE DISCOUNT WAS TAKEN TO ENSURE THE ACCURACY OF THE CALCULATION. WE REVIEWED EACH OF THE AUDIT EXCEPTIONS AND DETERMINED THAT IN TWO OF THE FIVE INSTANCES; WE GAVE A LARGER DISCOUNT THAN THE PATIENT QUALIFIED FOR. WE WILL NOT MAKE ACCOUNT ADJUSTMENTS TO COLLECT. IN ONE INSTANCE, WE GAVE A SMALLER DISCOUNT BY $45.50 AND THE BILLING TEAM IS CORRECTING THIS ACCOUNT TO ISSUE A REFUND FOR THE ADDITIONAL DISCOUNT. IN ONE INSTANCE, NO SLIDING FEE DISCOUNT WAS GIVEN AND THE VERIFICATION RETAINED IN THE SYSTEM INDICATED THAT THIS WAS CORRECT. HOWEVER, IT IS POSSIBLE THAT HAD STAFF REQUESTED ADDITIONAL INCOME VERIFICATION; THE PATIENT MAY HAVE HAD A DIFFERENT FPL ASSIGNED. IN ONE INSTANCE, IT APPEARS THE APPROPRIATE SLIDE FEE DISCOUNT WAS APPLIED BUT THE SUPPORTING DOCUMENTATION WAS NOT RETAINED IN THE PATIENT CHART. VFHC TAKES THESE ISSUES VERY SERIOUSLY AND WILL BEGIN CORRECTIVE ACTIONS IMMEDIATELY. PROPOSED COMPLETION DATE: WE ANTICIPATE THESE ACTIONS TO BE COMPLETED BY THE END OF THE 3RD QUARTER.

Categories

Special Tests & Provisions Internal Control / Segregation of Duties

Other Findings in this Audit

Programs in Audit

ALN Program Name Expenditures
93.526 Affordable Care Act (aca) Grants for Capital Development in Health Centers $327,702
93.527 Affordable Care Act (aca) Grants for New and Expanded Services Under the Health Center Program $277,055
93.224 Consolidated Health Centers (community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) $164,252
10.177 Regional Food System Partnerships (b) $135,139