Finding 485704 (2023-001)

Significant Deficiency
Requirement
N
Questioned Costs
-
Year
2023
Accepted
2024-09-04
Audit: 318513
Organization: Camillus Health Concern, Inc. (FL)
Auditor: Rlmolina LLC

AI Summary

  • Core Issue: CHC lacks effective internal controls over the sliding fee scale eligibility, leading to missing required patient information.
  • Impacted Requirements: Compliance with Uniform Guidance for sliding fee discount schedules is not being met, risking improper billing practices.
  • Recommended Follow-Up: Provide staff training on the EPIC system and implement a quality control process to regularly review patient encounters and documentation.

Finding Text

Ineffective Controls Over the Sliding Fee Scale Eligibility Requirements Federal Agency: Department of Health and Human Service Federal Program: Health Center Program Assistance Listing Number: 93:224/93.527 Type of Finding: Significant Deficiency Condition Community Health Concern, Inc. (“CHC”) did not effectively maintain an internal control system over its sliding fee and clinic service eligibility requirements. During the compliance testing of the Uniform Guidance “Special Tests and Provisions – Sliding Fee Applications” requirements, we noted: • Two (2) patient files/charts did not have the required eligibility information, including sliding fee scale assessments, proof of income, general consent, registration form, etc. • A Medicare patient was assessed a sliding fee scale discount for services that should have been charged to Medicare. Possible Asserted Criteria: Per the Uniform Guidance, health centers must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Possible Asserted Cause: Staff’s inability to fully grasp the new medical health system, EPIC is contributing to the internal controls ineffectiveness over the sliding fee scale application and the patient encounter process. Potential Asserted Effect of Condition: Lack of effective internal control procedures could result in unintentional errors that may not be detected in a timely manner by employees in the normal course of performing their assigned duties. Questioned Costs: N/A. Recommendation: Management should undergo additional training of its EPIC system to help mitigate potential patient encounter errors. Additionally, a system of quality control should be implemented to allow periodic assessment and transactions reviewed of patient’s encounter and charts to ensure the process is functioning properly. Management’s Views: Management’s response is included in the “Management’s Views and Corrective Action Plan” included at the end of this report after “Section IV – Status of Financial Statements Findings of Prior Audits.”

Corrective Action Plan

Ineffective Controls Over the Sliding Fee Scale Eligibility Requirements Condition Community Health Concern, Inc. (“CHC”) did not effectively maintain an internal control system over its sliding fee and clinic service eligibility requirements. During the compliance testing of the Uniform Guidance “Special Tests and Provisions – Sliding Fee Applications” requirements, we noted: • Two (2) patient files/charts did not have the required eligibility information, including sliding fee scale assessments, proof of income, general consent, registration form, etc. • A Medicare patient was assessed a sliding fee scale discount for services that should have been charged to Medicare. Management’s Views: CHC implemented a new electronic health record (EHR), Epic Platform, in October 2023 to replace its 15-year-old legacy system, Intergy. After one year of extensive training, CHC with the assistance of Health Choice Network (HCN), a Health Center Controlled Network, rollout the Epic Platform, During and post implementation of the new platform, CHC encountered significant challenges in its front desk operations (e.g. eligibility information, including registration form, general consent, proof of income and sliding fee scale assessments), hence, two patients’ charts did not cross over from the old system to the new platform and challenges with our outreach teams’ encounters. Also, a Medicare beneficiary was incorrectly assessed a sliding fee scale discount for services that should have been charged to Medicare. As a result of the audit findings, we have identified several areas for improvements to enhance the effectiveness and efficiency of our front desk and outreach teams processes. Corrective Action Plan: The following corrective action plan outlines the necessary steps to address these areas: 1. Monthly Chart Audit by the Lead Patient Services Representative (Lead PSR): • Checklist to include: o Eligibility verification o Consent to treat o Registration packet o Sliding Fee Application o Self-declaration 2. Utilization of HCN Teams Chat Tool • Leverage the HCN Teams chat for addressing insurance-related questions, such as duplicate commercial plans, to ensure accurate and timely responses. 3. Retraining Low Performing Staff • Low-performing staff will undergo retraining with the Lead PSR and HCN Revenue Cycle Management consultants to enhance their performance and understanding of the processes. 4. Competency Test Development • Develop and implement a competency test for PSRs to ensure all team members possess the required knowledge and skills. 5. Monthly Meetings • Hold monthly meetings between the PSR and Billing teams to share knowledge, address concerns, and promote continuous learning and improvement. 6. Staff Registration Limitation • Limit the number of staff able to register patients. PSRs will take the lead role in registration, with MAs serving as backup when necessary. 7. Creation of Insurance Quick-Guides • Create quick-guides to aid in the selection and verification of insurance, ensuring staff have easy access to essential information. 8. Hard Stops on EPIC workflow • Request hard stops on EPIC for the input of key information to prevent incomplete or incorrect data entry, thereby improving data integrity and patient care. Anticipated Date of Completion: Management has implemented approximately 80% of the strategies described in the Plan above. These corrective actions are designed to address the identified issues and enhance the efficiency and accuracy of the registration and billing processes. Management believes that these measures will also lead to significant improvements in the overall operations and patient satisfaction. Management anticipates the successful completion date for the entire Plan to be no later than August 31st, 2024. Contact Person: For inquiries regarding this finding, please contact Benjo Reyes at BenjoR@CamillusHealth.org who is responsible for the corrective actions.

Categories

Special Tests & Provisions Eligibility Significant Deficiency Internal Control / Segregation of Duties

Other Findings in this Audit

  • 485705 2023-002
    Significant Deficiency
  • 1062146 2023-001
    Significant Deficiency
  • 1062147 2023-002
    Significant Deficiency

Programs in Audit

ALN Program Name Expenditures
93.224 Consolidated Health Centers (community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) $829,647
93.526 Affordable Care Act (aca) Grants for Capital Development in Health Centers $254,967
32.006 Covid-19 Telehealth Program $253,396
93.498 Provider Relief Fund $239,102
93.527 Affordable Care Act (aca) Grants for New and Expanded Services Under the Health Center Program $155,833