Finding 501044 (2023-001)

Significant Deficiency
Requirement
N
Questioned Costs
$1
Year
2023
Accepted
2024-09-30

AI Summary

  • Core Issue: The Organization inaccurately applied sliding fee discounts, leading to overcharges and undercharges for patients.
  • Impacted Requirements: Compliance with the sliding fee discount criteria, including proper documentation of income and ability to pay.
  • Recommended Follow-Up: Strengthen controls, enhance staff training, and ensure proper monitoring of sliding fee processes to align with program requirements.

Finding Text

Finding No.2023-001: Inaccurate Application of Sliding fee Discounts (Significant Deficiency) Assistance Listing Number: 93.829 Assistance Listing Program Title: Section 223 Demonstration Programs to Improve Community Mental Health Services. Federal Agency: Department of Health and Human Services (HHS) - Substance Abuse and Mental Health Services Administration (SAMHSA) Passed Through Entity: Not applicable Federal Award Number: 1H79SM085136-01 Federal Award Year: August 31, 2021 – August 30, 2023 Compliance Requirement: Special Tests and Provisions – Sliding Fee Discounts Criteria or Specific Requirements Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and designed to cover their reasonable costs of operation. 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 official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services (HHS). The poverty guidelines are issued each year in the Federal Register and HHS maintains a web page that provides the poverty guidelines. Non-grant funds (State, local, and other operational funding and fees, premiums, and third-party reimbursements which the project may reasonably be expected to receive, including any such funds in excess of those originally expected), shall be used as permitted under the law and may be used for such other purposes as are not specifically prohibited under the law if such use furthers the objectives of the project. Condition The Organization determines the amount of fees to be charged to a patient based on the patient’s income, expense, and number of dependents in conjunction with the sliding fee schedule. Of the 25 patients selected for testing, we noted the following: - 4 patients were charged the incorrect sliding fee amount, which resulted in the Organization overcharging 2 patients by $10 each, while 2 patients were undercharged by $5 each. - 4 patients had no proof of income declaration and sliding fee application form on file. Due to an unsupported sliding fee discount, we were unable to determine if these 4 patients were eligible for the sliding fee and should have been charged the full amount totaling $523.48. Questioned Costs $513.48 in net undercharges for sliding fee patients sampled. Causes and Effect The potential cause for the above errors is as follows: - Error by staff in determining the patient’s ability to pay. - Lack of review and retention of sliding fee applications and income declaration forms. - Patients did not complete the required form necessary to determine the patient’s ability to pay. As a result, the determination of patient fees is not consistent with the sliding fee schedule. Recommendation We recommend that the Organization’s controls and procedures be strengthened to ensure 1) income declaration is properly verified and adequately documented and 2) the sliding fee discount is properly determined and applied. The Organization should also provide additional training to staff involved in the sliding fee process and ensure that appropriate individuals are properly monitoring and reviewing the Organization’s compliance with program requirements. This will help ensure that the proper sliding fee is charged to patients and that program goals and objectives are being met.

Corrective Action Plan

Views of Responsible Officials and Planned Corrective Actions The Organization have experienced turnover of staff in the Organization as well as changes in leadership. In response to this finding the Organization has put together a corrective action plan that targets training of staff and puts into place a monthly audit for ensuring compliance to the sliding fee discount policy. Responsible persons: Nichole Henderson, Quality Improvement Quality Assurance Director and Demetria Johnson, Billing Manager will be in charge of implementing the corrective action. Expected Implementation Date: Started August 1, 2024.

Categories

Questioned Costs Special Tests & Provisions Subrecipient Monitoring Cash Management Significant Deficiency Internal Control / Segregation of Duties

Other Findings in this Audit

  • 1077486 2023-001
    Significant Deficiency

Programs in Audit

ALN Program Name Expenditures
93.829 Section 223 Demonstration Programs to Improve Community Mental Health Services $1.30M
93.493 Community Funded Projects $666,666
93.224 Consolidated Health Centers (community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) $167,365
93.527 Affordable Care Act (aca) Grants for New and Expanded Services Under the Health Center Program $133,794