FAC Explorer

Finding 501227 (2024-001)

Significant Deficiency
Requirement
N
Questioned Costs
-
Year
2024
Accepted
2024-10-01
Audit: 323494
Organization: Pureview Health Center (MT)
Auditor: Kcoe Isom LLP

AI Summary

  • Five errors were found in applying the sliding fee scale during the audit, affecting patient billing.
  • Improper application of the sliding fee scale could lead to loss of funding and inequitable access to healthcare services.
  • We recommend strengthening internal controls by reviewing claims to ensure the sliding fee scale is applied correctly.

Finding Text

Condition: As a result of our audit procedures, we found five errors in the application of the sliding fee scale. Criteria: The sliding fee scale discount is based on patient income and demographic information. Controls should be in place to ensure the sliding fee scale is consistently applied for each patient. Effect: Continued noncompliance could result in a loss of funding. Additionally, it could result in inequitable access to healthcare services for patients and expose the Center to reputational risks. Context: During our testing, we found 5 of the 60 patients tested were not billed for the proper slide category based on the sliding fee scale provided by the PureView. No questioned costs were identified. Cause: The errors resulted from claims where the sliding scale was improperly recorded within the claim. There was no check to verify that the claim scale matched the scale within the patient files. These claims were missed during the billing department’s internal review of scale application. Individuals responsible for the primary and secondary review of sliding fee scale applications requires additional training and resources to ensure errors are detected timely. Recommendation: We recommend that PureView strengthen its internal controls by reviewing claims to ensure proper application of the sliding fee scale. Management Response: See Corrective Action Plan.

Corrective Action Plan

1. The CFO will generate an exception report directly from eCW, the health records system where billing records are recorded, to identify mismatches between the claim slide group write-off and the slide group assignment on the patient info screen. 2. The initial exception report will be run during the week of September 16th with a 12-month look-back period. Any slide adjustments posted in eCW with effective dates within those 12 months and later will be evaluated for matches to Patient Slide Group assignments determined during the slide eligibility process. 3. The billing team and CFO will meet on September 18th to review the report and findings. 4. All exceptions from the exception report will be reviewed by the billing team. Any necessary adjustments will be made in eCW. 5. All exceptions listed in the exception report will be marked, and comments will be added to the exception report regarding the actions taken on those exceptions. All changes will also be documented in eCW notes. 6. The exception report will be signed off by each billing team member who worked on it and sent for final review and approval to the CFO. 7. The CFO will train the billing team on how to run this report directly from eCW. 8. The report will be run monthly on the 10th business day of each month for the trailing prior 12 months as part of the month-end closing process. After initial report on September 18th, 2024, the next monthly report will start on October 14th, 2024.9. All exceptions from the report will be reviewed by the billing team. Any necessary adjustments will be made in eCW. 10. Any exceptions will be addressed, corrected within two business days, and posted in the month being closed for the month end. 11. All exceptions listed in the exception report will be marked, and comments will be added to the report regarding the actions taken on those exceptions. All changes will also be documented in eCW notes. 12. The exception report will be signed off by each billing team member who worked on it and sent for final review and approval by the CFO monthly.

Categories

Internal Control / Segregation of Duties

Other Findings in this Audit

  • 501228 2024-001
    Significant Deficiency
  • 1077669 2024-001
    Significant Deficiency
  • 1077670 2024-001
    Significant Deficiency

Programs in Audit

ALN Program Name Expenditures
93.527 Affordable Care Act (aca) Grants for New and Expanded Services Under the Health Center Program $2.10M
93.224 Affordable Care Act (aca) Grants for New and Expanded Services Under the Health Center Program $674,367