Finding 2024‐001 – Special Tests and Provisions – Significant Deficiency in Internal Control over Compliance
It was identified that the implementation of a new electronic health record system significantly impacted the control environment as it relates to compliance with federal awards. As a result, the control system did not consistently apply the appropriate sliding fee discounts for patients based on qualification criteria and certain patients were billed amounts less than the sliding fee discount schedule.
To address the finding related to system limitations that resulted in patients being billed amounts lower than those specified in the sliding fee discount schedule, the Organization will implement a comprehensive corrective action plan. First, a thorough review of the electronic health record system will be conducted to identify specific limitations as it relates to data capture of federal poverty level at time of patient registration. This has already been completed. Second, the Organization will modify the set-up of its electronic health record to systematically seek approved and active documentation related to sliding fee discounts and will modify the system to not allow sliding fee discounts without the presence of said documentation. The Organization is in the process of setting a meeting to modify its system build, which it expects to be finalized in 30 calendar days.
To ensure ongoing compliance, regular monitoring procedures will be established to review data capture accuracy, with the Chief Financial Officer overseeing this effort and the first review scheduled for 30 calendar days from the date on which the electronic health record system fix is implemented.
Finally, thorough documentation of all corrective actions taken, including system changes and monitoring results, will be maintained. The Chief Financial Officer will report findings to management on a monthly basis, with the first report due one month from date on which the system fix is implemented. Through these measures, the Organization aims to enhance billing accuracy, ensure compliance with federal requirements, and prevent future discrepancies.