Finding Text
Finding Number 2023-004 – Ineffective Internal Controls over Sliding Fee Revenues
Federal Program Name Health Center Program
Project NO. H80CS00680-21-00, H80CS00680-22-00
CFDA # 93.224/93.527
Federal Agency Department of Health and Human Services
Criteria
The Corporation is responsible for establishing and maintaining an internal control system over sliding fee and clinic service eligibility requirements. Specifically, 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 as follows:
• Sliding fee discounts are applied to fees for health center services provided to all individuals and families with annual incomes at or below 200 percent of the Federal Poverty Guidelines (FPG);
• A full 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;
• Fees for health center services are discounted based on graduations in family size and income for individuals and families with incomes above 100 and at or below 200 percent of the FPG; and
• No sliding fee discount is applied to fees for health center services provided to individuals and families within 200 percent or more of the FPG.
Condition
During the compliance testing of the Uniform Guidance “Special Tests and Provisions – Sliding Fee Applications” requirements, we noted the following exceptions:
• Three (3) out of eighteen (18) sampled did not have the slide fee applied to the lab portion.
• Two (2) out of eighteen (18) sampled were calculated incorrectly based on the sliding fee schedule (wrong sliding fee applied based on application).
• Two (2) out of eighteen (18) sampled were missing applications.
• One (1) out of eighteen (18) sampled were incorrectly in the system with a medical slide A on a dental charge. This patient was also one of the sampled items missing an application so it could not be determined if slide A would have been correct. Questioned Costs:
Not applicable.
Context
The population of patients receiving slide adjustments is approximately 70 patients, 170 encounters and gross charges of approximately $25,000. The sample size represented 18 encounters $2,455 in charges of which 18 encounters (approximately $1,000 in charges) were found to have compliance issues noted above.
Cause
Lack of oversight and turnover in key positions resulting in lack of training over sliding fee applications and calculations.
Effect
Lack of effective internal control procedures could result in unintentional or intentional errors that may not be detected in a timely manner by employees in the normal course of performing their assigned duties.
Recommendation
Management should take steps to ensure procedures over sliding fee applications are properly designed and operating effectively.
Management’s Response
Management agrees with the finding.