Finding Text
Criteria: An individual must meet the eligibility requirements as defined by Federal regulations published
in Code of Federal Regulations (CFR), at Title 42, Section 136.21 through 136.25, and Indian Health
Services, Part 2, Chapter 3, “Contract Health Services” dated January 5, 1998.
Condition: Of the 60 participant files reviewed, the following was noted:
• 60 samples out of 60 did not have record of review and approval separate from the person entering
the information.
• 6 samples out of 60 did not have proper proof of tribal membership to receive medical services and/or
proper proof of residence covering the testing period to receive medical services.
Context: The audit findings represent a systematic problem, see condition above.
Cause: There were ineffective controls in place during the period, along with lack of management
oversight.
Effect: By not ensuring proper reviews are occurring by a supervisor or other authorized individual,
inaccurate information may have been entered into the online system, and ineligible participants could be
receiving benefits.
Questioned Costs: Not applicable.
Repeat Finding: Yes, 2022-004 and 2023-001.
Recommendation: We recommend that the Clinic adhere to program policies and procedures as
documented and the files are reviewed annually for completeness, and that review of the online checklist
is reviewed by someone other than the Patient Care Representative, and that this review is documented
and maintained for review at a later date.
Views of Responsible Officials and Planned Corrective Action: The Clinic will review all patient files to
ensure all applicable documentation is located within each file. Any applicable documentation that is
missing from the file will be requested from the patient to verify continued eligibility or services will be
terminated. The Clinic will also implement an approval process for new patients to ensure patient
eligibility is reviewed and approved prior to providing services.