Finding 528658 (2024-001)

Significant Deficiency Repeat Finding
Requirement
N
Questioned Costs
-
Year
2024
Accepted
2025-03-18
Audit: 346667
Organization: Marin Community Clinics, Inc. (CA)

AI Summary

  • Core Issue: Patients received sliding fee discounts that did not match the organization's policy categories.
  • Impacted Requirements: Compliance with sliding fee discount provisions under federal regulations (42 USC 254 and 42 CFR sections 51c.303 and 56.303).
  • Recommended Follow-Up: Enhance training for staff on the sliding fee scale policy and implement procedures to ensure discounts align with the established guidelines.

Finding Text

Health Center Program Cluster Assistance Listing Numbers 93.224 and 93.527 U.S. Department of Health and Human Services Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g); and 42 CFR sections 56.303 (f)) Condition – Patients received a sliding fee discount that was inconsistent with the stated sliding fee discount categories under the Organization’s policy. Questioned cost – None Context – A sample of 40 encounters were tested out of the total population of 220,121 encounters. The sampling methodology used is not and is not intended to be statistically valid. Six patients received a sliding fee adjustment that was inconsistent with the approved policy for the proper sliding fee adjustments based on their income documentation Effect – Sliding fee balances of the patients were inconsistent with the Organization’s sliding fee discount policy. Cause – The Organization did not comply with their sliding fee policy. Identification as a repeat finding, if applicable – Yes. Finding 2023-001. Recommendation – We recommend management continue to train personnel and ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale and the Health Center Program Compliance Manual.

Corrective Action Plan

MCC will take the following action to halt, identify and correct these inaccuracies. This is a new finding associated with the application of adjustment codes in the new billing system, EPIC. The previous year finding was errors with manual input by the front desk staff and was remediated. Patients were not charged incorrectly or more than the discount, and also there was no balance billed to the patient. Adjustments of Sliding Fee Correction: Based on the findings, patients paid less than the amount due under their discount class, and incorrect adjustment types were applied to the remaining balances. To ensure accuracy going forward, all adjustments will use the correct adjustment codes for any remaining balances. These adjustments will follow a standardized process and include appropriate descriptions and categories within the system. If a patient cannot pay the difference between the discount class amount and their payment, the unpaid portion will be adjusted and written off as bad debt. The remediation of this issue involves two main corrective actions. First, a correction has been made in the EPIC billing system to properly adjust bundled service codes and automatically write off incorrect bundle service fees. Second, a fix is being implemented to prevent the system from generating multiple billings due to the use of multiple sliding scale adjustment codes. Additionally, a rule has been set up to audit changes, ensuring that statements with sliding scale balances outside the normal range are held in the Statement Work Queue for review. The billing team will also undergo training to ensure accurate input of adjustments into the system. Timeline – Training will be completed by end of Q3-FY25. Completion: All trainings will be completed by end of Q3-FY25 Team Training • MCC will continue to conduct trainings for all Clinic Managers, Front Office staff and Call Center staff. • The topics at these trainings covered: o The overall philosophy and purpose of collecting accurate data o The importance of collecting all necessary forms and documents from patients in order to insert their financial status into MCC’s sliding fee scale. o Definition of income; how to accurately calculate income. o Definition of family size / household. o The call center role in scheduling the patient appointments and how to set the document expectations. o The importance of collecting all necessary forms and documents from patients in order to insert their financial status into MCC sliding fee scale. o How to enter accurate information into all the applicable forms in the EHR. o Operational workflow. Team Training Timeline - the training will continue annually. Completion: the training will be completed by end of Q3-FY25. Internal Audits: Timeline: Internal audit will be conducted on a monthly basis and findings will be discussed with clinic operation teams with the Interim Director of Billings and Interim Chief Financial Officer for corrective action. Completion: We attest that monthly audits are implemented and discussed with clinic operations. Responsible- There are multiple team members that are actively responsible for documentation and preservation of these documents in the correct patient charts: Clinic Manager, Front Office Supervisors, Director of Patient Services. Ultimately, MCC views this as a measure that the Interim Chief Financial Officer and Interim Director of Billings all hold responsibility to ensure this policy is adhered to closely. Contact person for Corrective Action Plan listed above: Kathy Sonnenberg, Senior Compliance Coordinator Tel: 415-755-2509 Email: ksonnenberg@marinclinic.org

Categories

Special Tests & Provisions

Other Findings in this Audit

  • 528659 2024-001
    Significant Deficiency Repeat
  • 528660 2024-001
    Significant Deficiency Repeat
  • 1105100 2024-001
    Significant Deficiency Repeat
  • 1105101 2024-001
    Significant Deficiency Repeat
  • 1105102 2024-001
    Significant Deficiency Repeat

Programs in Audit

ALN Program Name Expenditures
93.224 Grants for New and Expanded Services Under the Health Center Program $1.54M
93.527 Grants for New and Expanded Services Under the Health Center Program $1.47M
93.526 Grants for Capital Development in Health Centers $615,153
10.569 The Emergency Food Assistance Program $518,849
93.527 Covid-19 - Health Center Program $408,461
93.917 Hiv Care Formula Grants $112,116
21.019 Coronavirus Relief Fund $27,405
97.024 The Emergency Food Assistance Program $173