Finding Text
Criteria or Specific Requirement – In accordance with the Health Resources & Services Administration Health Center Program Compliance Manual, Chapter 9: Sliding Fee Discount Program, health centers must prepare and apply a sliding fee discount schedule so that amounts owed for health care services by eligible patients are adjusted based on the patients’ ability to pay. In accordance with 42 CFR 56.303, health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted based on the patient’s ability to pay. The patient’s ability to pay is determined based on the official poverty guidelines, as revised annually by U.S. Department of Health and Human Services (HHS). The schedule of discounts must provide for a full discount to individuals and families with annual incomes at or below those set forth in the most recent poverty income guidelines (except that nominal fees for service may be collected from such individuals and families) and for no discount to individuals and families with annual incomes greater than twice those set forth in such guidelines.
Condition –The Organization determines the sliding fee discount charged to the patients based on their annual gross income and household size. During our testing of sliding fee discounts, we found that two encounters selected where the patients were charged incorrect copays.
Context – In testing of sliding fee discounts, we selected 40 encounters with sliding fee discounts applied during the year. There were 42,422 encounters in the population totaling $13,260,495. Sliding fee discounts provided to the two encounters totaled $468. Total discounts in the sample were $22,415. The sample procedures were not statistical. The audit finding represents a systematic problem, see condition above.
Cause – Condition found was due to inadvertent errors.
Effect or Potential Effect – Patients received an improper sliding fee discount.
Questioned Costs – $468. The amount was determined by totaling all the inaccurate discounts received by the two patients.
Recommendation – The Organization should strengthen processes surrounding the monitoring of the program to ensure the Organization’s policies are consistently and properly applied.
Views of Responsible Officials and Planned Corrective Actions – Management agrees with the finding. The Organization has developed a plan for addressing this issue that includes updated procedures, training, and auditing. All teams engaged in the enrollment and eligibility process, including our Enrollment, Reception, and Billing teams will be retrained on the process with emphasis on proper documentation. The Organization management plans to incorporate into our quality assurance audits the documentation for single service date discount applications and provide feedback and retraining as necessary to staff as needed.