Finding Text
2024-001 – Special Tests and Provisions – Sliding Scale – Noncompliance and Significant Deficiency in Internal Control over Compliance
Federal program information:
Funding Agency: U.S. Department of Health and Human Services
Title: Health Center Program Cluster
Assistance listing numbers: 93.224 and 93.527
Award Year and number: 2024; 5 H80CS00205‐22‐05; H8FC540998-01-00;
H8GCS47875-01-00
Criteria: According to 42 USC 254(k)(3)(E), (F), and (G) and Health Resources and Services Administration (HRSA) regulations, health centers are required to develop and implement a sliding fee discount schedule that adjusts service charges for eligible patients in accordance with their ability to pay.
Condition: Documentation supporting income verification for eligible patients did not agree to the amounts applied to the sliding fee discount schedule; the recorded income was based on either estimations or rounded amounts. Additionally, the required documentation of income verification was either not provided or retained.
Known Questioned Costs Exceeding $25,000: None.
Context: Of a sample of 25 patients who received sliding fee discounts, five had documentation of income that was inaccurately computed when determining their applicable sliding fee discount. Of the same sample of 25 patients, five additional patients did not have documentation of income supporting the amounts used in applying the sliding fee discount.
Cause and Effect: The required forms of patient income verification were either not consistently obtained during intake or patient income was not recorded accurately when applying the slide fee discount due to staff turnover and staff training. Without sufficient documentation verifying income, or if income is inaccurately computed, patients may receive discounts for which they are not eligible, potentially leading to financial losses and noncompliance with HRSA regulations.
Identification as a Repeat Finding: This is a repeat finding from prior year. This was reported as finding 2023-001 in the 2023 report.
Recommendation: Management should implement additional staff training on the sliding fee discount documentation policies and procedures. Additionally, management should enhance internal controls to ensure all income documentation is collected, reviewed for accuracy and completeness, and retained. Follow up procedures should be performed to verify that corrective action has been taken.
Management’s Response: Due to ongoing turnover within the Customer Access Representative (CAR) team, staffing and training on the sliding fee scale have been inadequate. To address this, we will implement targeted training to ensure full compliance with sliding scale requirements. A new income calculation section has been added to patient intake forms, and monthly audits will be conducted to ensure accuracy and continuous improvement throughout 2025. Audits by location will be carried out by CBO staff and financial analysts, with results shared with administrators and CARs for accountability. Clinics showing minimal improvement will receive additional training. Two mandatory sliding fee scale training sessions will also be scheduled for all CARs, AR staff, and administrators.