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 patients based on the patient’s annual gross income and household size. We found two encounters where applications were not retained. Therefore, we could not determine if the sliding fee discount applied was in accordance with the guideline.
Context – In testing of sliding fee discounts, we selected 40 encounters with sliding fee discounts applied during the year. There were 25,539 encounters in the population. Sliding fee discounts provided to the two encounters totaled $335. Total discounts in the sample were $13,734. The sample procedures were not statistical. The audit finding represents a systematic problem, see condition above.
Cause – Condition found related to the encounters whose applications were not retained was due to missing documentation of the application. This activity occurs at the time of service by the reception team and there are times when the paperwork is not scanned into the patient’s health record.
Effect or Potential Effect – Without documentation to support that the patient qualified based on their income, patients may have been given an improper sliding fee discount. For patients who did not meet the guidelines to receive a discount and the patient who received an incorrect co‐pay, patients received an improper sliding fee discount.
Questioned Costs – $335. The amount was determined by totaling all of the discounts received by the two patients, and assumed the two patients without supporting documentation were ineligible for the discount received.
Recommendation – We recommend that the Organization's procedures be strengthened to ensure income is properly verified and adequately documented and retained. The Organization should strengthen processes surrounding 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.