FlatheadCommunity Health Center Inc. dba Greater Valley Health CenterNon-Profit

Finding 2023-002 Application of Sliding Fee Discount Program Information: Federal Agency U.S. Department of Health and Human Services Federal Assistance Listing Number 93.224 and 93.527 Health Center Program Cluster Award Number H80CS40219 Criteria [X] Compliance Finding [ ] Significant Deficiency [X] Material Weakness OMB 2 CFR 200, Subpart F Compliance Supplement, Part 4, Compliance Requirement N, Special Tests and Provisions states, “Health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay.” Condition In our testing of 40 sliding fee discounts for health center patients qualifying for reduced charge visits, we identified 1 instance where no application was maintained. We also identified 6 instances where the incorrect sliding fee was applied to the patient. Cause The Center did not have a review process in place to verify eligible patients completed the required application to receive a sliding fee discount and that each application contained the required information. Additionally, the Center did not verify the correct sliding fee discount was based on the Center’s sliding fee scale. Context The finding appears to be a systemic problem. Effect Missing applications could indicate that patients who received a sliding fee discount may not have been eligible. Additionally, the sliding fee discount could be applied incorrectly and not in accordance with the Center’s policy. Recommendation We recommend developing proper controls around obtaining and maintaining sliding fee applications, verifying required patient information is present and complete, and apply the sliding fee discount in accordance with written policy. To ensure sliding fee discounts are properly calculated and documented, the Center should increase the frequency of random reviews of its sliding fee discount applications to help detect and correct errors or incomplete applications on a timely basis. In addition, the Center should provide additional training of staff involved in the application of sliding fee discounts. View of responsible officials and planned corrective action. GVHC implemented the physical review and controls described in the 2022 audit response. Our efforts were largely successful as the missing application was the only failure of the physical audit process we put in place. However, a failure of our technology and billing software was revealed. Our plan it to: 1. Continue to provide frequent education and training for front-desk staff to assist in preparation and required completion of the sliding fee applications and proof of income. 2. Continue to identify patients who have exhausted their limited Medicaid benefits and will now qualify for sliding fee scale for dental work. 3. Continue to review reports identifying patients with no end date identified for their sliding fee scale. For identified accounts, determine correct date and enter in the system. 4. Continue 100% audit of all sliding fee scale applications for accuracy of calculation and presence of necessary paperwork. Provide direct feedback to staff when errors are identified. Integrate changes to billing software into the process when sliding fee scales are adjusted and posted. Run reports of sliding fee scale discounts and audit for correct calculation.

Finding 2022-002 Application of Sliding Fee Discount Program Information: Federal Agency: U.S. Department of Health and Human Services Federal Assistance Listing Number: 93.224 and 93.527 Health Center Program Cluster Award Number: H80CS40219 Criteria: [X] Compliance Finding [ ] Significant Deficiency [X] Material Weakness OMB 2 CFR 200, Subpart F Compliance Supplement, Part 4, Compliance Requirement N, Special Tests and Provisions states, ?Health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient?s ability to pay.? Condition: In our testing of 40 sliding fee discounts for health center patients qualifying for reduced charge visits, we identified 3 instances where no application was maintained. We also identified 2 instances where the incorrect sliding fee was applied to the patient. Cause: The Center did not have a review process in place to verify eligible patients completed the required application to receive a sliding fee discount and that each application contained the required information. Additionally, the Center did not verify the correct sliding fee discount was based on the Center?s sliding fee scale. Context: The finding appears to be a systemic problem. Effect: Missing applications could indicate that patients who received a sliding fee discount may not have been eligible. Additionally, the sliding fee discount could be applied incorrectly and not in accordance with the Center?s policy. Recommendation: We recommend developing proper controls around obtaining and maintaining sliding fee applications, verifying required patient information is present and complete, and apply the sliding fee discount in accordance with written policy. To ensure sliding fee discounts are properly calculated and documented, the Center should increase the frequency of random reviews of its sliding fee discount applications to help detect and correct errors or incomplete applications on a timely basis. In addition, the Center should provide additional training of staff involved in the application of sliding fee discounts. View of responsible officials and planned corrective action: The Center plans to: 1. Continue to provide frequent education and training for front-desk staff to assist in preparation and required completion of the sliding fee applications and proof of income forms. 2. Meet with front desk staff to identify and correct barriers to compliance with completion of sliding fee application and income verification and retention of those documents within the electronic record. 3. Develop workflow to identify when patients have exhausted their limited Medicaid dental benefits and would now qualify for sliding fee discount. Ensure sliding fee scale application and verification of income are completed prior to delivery of additional services. 4. Develop internal report to identify accounts with sliding fee scale identified with no end date recorded. For identified accounts, determine appropriate end date for sliding fee discount and enter it into the system. 5. Continue to do real time audits of front desk personnel to identify needs for additional training and to reinforce the process and appropriate documentation. 6. Institute a separate QA position for the purpose of review of patients with an identified sliding fee scale discount in place.

Finding 2021-001 Application of Sliding Fee Discount Program Information: Federal Agency U.S. Department of Health and Human Services Federal Assistance Listing Number 93.224 and 93.527 Health Center Program Cluster Award Number H80CS40219 Criteria [X] Compliance Finding [ ] Significant Deficiency [X] Material Weakness OMB 2 CFR 200, Subpart F Compliance Supplement, Part 4, Compliance Requirement N, Special Tests and Provisions states, ?Health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient?s ability to pay.? Condition In our testing of 25 sliding fee discounts for health center patients qualifying for reduced charge visits, we identified 3 instances where no application was maintained. We also identified 10 instances where the incorrect sliding fee was applied to the patient and 1 instance where the patient did not qualify for the discount received. Cause The Center did not have a review process in place to verify eligible patients completed the required application to receive a sliding fee discount and that each application contained the required information. Additionally, the Center did not verify the correct sliding fee discount was based on the Center?s sliding fee scale. Context The finding appears to be a systemic problem. Effect Missing applications could indicate that patients who received a sliding fee discount may not have been eligible. Additionally, the sliding fee discount could be applied incorrectly and not in accordance with the Center?s policy. Recommendation We recommend developing proper controls around obtaining and maintaining sliding fee applications, verifying required patient information is present and complete, and apply the sliding fee discount in accordance with written policy. To ensure sliding fee discounts are properly calculated and documented, the Center should increase the frequency of random reviews of its sliding fee discount applications to help detect and correct errors or incomplete applications on a timely basis. In addition, the Center should provide additional training of staff involved in the application of sliding fee discounts. View of responsible officials and planned corrective action. Management has engaged the services of a consulting firm which specializes in providing financial services and consulting on best practices regarding finance department policies and procedures. With respect to audit finding, the consulting firm will address the following: ? Review and recommend revisions to the sliding fee applications and proof of income forms ? Assist in developing trainings for front-desk staff in the appropriate procedures to assist in preparation and require completion of the sliding fee applications and proof of income forms ? Assist in developing trainings for staff on appropriate evaluation of the forms and determining the appropriate category on which to place patients in regards to the sliding fee program ? Assist in developing trainings for staff on monitoring the periodic update of the patients sliding fee application and related information ? Assist in developing trainings for staff on coordinating initial placement and subsequent updates with billing so the billing system is consistent with the supporting information for the sliding fee program ? Review document retention procedures regarding the sliding fee program to ensure each patient participating in the program has documentation supporting their classification within the billing system This should address the deficiencies noted in correct placement of patients on the sliding fee scale and the issue of missing supporting documentation.