Tensas Community Health CenterNon-Profit

Criteria: Health Centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted or discounted based on the patient’s ability to pay. Condition: Some patients did not receive the proper sliding fee discount. For other patients, there was also a discrepancy between the amounts paid for services and the amounts charged. Cause: Errors within the setup of the Center’s billing software. Questioned Costs: Known or likely questioned costs are less than $25,000. Context: Of the 60 patients tested, 2 patients received an improper adjustment or discount, and 3 patients paid for lab charges that were not billed in the Center’s billing software. Effect: Improper adjustments and billings could lead to inaccurate financial statements. Auditor’s Recommendation: Management should have procedures in place to ensure that each eligible patient receives the proper discount and adjustment based on their ability to pay. There should also be procedures in place to ensure that all patient charges get properly billed. View of Responsible Officials and Planned Corrective Actions: The Center acknowledges the audit finding and has taken corrective actions to address the issue identified in 2024-005. This included collaborating with the electronic health record (EHR) vendor to resolve the sliding fee setup in the system. However, some remaining issues require additional improvements through updated standard operating procedures (SOP). To address these, the Center will create SOPs for fee updates related to sliding fee schedules and provide clarification on how the system calculates discounts. Additionally, the Center identified an error in the sliding fee discount setup for dental fee calculations, which will be resolved by the end of March 2025. Staff have been directed to manually verify sliding fee calculations performed by the EHR system until all identified issues with the billing system have been resolved.

Criteria: Health Centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted or discounted based on the patient's ability to pay. Condition: Some patients did not receive the proper sliding fee discount. Cause: Errors within the setup of the Center's billing software and front desk turnover. Questioned Costs: Known or likely questioned costs are less than $25,000. Context: Of the 60 patients sampled, 13 patients did not receive the proper adjustment or discount. Effect: Improper adjustments or discounts could lead to inaccurate financial statements as well as improper patient billings. Auditor's Recommendation: Management should have procedures in place ensureing that each eligible patient receives the proper discount or adjustment based on their ability to pay. Management's Response: The Center agrees with the finding. While additional training and corrections to the practice management system were completed in the prior fiscal year, turnover and additional system issues still plague the process. The Center has developed an improved front desk audit tool in response to this finding which includes verifying certain sliding fee components with an updated methodology increasing the number in the sample per month. The new front desk audit tool will be tested by February 28, 2024 and continue monthly with changes suggested during the test as needed throughout the next 12 months.

Criteria: A non-federal entity must minimize the time elapsing between the transfer of funds from the U.S. Treasury and disbursement by the non-federal entity for direct program or project costs. Condition: The Center had $116,113 in drawdowns on a federal grant for which no funds had been expended. Cause: The drawdown was inadvertently made out of the wrong grant and not detected by management until several months after year-end. Context: Management made two drawdowns near the end of the fiscal year totaling $116,113. Effect: The Center is not in compliance with the cash management compliance requirement. Auditor's Recommendation: The Center should have proper internal procedures in place to regularly reconcile drawdowns made per grant to ensure the funds are being drawn from the appropriate grant.

Criteria: Health Centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted or discounted based on the patient?s ability to pay. Condition: Some patients did not receive the proper sliding fee discount. Cause: Errors within the setup of the Center?s billing software. Context: Of the 60 patients sampled, 17 patients did not receive the proper adjustment or discount. Effect: Improper adjustments or discounts could lead to inaccurate financial statements as well as improper patient billings. Auditor's Recommendation: Management should have procedures in place ensuring that each eligible patient receives the proper discount or adjustment.

Criteria: Health Centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted or discounted based on the patient?s ability to pay. Condition: Patients were not receiving the proper discount. Questioned Costs: Known or likely questioned costs are less than $25,000. Context: Of the 60 patients sampled, 22 patients did not receive the proper adjustment or discount. Effect: Improper adjustments or discounts could lead to inaccurate financial statements as well as improper patient billings. Auditor's Recommendation: Management should have procedures in place ensuring that each eligible patient receives the proper discount or adjustment. Views of responsible officials and planned corrective actions: The Center agrees with the finding and will implement additional controls designed to ensure proper sliding fee discounts are applied. The organization transitioned practice management systems in August 2020. Due to the pandemic, setup, training and implementation was conducted virtually, which was not optimal on the health center?s end. We were under the impression that sliding fee incomes updated automatically, which was not the case; the board has approved the new poverty guidelines each year when released. In addition, as we recently found the sliding fee setup was not 100 percent correct and some procedures were not ?sliding? correctly. Management understands that oversight responsibility remains with the health center. In response, as of May 2022, the incomes have been updated in the system to correspond to current poverty guidelines. The health center also had additional training on-site from the EHR system vendor in May/June 2022; during this training, sliding fee setup in the system was reviewed and training provided to update. Management will update written procedures to reconcile with actual steps occurring (including responsible person, etc.). In addition, an audit procedure will be documented and implemented so periodic surveys can determine if policies and procedures are being followed. The health center has also had turnover in front desk staff over the past 2 years due to Covid, attrition and, unfortunately, the death of an employee, which gives rise to the need for training staff on the sliding fee policy and procedure when onboarded as well as annually. All these steps will be completed by October 31, 2022.

2019-001: Sliding Fee Discounts Federal Program Information: CFDA 93.2241/93.527: Health Centers Cluster Criteria: Health centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted or discounted based on the patient?s ability to pay. Condition: Found instances of two patients receiving an incorrect discount. Questioned costs: Known or likely questioned costs are less than $25,000. Context: Of the 25 patients sampled, two patients did not receive the proper adjustment or discount. Cause: Patient adjustments were not manually applied by health center staff. Effect: Improper adjustments or discounts could lead to inaccurate financial statements as well as improperly billing patients. Auditor's recommendation: Management should have proper procedures in place ensuring that each eligible patient receives the proper discount or adjustment. Views of responsible officials and planned corrective actions: Tensas Community Health Center is very conscientious of complying with all requirements of the Sliding Fee Discounts. After becoming aware of this problem, a report was developed to determine all encounters that might have been affected. Of 214 possible encounters, less than 15% were affected. Upon further examination, it was determined that the sliding fee table within the electronic medical records system had an error. This problem was immediately corrected. As an additional precaution to ensure the prevention of this with future visits, the TCHC Billing Department is reviewing all sliding fee visits charges. Total Gross Charges of encounters, which could have been affected, were less than $6,000. Tensas Community Health Center will be converting in 2020 from its current electronic medical records system, CMS WinMed, to EClinicalWorks.