MOUNTAIN FAMILY HEALTH CENTERSNon-Profit

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 are required to implement and apply a sliding fee discount schedule so that amounts owed for health care services by eligible patients are adjusted based on their 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 two encounters 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 25,745 encounters in the population totaling $5,030,569. Sliding fee discounts provided to the two encounters totaled $47. Total discounts in the sample were $4,603. 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 – $47. 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 patient collection, enrollment, and eligibility process will be retrained on the process with emphasis on proper documentation and provide feedback and retraining as necessary to staff as needed.

Criteria or specific requirement: According to §200.331 Requirements for pass-through entities of two CFR Part 200, all pass-through entities must evaluate each subrecipient's risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring. In addition, the pass-through entity must monitor the activities of the subrecipient as necessary to ensure that the subaward is used for authorized purposes, in compliance with Federal statutes, regulations, and the terms and conditions of the subaward; and that subaward performance goals are achieved. Condition and Context: During our testing, we noted the Organization did not have adequate internal controls in place to ensure compliance with subrecipient monitoring. Questioned costs: N/A Cause: The Organization was unaware of the subrecipient monitoring requirements. Also, the Organization lacks established internal controls and procedures for monitoring pass-through funds to subrecipients to ensure compliance with applicable compliance requirements. Effect: The lack of internal controls over this compliance requirement provides an opportunity for noncompliance. The auditor noted instances of material noncompliance. Noncompliance results in possible Federal funds provided to ineligible subrecipients or that the grant funds are not used for authorized purposes or in line with the grant terms and conditions. Recommendation: We recommend that the Organization create an internal policy over sub-grant recipient procedures and create effective internal controls and procedures over subrecipient monitoring and tracking that allow for compliance with all applicable Federal laws, regulations, and compliance requirements of various Federal grants Management Response: Management has accepted the recommendation and will add language to the existing Grant Funds Tracking Policy and Procedure outlining the Organization’s responsibilities for establishing effective internal controls and procedures over subrecipient monitoring. The updated policy will also include reference to the Information to Provide to Every Subrecipient for Each Subaward form. This form outlines details of the pass-through grant, and subrecipient responsibilities, and will be signed by each subrecipient prior to any pass-through fund disbursement. Also, the Organization will educate supervisors on this policy update at an upcoming training meeting no later than October 31, 2024.

Criteria or specific requirement: 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Award requires compliance with the provisions of procurement and suspension and debarment. The Organization should have internal controls designed to ensure compliance with these provisions. Condition and Context: During our testing, we noted an instance where the Organization was unable to locate the procurement files to support sole source justification for procurement transactions. Questioned costs: N/A Cause: The Organization lacks established internal controls and procedures over financial grant management. The Organization did not maintain files related to the procurement process of expenditures being allocated to a federal grant. Effect: The lack of internal controls over this compliance requirement provides an opportunity for noncompliance. The auditor noted instances of material noncompliance. Noncompliance results in possible Federal funds provided to ineligible vendors. Recommendation: We recommend that the Organization create an internal policy over the documentation of sole source/non-competitive bid justification prior to contracting with a vendor using federal funds. Management Response: Management has accepted the recommendation and will add language to the existing Purchasing and Procurement Guidance Policy and Procedure outlining the requirement for documentation of sole source/noncompetitive bid justification. In instances where the item or service is only available from one source or competition is deemed inadequate, the Organization will keep written documentation of justification for sole source. Also, the Organization will educate supervisors on this policy update at an upcoming training meeting no later than October 31, 2024.

Criteria Per Title 42 Chapter 1 Subchapter D Section 51c303(f), ?Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted on the basis of the patient?s ability to pay.? Condition Found and Context During our testing of forty sliding fee discounts for health center patients qualifying for reduced charge visits, we identified two visits that received the incorrect sliding fee discount. Effect Potential that a patient would not receive the appropriate sliding fee discount. Questioned Costs None identified. Cause Clerical error in which the incorrect discount was applied due to lack of an oversight process in place. Recommendation We recommend the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter. Views of Responsible Officials and Planned Corrective Actions Management has accepted the recommendations and has scheduled time at bi-weekly front desk/billing meetings to retrain staff on processes that ensure appropriate sliding fee rates are utilized for each sliding fee encounter. Specifically, training will focus on confirming fee schedules are updated on a timely basis per the effective date of the fee change, and encounters with both an office visit and procedure are properly identified so that the procedure co-pay is adjusted off in entirety, leaving only the office visit co-pay as the patient responsibility.

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