Presbyterian Medical ServicesNon-Profit

2025-001 – 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: 2025; 6 H80CS00205‐24‐08; 4 H8NCS53926-01-02; 6 H2ECS45598-02-03; 5 H8KCS49758-02-00; 1 Q8JCS54522-01-00 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 was obtained and maintained in patient files; however, income frequency entered into the software by customer access representatives (CARs) was not always consistent with the frequency reflected on the supporting documentation. As a result, income amounts were incorrectly calculated by the system and did not agree to the amounts that should have been used to determine eligibility and apply the sliding fee discount schedule. Specifically, income documented as weekly, biweekly, bimonthly, monthly, or annual was in some instances entered under an incorrect pay frequency, resulting in miscalculated annualized income and the application of an incorrect sliding fee discount. In addition family size was entered incorrectly in the system for one patient, which resulted in the patient being placed in the wrong sliding fee discount category. Known Questioned Costs Exceeding $25,000: None. Context: Of a sample of 25 patients who received sliding fee discounts, four had documentation of income that was inaccurately computed when determining their applicable sliding fee discount. Of the same sample of 25 patients, one additional patient had an inaccurate family size used when determining the sliding fee discount. Cause and Effect: Patient income and family size information entered into the system used to calculate annual income and determine the applicable sliding fee discount was not always recorded accurately. These errors were attributable to human error during the data entry and eligibility determination process. As a result, sliding fee discounts were calculated using inaccurate household income or family size information, which could cause patients to receive discounts for which they do not qualify. This increases the risk of lost program revenue and noncompliance with HRSA sliding fee discount requirements. Identification as a Repeat Finding: This is a repeat finding from prior year. This was reported as finding 2024-001 in the 2024 report. Recommendation: We recommend management strengthen controls over the sliding fee discount program by implementing technology-based validation and documentation procedures, along with enhanced staff training and continued internal audits. Specifically, PMS should utilize system controls that flag incomplete and incorrect amounts before a sliding fee discount can be approved. In addition, management should provide formal initial and refresher training to staff responsible for determining eligibility, with emphasis on HRSA sliding fee discount requirements and proper inputs of household income and family size. Management should also consider supervisory review and continue performing periodic quality control testing of sliding fee discount determinations to ensure compliance and reduce the risk of errors resulting from staff turnover. Management’s Response: Management has taken corrective action to strengthen compliance with Sliding Fee Discount Program requirements. Actions include targeted staff training, revisions to patient intake forms to standardize income calculations, and implementation of monthly audits throughout 2026. Clinics with error rates of 10% or higher are subject to focused retraining and continued monitoring. Audit results are reported to leadership to support accountability, and two mandatory training sessions for CARs, AR staff, and administrators are being conducted to reinforce consistent and compliant implementation.

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.

2024-002 – Single Audit Report Submission – Noncompliance and Significant Deficiency in Internal Control over Compliance Federal program information: Funding Agency: All Major Programs Title: All Major Programs Assistance listing numbers: All Major Programs Award Year and number: All Major Programs Criteria: In According to Section 200.512(a) of the Uniform Guidance, the Single Audit reporting package must be submitted within the earlier of 30 calendar days after receipt of the auditor’s report, or nine months after the end of the audit period. Condition: PMS’ Single Audit reporting package for the year ended December 31, 2023 was prepared, however, was not officially submitted to the Federal Audit Clearinghouse within the nine months after the fiscal year end. Known Questioned Costs Exceeding $25,000: None. Cause and Effect: Although PMS has implemented internal controls to ensure timely and accurate financial reporting, the Single Audit reporting package was not submitted to the Federal Audit Clearinghouse. As a result, the Singe Audit reporting package was submitted after the required reporting deadline. Recommendation: To comply with Uniform Guidance requirements, PMS should ensure the timely submission of the Single Audit reporting package within nine months after fiscal year end. Management’s Response: PMS will coordinate with the Audit Team to schedule a walkthrough of the Federal Clearinghouse submission process within the first week after Board approval of the Audit, to ensure timely filing.

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: 2022; H80CS00205-21-00; H80CS00205-21-01 Criteria: According to 42 USC 254(k)(3)(E), (F), and (G), health centers must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient?s ability to pay. Condition: Documentation supporting income verification for eligible patients did not agree to the income amounts applied to the sliding fee discount schedule. The amount of income applied to the sliding fee discount schedule was either estimated or rounded down. Questioned Costs: None. Context: Of a sample of 25 patients who received sliding fee discounts, five patients did not have documentation of income supporting the amounts used in applying the sliding fee discount schedule. Cause: Documentation of patient income was not accurately documented at the time of intake as a result of staffing turnover. Effect: Without accurate documentation of patient income, the sliding fee discount was not correctly applied. Auditor?s Recommendations: Management should reiterate the importance of using accurate documentation of patient income when applying the sliding fee discounts. Management should consider providing additional training to staff over the patient intake process and perform periodic spot checks to verify the accuracy of patient income.

Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Provider Relief Fund Assistance listing number: 93.498 Criteria: Recipients of amounts from the Provider Relief Fund (PRF) must complete the required information in the Health Resources and Services Administration (HRSA) Provider Relief Fund Reporting Portal. The amounts reported as ?Other Provider Relief Fund Expenses for Payments Received During Payment Period? must be to prevent, prepare for, or respond to coronavirus. Recipients must maintain adequate documentation to substantiate that the reported expenses were for this purpose. Condition: Based on a sample of 25 expenses from the HRSA submission, one ineligible cost was identified. However, PMS had other eligible expenses far in excess of the PRF amounts received and therefore met the requirements to keep the PRF funds. Questioned Costs: N/A. Context: One out of 25 expenses tested. Cause: An unqualified expense was inadvertently applied to the PRF program funding. Further, the PRF was a new program and much of the guidance was changing throughout the fiscal year and beyond which made it more difficult to ensure proper tracking of qualified expenditures. Effect: The HRSA PRF submission is inaccurate. Auditor?s Recommendations: Management should revisit the detail of the PRF submission and review each qualified expense coded to ascertain if other ineligible expenses were included. Additionally, management should consider identifying other qualified expenses that were presented as excess expenditures above the PRF received to cover the ineligible costs. Management?s Response: PMS has and will review the detail of reporting submissions for ineligible costs. PMS has confirmed that the one ineligible cost ($14) in the sample was the result of a general ledger expense being coded and entered incorrectly. The identified expense should have been coded to a general ledger account which was specifically excluded from the reporting submission. PMS has a significant amount of unreimbursed qualifying PRF expenses and will identify additional qualifying costs to cover any potential PRF ineligible costs identified in the review of the detail of the submitted report. PMS will also counsel assigned staff on the proper PMS standards in coding of expenses and provide training to refresh the importance of proper coding to help eliminate future coding errors in the general ledger.

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