Mosaic Community Health

Type: Significant deficiency in internal control over compliance and immaterial noncompliance with respect to special tests and provisions requirement. Federal program: CFDA #93.224, Health Center Program, and #93.527, Grants for New and Expanded Services under the Health Center Program. Criteria: PHS Act Section 330(k)(3)(E) requires Health Centers to prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are discounted based on the patient's ability to pay. Questioned costs: None. Condition: During my audit procedures it was identified that certain patient encounters eligible for a sliding fee discount were not charged the correct nominal fee based on the patient?s documented income level. Effect: Not charging the correct nominal fee to all patients eligible for a sliding fee discount resulted in noncompliance with certain special tests and provisions of the major federal program. Cause: The Organization has properly designed controls that allow billing personnel to timely and accurately assess a patient?s sliding fee discount eligibility and charge patients a nominal fee based on their income level. However, the controls were not fully implemented in all cases during the fiscal year ended June 30, 2020. Prevalence/Context: This is an internal control implementation deficiency. In a sample of 40 sliding fee encounters reviewed, which the auditor considers to be a statistically valid sample, two instances were identified where the Organization charged patients an incorrect nominal fee based on the Organization?s assessment of the patient?s income level. Repeat finding: No. Auditor?s recommendation: The Organization should monitor its current, and appropriate, controls over its sliding fee discount billing cycle to ensure full compliance. The Organization?s management team may consider consolidating the head count of billing personnel who have access to, prepares and reviews sliding fee discount billings. This could improve consistency with the Organization?s sliding fee discount program. The Organization?s response: Management agrees with the above finding and will consider the recommendation. See attached corrective plan prepared by management.

In the course of completing their June 30, 2020, audit of Mosaic Medical's compliance with the major federal award program. Hamlin CPA identified one significant deficiency in internal control which is required to be reported. An internal control implementation deficiency over correctly charging the sliding fee based on the patient's documented income level was identified in 2 of the 40 sampled sliding fee encounters. As noted by Hamlin CPA, properly designated controls do exist at Mosaic that allow billing personnel to timely and accurately assess a patient's sliding fee discount eligibility and charge patients the appropriate sliding fee based on their income level. However, the controls were not effectively applied in all cases. In response to the finding Mosaic will implement the corrective action steps outlined below. Billing System Changes: Mosaic's EMR system, implemented a new "recalculate discount" feature on 9/1/2020. Because there can be a lag between when the first charge is posted and when the sliding scale information is verified, there was a need to manually calculate the discount. Now that we have the automated option, errors will reduce. Additionally, reviews have been completed to consolidate underlying sliding fee tables to eliminate future errors where incorrect associations are made. Staff Training and Approver Management: We will be providing additional sliding scale training for Clinic Operations Supervisors as this group is responsible for training Patient Service Representatives. We will be asking for a list of designated approvers, post training, so that we have a specific group to audit and inform of updates. The supervisor team will be responsible for assuring that no one outside of the designated list of approvers is performing sliding scale final approvals. This will be completed by 12/31/2020. Centralized Processing: Mosaic's management team will explore centralizing the review and approval process for sliding scale applications. This could improve consistency within the Organization's sliding fee discount program by creating knowledge specialists who do this work repetitively. This will be evaluated by 3/31/2021. Additional Next Steps: Existing procedures and controls will be continued, and efforts will be made to ensure those processes are properly executed.

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