Wellspace HealthNon-Profit

Criteria: 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 amount of fees to be charged to the patients based on their annual gross income and household size in conjunction with the sliding fee schedule. During our testing of sliding fee discount, we noted the following:  Three (3) out of 60 patients selected were given a sliding fee discount that was improperly calculated, resulting in overstatement of the sliding fee discount by $420.  Twenty-seven (27) out of 60 selections were missing either updated proof of income or complete requested support. Therefore not able to confirm that sliding fee adjustment were applicable to these patients.  Context: The audit findings represent a systematic problem, see condition above. Questioned Costs: $420 of the $8,717 patient charges sampled. Effect: Patients were improperly categorized on the Organization’s sliding fee scale and were given an improper sliding fee discount. Cause: The inaccuracies in the application of the sliding fee program discounts were due to human error and inadequate oversight and review. Recommendation: We recommend that the Organization’s procedures be strengthened to ensure 1) income is properly verified and adequately documented and 2) the sliding fee discount is properly determined and applied. The Organization should strengthen processes surrounding monitoring of the program to ensure the Organization’s policies are consistently and properly applied. Repeat finding: This is a repeat finding to 2024-04 and 2023-002. Views of responsible officials and planned corrective actions: While staff training is ongoing to ensure the sliding fee program is applied correctly, Management is concurrently exploring strategies to strengthen the program overall. This includes reviewing current materials and processes, enhancing staff competencies, provide additional tools to support staff, and developing clearer workflows to support consistent and accurate application.

Criteria: In accordance with OMB No. 0915-0193, the Uniform Data System (UDS) report is required to be submitted for the Health Centers Cluster program annually on a calendar year basis. 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 amount of fees to be charged to the patients based on their annual gross income and household size in conjunction with the sliding fee schedule. During our testing of sliding fee discount, we noted the following:  One (1) out of 60 patients selected was given a sliding fee discount when the patient did not qualify for any discount under the program, resulting in overstatement of the sliding fee discount by $289.  One (1) out of 60 selections were given a discount, however, the Organization did not retain physical support for proof of income for the verification of the eligibility and appropriate sliding fee scale, resulting in a possible overstatement of the sliding fee discount by $129. Context: The audit findings represent a systematic problem, see condition above. Questioned Costs: $418 of the $8,533 patient charges sampled. Effect: Patients were improperly categorized on the Organization’s sliding fee scale and were given an improper sliding fee discount. Cause: The inaccuracies in the application of the sliding fee program discounts were due to human error and inadequate oversight and review. Recommendation: We recommend that the Organization’s procedures be strengthened to ensure 1) income is properly verified and adequately documented, and 2) the sliding fee discount is properly determined and applied. The Organization should strengthen processes surrounding monitoring of the program to ensure the Organization’s policies are consistently and properly applied. Repeat finding: This is a similar repeat finding to last year’s audit #2023-002. Views of responsible officials and planned corrective actions: The Organization will strengthen procedures to ensure discounts for sliding fee is applied consistently and accurately. Immediately, the Organization will conduct monthly application audits. An audit of 25 sliding fee application forms completed in the month prior will be examined for accuracy, along with their supporting data. All information from these applications will be cross-verified in NextGen. The results from the sliding fee monthly audits will be monitored and reported quarterly at the Quality Assurance and Quality Improvement meetings. The Organization will be implementing a workflow adjustment stating all Slide applications will be noted in the system with a 30-day expiration deadline. This will ensure the staff will be able to notify the patient they would need to begin the process over and present the supporting documentation. Once the documentation is received the timeframe will extend to one year. Furthermore, the Organization will continue the practice of conducting skills assessments at the start of the year and once more in July. These assessments are crucial as they help pinpoint staff members who might benefit from refresher training. Moreover, a meeting has been scheduled to finalize the days and times for virtual sliding fee application training. This training, aimed at all staff who handle a sliding fee form, will be spread out over four weeks, with one session per week lasting an hour. Additionally, the Organization will introduce a sliding fee training video to the new employee orientation. After completing their NextGen training, staff will receive this training video via email. Furthermore, this video will also be sent to all health center leadership to be utilized at the health center level.

Criteria: The requirements for matching are contained in 2 CFR section 200.306, program legislation, Federal awarding agency regulations, and the terms and conditions of the award. The requirements for level of effort and earmarking are contained in program legislation, Federal awarding agency regulations, and the terms and conditions of the award. Per review of the award documents for Certified Community Behavioral Health Clinics Program, key staff have identified the following level of effort requirements:  Project Director at 50%  Evaluator at 50% Any changes in the key staff including level of effort, involving separation from the projects for 3 or more months, or a 25% reduction in time dedicated to the projects requires prior approval from SAMHSA. Condition: During the audit, we noted that a level of effort for the Evaluator was below the 50% required minimum by the grant agreement. Context: The audit findings represent a systematic problem, see condition above. Effect: By not obtaining minimum level of effort percentages, the Clinic may have level of effort not in compliance with the requirement. Cause: There were ineffective controls in place during the period to ensure minimum level of effort requirement for key staff was tracking properly. Recommendation: We recommend that the Clinic work on improving tracking system for level of effort requirement to make sure the Organization stays in compliance. We would also recommend to contact SAMHSA staff that is identified in the Notice of Award if there is some uncertainty to address it timely. Repeat finding: This is not a repeat finding. Views of responsible officials and planned corrective actions: The Organization will ensure to track minimum level of effort requirement in regard to any key staff to stay in compliance. All invoices will be reviewed to ensure level of effort requirements are in compliance.

Criteria: In accordance with OMB No. 0915-0193, the Uniform Data System (UDS) report is required to be submitted for the Health Centers Cluster program annually on a calendar year basis. 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 amount of fees to be charged to the patients based on their annual gross income and household size in conjunction with the sliding fee schedule. During our testing of sliding fee discount, we noted the following:  Two (2) out of 60 patients selected was given a sliding fee discount when the patient did not qualify for any discount under the program, resulting in overstatement of the sliding fee discount by $96.  One (1) out of 60 selections were given a discount that was not consistent with the scale for which they were eligible based on their proof of income, resulting understatement of the sliding fee discount by $10. Context: The audit findings represent a systematic problem, see condition above. Effect: Patients were improperly categorized on the Organization’s sliding fee scale and were given an improper sliding fee discount. Cause: The inaccuracies in the application of the sliding fee program discounts were due to human error and inadequate oversight and review. Recommendation: We recommend that the Organization’s procedures be strengthened to ensure 1) income is properly verified and adequately documented and 2) the sliding fee discount is properly determined and applied. The Organization should strengthen processes surrounding monitoring of the program to ensure the Organization’s policies are consistently and properly applied. Repeat finding: This is a similar repeat finding to last year audit #2022-003. Views of Responsible Officials and Planned Corrective Actions: The Organization will strengthen procedures to ensure discounts for sliding fee is applied consistently and accurately. Immediately, the Organization will conduct monthly application audits. An audit of 25 sliding fee application forms completed in the month prior will be examined for accuracy, along with their supporting data. All information from these applications will be cross-verified in NextGen. The results from the sliding fee monthly audits will be monitored and reported quarterly at the Quality Assurance and Quality Improvement meetings. The Organization will be implementing a workflow adjustment stating all Slide applications will be noted in the system with a 30day expiration deadline. This will ensure the staff will be able to notify the patient they would need to begin the process over and present the supporting documentation. Once the documentation is received the timeframe will extend to the one year. Furthermore, the Organization will continue the practice of conducting skills assessments at the start of the year and once more in July. These assessments are crucial as they help pinpoint staff members who might benefit from refresher training. Moreover, a meeting has been scheduled to finalize the days and times for virtual sliding fee application training. This training, aimed at all staff who handle a sliding fee form, will be spread out over four weeks, with one session per week lasting an hour. Additionally, the Organization will introduce a sliding fee training video to the new employee orientation. After completing their NextGen training, staff will receive this training video via email. Furthermore, this video will also be sent to all health center leadership to be utilized at the health center level.

2002-003 - Special Test and Provisions ? Sliding Fee Discounts Significant Deficiency over Internal Controls over Compliance Federal Assistance Listing Number: 93.224 Name of Federal Program or Cluster: Health Centers Program Cluster Federal Agency/Pass-Through Entity: U.S. Department of Health and Human Services Federal Award Number: H80CS12872 & H8F41209 Award Year: 2021-2022 Criteria: In accordance with OMB No. 0915-0193, the Uniform Data System (UDS) report is required to be submitted for the Health Centers Cluster program annually on a calendar year basis. 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 amount of fees to be charged to the patients based on their annual gross income and household size in conjunction with the sliding fee schedule. During our testing of sliding fee discount, we noted the following: - One (1) out of 65 patients selected was given a sliding fee discount when the patient did not qualify for any discount under the program, resulting in overstatement of the sliding fee discount by $10. - Five (5) out of 65 selections were given a discount that was not consistent with the scale for which they were eligible based on their proof of income, resulting understatement of the sliding fee discount by $79.91. Questioned Costs: $69.91 of the $704.12 patient charges sampled. Context: The audit findings represent a systematic problem, see condition above. Effect: Patients were improperly categorized on the Organization?s sliding fee scale and were given an improper sliding fee discount. Cause: The inaccuracies in the application of the sliding fee program discounts were due to human error and inadequate oversight and review Recommendation: We recommend that the Organization?s procedures be strengthened to ensure 1) income is properly verified and adequately documented and 2) the sliding fee discount is properly determined and applied. The Organization should strengthen processes surrounding monitoring of the program to ensure the Organization?s policies are consistently and properly applied. Repeat finding: This is a similar repeat finding to last year audit #2021-002. Views of Responsible Officials and Planned Corrective Actions: The Organization will strengthen procedures to ensure discounts for sliding fee is applied consistently and accurately. Immediately, the Organization will conduct monthly application audits. An audit of 25 sliding fee application forms completed in the month prior will be examined for accuracy, along with their supporting data. All information from these applications will be cross-verified in NextGen. The results from the sliding fee monthly audits will be monitored and reported quarterly at the Quality Assurance and Quality Improvement meetings. Furthermore, the Organization will continue the practice of conducting skills assessments at the start of the year and once more in July. These assessments are crucial as they help pinpoint staff members who might benefit from refresher training. Moreover, a meeting has been scheduled to finalize the days and times for virtual sliding fee application training. This training, aimed at all staff who handle a sliding fee form, will be spread out over four weeks, with one session per week lasting an hour. Additionally, the Organization will introduce a sliding fee training video to the new employee orientation. After completing their NextGen training, staff will receive this training video via email. Furthermore, this video will also be sent to all health center leadership to be utilized at the health center level.

2021-002 ? ELIGIBILITY Federal Program: Consolidated Health Centers and Affordable Care Act (ACA) Grants for New and Expanded Services under the Health Center Prog. (Health Center Cluster) Federal Agency: U.S. Department of Health and Human Services Assistance Listing Number: 93.224 Grant Award Number and Year: H80CS12872-11-04, 3/1/2020 ? 2/28/2021; H8CCS34240-01-00, 3/15/2020 ? 3/14/2021; H8DCS35770-01-00, 4/1/2020 ? 3/31/2021; H8ECS38672-01-00, 5/1/2020 ? 4/30/2021; H80CS12872-12-00, 3/1/2021 ? 2/28/2022; Criteria: The Consolidated Health Centers and Affordable Care Act (ACA) Grants for New and Expanded Services under the Health Center Programs (Health Center Cluster) requires health centers to prepare and apply a sliding fee discount schedule so that the amounts owed for health care center services by eligible patients are adjusted (discounted) based on the patient?s ability to pay. Additionally, entities receiving federal funding are required by 2 Code of Federal Regulations (CFR) ?200.334 to retain supporting documents and all other non-Federal entity records pertinent to a Federal award for a period of three years from date of submission of the final expenditure report, or Federal awards that are renewed quarterly or annually, from the date of the submission of the quarterly or annual financial report. An effective internal control system over compliance with this requirement provides reasonable assurance for the safeguarding of assets, the reliability of financial information, and compliance with laws and regulation. Condition: We selected 40 patients who received services under the Consolidated Health Centers and Affordable Care Act (ACA) Grants for New Expanded Services under the Health Center Programs (Health Center Cluster), to test application of the sliding fee discount to patients under the federal grant. Out of our 40 selected patients, one patient was charged at an incorrect rate for services provided and the Organization did not retain appropriate documentation to support the sliding fee discount applied for one patient encounter. The Organization did not comply with its policies and procedures to accurately apply the sliding fee discount to eligible patients and maintain accurate documentation. Questioned Costs: None ? Identified patients appropriately received the services that were reported for reimbursement under this award. Cause: Staff at the Organization concluded the misapplication of discounted fees and lack of retention of patients? applications occurred due to error. Effect: Appropriate fee discounts were not applied or could not be determined to be applied accurately to eligible participants for services performed, which could lead to unfavorable outcomes in future program audits. Recommendation: This is a repeat of finding #2020-001 in a previous year audit. We recommend that the Organization review its policies and procedures to ensure compliance with internal policies and granting requirements to ensure appropriate application of approved sliding discount fees to services for eligible patients and retention of appropriate documentation. Organization?s Corrective Action Plan: The Organization has updated its sliding fee application and a staff acknowledgement line was added. Prior to roll out, training was provided to the staff which included a Q&A. A training video was done as well as a FAQ for staff reference. In addition, two boot camps were performed to review registration packet completion and included a system walkthrough explaining where the information on the forms is inputted into the system and the retention requirements have been reviewed. The training also included insurance training on the types of insurance and an in-depth explanation of the sliding fee. Currently, the billing team is auditing sliding fee applications and registration packet and data input for completion. An annual skills assessment will be completed for all front desk staff. Several scenarios will be used, and the staff will be required to complete the task virtually in the system. Results will help identify staff that need coaching.

2021-003 ? ELIGIBILITY Federal Program: Medical Assistance Program (Medicaid Cluster) Federal Agency: U.S. Department of Health and Human Services Assistance Listing Number: 93.778 Grant Award Number and Year: 7206000-19-017 A3, 7/1/2020 ? 6/30/2021; 4121, 6/1/2019 ? 6/30/2021; 7207500-18/21-290, 7/11/2017 ? 12/31/2020; Criteria: The Medical Assistance Program (Medicaid Cluster) requires health centers to verify that patients receiving matching funds from the federal government meet certain eligibility requirements. The objective is to help provide medical assistance to residents whose incomes and resources are insufficient to meet the costs of necessary medical services. Additionally, entities receiving federal funding are required by 2 CFR ?200.334 to retain supporting documents and all other non-Federal entity records pertinent to a Federal award for a period of three years from date of submission of the final expenditure report, or Federal awards that are renewed quarterly or annually, from the date of the submission of the quarterly or annual financial report. An effective internal control system over compliance with this requirement provides reasonable assurance for the safeguarding of assets, the reliability of financial information, and compliance with laws and regulation. Condition: We selected 40 patients who received services under the Medical Assistance Program (Medicaid Cluster), to test application of eligibility under the federal grant. The Organization did not retain appropriate documentation to support the eligibility of three patients. The Organization did not comply with its policies and procedures to maintain accurate documentation. Questioned Costs: None ? Identified patients were eligible to receive services under the Medicaid Cluster and appropriately received the services that were reported for reimbursement under this award. Cause: Staff at the Organization concluded the lack of retention of patients? eligibility documentation occurred due to error. Effect: Eligibility criteria was not properly applied or could not be determined to be applied accurately to eligible participants for services performed, which could lead to unfavorable outcomes in future program audits. Recommendation: We recommend that the Organization review its policies and procedures to ensure compliance with internal policies and granting requirements to ensure retention of appropriate documentation. Organization?s Corrective Action Plan: The Organization has updated its policy to ensure that staff (either administrative or billing staff depending on location) run Medi-Cal eligibility on the 1st of every month, for every patient, no matter their documented funding source to ensure the Organization is not billing an alternative funding source for patients that have active Medi-Cal. The printed Medi-Cal eligibility then gets placed in the patient file to document the monthly checks. The Organization has added Medi-Cal eligibility to not just the file review checklist, but also the monthly Medi-Cal eligibility as well. Previous policy was to discard each month?s eligibility, but policy is updated that all locations will keep all months? eligibility to the patient file to show the full length of service is documented.

2020-001 ? ELIGIBILITY Federal Program: Consolidated Health Centers and Affordable Care Act (ACA) Grants for New and Expanded Services under the Health Center Prog. (Health Center Cluster) Federal Agency: U.S. Department of Health and Human Services CFDA Number: 93.224 Grant Award Number and Year: H80CS12872-10-00, 3/1/2019 ? 2/29/2020; H80CS12872-11-04, 3/1/2020 ? 2/28/2021; Criteria: The Consolidated Health Centers and Affordable Care Act (ACA) Grants for New and Expanded Services under the Health Center Programs (Health Center Cluster) requires health centers to prepare and apply a sliding fee discount schedule so that the amounts owed for health care center services by eligible patients are adjusted (discounted) based on the patient?s ability to pay. An effective internal control system over compliance with this requirement provides reasonable assurance for the safeguarding of assets, the reliability of financial information, and compliance with laws and regulation. Condition: We selected 40 patients who received services under the Consolidated Health Centers and Affordable Care Act (ACA) Grants for New Expanded Services under the Health Center Programs (Health Center Cluster), to test application of the sliding fee discount to patients under the federal grant. Two patients were charged at an incorrect rate for services provided. The Organization did not comply with its policies and procedures to accurately apply the sliding fee discount to eligible patients. Questioned Costs: None ? Identified patients appropriately received the services that were reported for reimbursement under this award. Cause: Staff at the Organization concluded the misapplication of discounted fees and lack of retention of patients? applications occurred due to error. Effect: Appropriate fee discounts were not applied or could not be determined to be applied accurately to eligible participants for services performed, which could lead to unfavorable outcomes in future program audits. Recommendation: This is a repeat of finding #2019-001 in the previous year audit. We recommend that the Organization review its policies and procedures to ensure compliance with internal policies and granting requirements to ensure appropriate application of approved sliding discount fees to services for eligible patients and retention of appropriate documentation. Organization?s Corrective Action Plan: Recognizing that WellSpace Health could be more deliberate and accurate in the processes used to determine eligibility for Sliding Fee discounts, the application form and policy has been updated to provide a more definitive process to both accurately collect the information and to monitor it on a more consistent basis. Given the audit both internally and externally, we recognize the necessity of on-going tracers to ensure that we are providing the necessary guidance and direction to employees on a consistent basis. All frontline employees are in the process of being retrained and will be given follow-up trainings throughout the year to ensure understanding and compliance.

2019-001 ? ELIGIBILITY Federal Program: Consolidated Health Centers and Affordable Care Act (ACA) Grants for New and Expanded Services under the Health Center Prog. (Health Center Cluster) Federal Agency: U.S. Department of Health and Human Services CFDA Number: 93.224 Grant Award Number and Year: H80CS12872-09-00, 3/1/2018 ? 2/29/2019; H80CS12872-10-00, 3/1/2019 ? 2/29/2020; Criteria: The Consolidated Health Centers and Affordable Care Act (ACA) Grants for New and Expanded Services under the Health Center Programs (Health Center Cluster) requires health centers to prepare and apply a sliding fee discount schedule so that the amounts owed for health care center services by eligible patients are adjusted (discounted) based on the patient?s ability to pay. An effective internal control system over compliance with this requirement provides reasonable assurance for the safeguarding of assets, the reliability of financial information, and compliance with laws and regulation. Condition: We selected 40 patients who received services under the Consolidated Health Centers and Affordable Care Act (ACA) Grants for New Expanded Services under the Health Center Programs (Health Center Cluster), to test application of the sliding fee discount to patients under the federal grant. Three patients were charged at an incorrect rate for services provided. The Organization did not retain appropriate documentation to support the sliding fee discount applied for three patient encounters. The Organization did not comply with its policies and procedures to accurately apply the sliding fee discount to eligible patients and maintain the appropriate support. Questioned Costs: None ? Identified patients appropriately received the services that were reported for reimbursement under this award. Cause: Staff at the Organization concluded the misapplication of discounted fees and lack of retention of patients? applications occurred due to error. Effect: Appropriate fee discounts were not applied or could not be determined to be applied accurately to eligible participants for services performed, which could lead to unfavorable outcomes in future program audits. Recommendation: We recommend that the Organization review its policies and procedures to ensure compliance with internal policies and granting requirements to ensure appropriate application of approved sliding discount fees to services for eligible patients and retention of appropriate documentation. Organization?s Corrective Action Plan: The Organization will immediately review its policies and procedures with all pertinent employees to ensure compliance of both internal and external policies as they relate appropriate fee discounts for patients. All pertinent employees will receive new training and review of patient application process and appropriate documentation. Employees will be required to sign acknowledgement verifying they understand the process for administering sliding fee discounts to eligible patients. Random audits of patient charts will be conducted monthly to ensure all policies are adhered to and that appropriate fee discounts are being provided.