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HomeMy WebLinkAbout1920-2 Follow-up Health Services-Fiscal Revenue Controls report (8-9-19 FINAL)Follow-up Health Services – Fiscal Revenue Controls #19/20-2 August 2019 Follow-up Report Health Services – Fiscal Revenue Controls To request this information in an alternate format, please call (541) 330-4674 or send email to David.Givans@Deschutes.org Deschutes County, Oregon David Givans, CPA, CIA County Internal Auditor 1300 NW Wall St Bend, OR 97703 Audit committee: Daryl Parrish, Chair - Public member Tom Linhares - Public member Scott Reich - Public member Stan Turel – Public member Patti Adair, County Commissioner Nancy Blankenship, County Clerk James Lewis, Property Manager Follow-up Health Services – Fiscal Revenue Controls #19/20-2 August 2019 TABLE OF CONTENTS: HIGHLIGHTS 1. INTRODUCTION 1.1. Background on Audit …………..……………………………………………………………. 1 1.2. Objectives and Scope ……………….………………………………….…………………… 1 1.3. Methodology …………………………………….………………………………………….…… 1 2. FOLLOW-UP RESULTS …………………….………..…………………………………………… 2 APPENDIX I – Updated workplan (status as of August 2019) ......................... 3-12 Follow-up Health Services – Fiscal Revenue Controls #19/20-2 August 2019 Page 1 1. Introduction 1.1 BACKGROUND ON AUDIT Audit Authority: The Deschutes County Audit Committee has suggested that follow-ups occur within nine months of the reports. The Audit Committee’s would like to make sure departments satisfactorily address recommendations. 1.2 OBJECTIVES and SCOPE “Audit objectives” define the goals of the audit. Objectives: The objective was to follow-up on recommendations. Scope: The follow-up included twenty-three (23) recommendations from the internal audit report on Health Services – Fiscal Revenue Controls (#17/18-8, issued in October 2018). The original internal audit report should be referenced for the full text of recommendations and associated discussion. The follow-up reflects the status as of August 2019. 1.3 METHODOLOGY The follow-up report was developed from information provided by the Health Services. In cases where recommendations have not been implemented, comments were sought for the reasons why and the timing for addressing these. The follow-ups are, by nature, subjective. In determining the status of recommendations that were followed up, we relied on assertions provided by those involved and did not attempt to independently verify those assertions. The updates received are included in Appendix I. Since no substantive audit work was performed, Government Auditing Standards issued by the Comptroller General of the United States were not followed. Follow-up Health Services – Fiscal Revenue Controls #19/20-2 August 2019 Page 2 2. Follow-up Results Figure I - How were recommendations implemented? The follow-up included twenty-three (23) recommendations agreed to by Health Services. Health Services agreed with all of the recommendations. Figure I provides an overview of the implementation status of the recommendations. With this follow-up, fifty-seven percent (57%) of the recommendations have been completed. Health Services should be commended on their progress towards addressing the recommendations and prioritizing the outstanding recommendations. They have established expectations for completing the balance of the recommendations by June 2020. A detailed listing of all of the recommendations followed up on and their status is included at the end of the report in Appendix I. In interpreting the status, the County Internal Auditor may sometimes raise or lower the status provided by the department based on the communication(s) received from the department. Follow-up Health Services – Fiscal Revenue Controls #19/20-2 August 2019 Page 3 APPENDIX Appendix I – Updated workplan for Report #17/18-8 (status as of August 2019) Items that are not completed are greyed out. Rec # Recommendations Completed Underway Planned Estimated Date of Completion Updated Follow-up comments Initial Comments 1 It is recommended for the Department to actively utilize and share information with the Administrative Services Division, County Finance, and County Administration for all financial discussions involving the CCO on resource modeling, reconciliations, and accounting issues. X Dec-19 CCO Contract discussions have begun with Pacific Source. These meetings have been regularly attended by the BH Deputy Director, Admin Deputy Director and Management Analyst on Data Analytics team. Regular communication and one face- to-face meeting has occurred with County Legal Counsel. Deputy Director of the Administrative Services Division, is a part of the department’s team negotiating a new contract with Pacific Source, the local coordinated care organization (CCO). Once the new contract with Pacific Source has been finalized, the Business Intelligence Team will develop modeling and reporting supporting for the tracking of services provided and the distribution of revenue from Pacific Source. 2 It is recommended for the Behavioral Health Division in coordination with their Administrative Services Division revise the collection policies and procedures to collect the required copays and balances due from all programs (while taking into account appropriate sliding fee scales) and take steps to educate staff on the changes. X Billing Supervisor has completed policy/procedure update submitted to compliance after review and signoff by Admin & BH Deputy Directors. Billing Supervisor has attended staff meetings to provide education on changes. Once the new process has been finalized, all relevant policies and procedures will be updated to reflect the changes. Any changes to the sliding fee scales will require approval from the Board of Commissioners. Follow-up Health Services – Fiscal Revenue Controls #19/20-2 August 2019 Page 4 Rec # Recommendations Completed Underway Planned Estimated Date of Completion Updated Follow-up comments Initial Comments 3 It is recommended the policies developed above include the process for considering waivers of fees for financial hardship. It is recommended for those situations where waivers are being considered for financial hardship, that staff document the initial rationale and periodically revisit that assessment over time. The policy in developing a case for financial hardship should consider factors, which might include local cost of living, income, assets, expenses, and scope of the individual’s medical bills. X Billing Supervisor has completed a new document, Financial Exemption Waiver, was created and implemented that consider the client's financial situation, changes to their income, the quantity and frequency of services, etc.; Reporting dashboards that include tracking of services to targets related to contract terms developed by Business Intelligence Team and rolled out to all Behavioral Health programs. A workgroup will be created to identify means to collect payments from all programs and eliminate any programmatic exemptions. The current guidelines (a statement every 30 days and two past due letters) will be used for all clients, which should meet requirements to attempt to collect payments. Simultaneously, the sliding fee scale amounts and thresholds will be reviewed in response to concerns about the billing of a delicate and sometimes unstable population of clients. The current individualized exemption process relies on medical criteria in determining exceptions. This process will be revised to remove medical criteria and replace it with financial hardship criteria. This may require renewed authorization from the client to release financial information to their insurance company. Follow-up Health Services – Fiscal Revenue Controls #19/20-2 August 2019 Page 5 Rec # Recommendations Completed Underway Planned Estimated Date of Completion Updated Follow-up comments Initial Comments 4 It is recommended for the billing manager to develop written procedures for staff on billing and collections procedures including how to properly process and apply payments received. X Dec-19 This is currently in process. Time commitment was greater than originally anticipated due to the number of policies/procedures that will need to be written from scratch. The anticipated completion date is December, 2018. Upon completion of the training, the Billing Team will begin applying copays to date of service paid. A procedure addressing the distribution and application of copays and payments to client accounts will be created. 5 It is recommended for copayments collected to be attributed by date of service. X Billing team was re-trained on how to apply copays and where to attribute that copay if one was paid but ultimately not needed for that date. The Billing Team will receive training on the requirements regarding attribution of a copayment to date of service paid rather than carrying an outstanding balance. 6 It is recommended for the department to establish a periodic review to correct overridden income and family members entered. X Annual Federal Poverty Level (FPL) report is pulled and updated by billing team. The Billing Supervisor will review a Federal Poverty Level (FPL) report annually to identify and correct overridden income and family members entered. The review of this report will correspond with the annual update to the Federal Poverty Guidelines, released March 1 of each year. Follow-up Health Services – Fiscal Revenue Controls #19/20-2 August 2019 Page 6 Rec # Recommendations Completed Underway Planned Estimated Date of Completion Updated Follow-up comments Initial Comments 7 It is recommended for the department to default to no sliding scale to reinforce the receipt of support for financial information. X All divisions have implemented the standard "dummy" Federal Poverty Level of $99,999/family size 1 when income data is unknown. A new default to no sliding fee schedule will be established. Any clients currently defaulting to a sliding fee schedule will be expired and replaced with the new default system. 8 It is recommended for the Department with support from the Administrative Services Division consider updating to a consistent single sliding fee scale, further developing the parameters around its use, and assessing the impacts from the scale to County resources. X A review was completed and it was determined that based on the different governing regulations and rules for the two divisions, as well as the variance in how fees are charged, a single sliding fee scale for the two divisions is not appropriate to implement. Based on the unique funding requirements and the variable nature of billed rates in between Public Health and Behavioral Health, the Health Services Department does not see a viable means to establish one sliding fee scale to serve both the Public Health Division and the Behavioral Health Division. Public Health and Behavioral Health receive funding through two different divisions of the State and are required to follow different federal guidelines. Reproductive Health funding is from a Title X grant from the U.S. Department of Health and Human Services office. Behavioral Health funding is by Title XIX reimbursement through Medicaid. ... Although one consistent sliding fee schedule for both the Public Health Follow-up Health Services – Fiscal Revenue Controls #19/20-2 August 2019 Page 7 Rec # Recommendations Completed Underway Planned Estimated Date of Completion Updated Follow-up comments Initial Comments (continued) Division and Behavioral Health Division may not be viable, both schedules will be reviewed by the Administrative Services Division for both operational and fiscal considerations. Monitoring of fiscal implications of each sliding fee scale will be ongoing. Based on this review and monitoring, necessary revisions will be made to create more consistent and financially equitable sliding fee scales across both divisions. 9 It is recommended for the Department to consider centralizing the overall department collection supervision duties. X Dec-19 This has not been initiated. The Health Services Department will assess the feasibility of means to centralize, track and report on all collections activities. 10 It is recommended for the Department to put in place appropriate controls over adjustments to any collections. X Dec-19 This has not been initiated. The Health Services Department will assess the feasibility of means to centralize, track and report on all collections activities. Follow-up Health Services – Fiscal Revenue Controls #19/20-2 August 2019 Page 8 Rec # Recommendations Completed Underway Planned Estimated Date of Completion Updated Follow-up comments Initial Comments 11 It is recommended for the billing manager to have the ability to collect, analyze and report data on the activities they supervise/oversee. X Billing Supervisor was given a Business Objects reporting license as well as some access to different reporting tools within Epic and is utilizing these reports to oversee work within her team. The Billing Supervisor has been provided with access to reporting tools, usually limited to the Business Manager, in the Epic electronic health records (EHR) system. Additional software tools and applications will be assessed to enable the Billing Supervisor to more effectively access and analyze data regarding billing and payments. 12 It is recommended for the Department to understand, evaluate, and monitor the audit trails available for its collection system. X The Business Intelligence Team and Billing Team met, and it was determined that Epic reporting tools were sufficient for current needs. Additional tools will be evaluated annually during the Billing Team's action planning process and incorporated into the Business Intelligence's annual workplan, as appropriate. Leveraging the Business Intelligence Team, tools will be developed to enable the Billing Team to track and report on collections activities. Follow-up Health Services – Fiscal Revenue Controls #19/20-2 August 2019 Page 9 Rec # Recommendations Completed Underway Planned Estimated Date of Completion Updated Follow-up comments Initial Comments 13 It is recommended for the Department to develop written policies and procedures over the billing and collection oversight activities. X Dec-19 This is currently in process. Time commitment was greater than originally anticipated due to the number of policies/procedures that will need to be written from scratch. Once the previous responses have been completed, billing policies and procedures will be revised or developed to reflect current practices. 14 It is recommended for the Administrative Services Division (or selected supervisors) periodically audit gift card accounting in a comprehensive way and periodically check custody logs for completeness and accuracy. X Jan-20 The Administrative Services Division piloted auditing of one program's gift cards and is revising to ensure a sustainable process. Review of all gift cards is expected in January 2020. The Administrative Services Division will establish an annual process to audit gift card accounting. 15 It is recommended staff use another procurement method (petty cash, purchasing cards, or employee reimbursement) with receipts to make approved purchases for the benefit of clients. X Staff are no longer using gift cards to make approved purchases for the benefit of clients. This is an item to be included in revised Fiscal policies and procedures that are still underway. The Administrative Services Division will conduct a review of gift card utilization and examine possible alternatives with program leadership. Follow-up Health Services – Fiscal Revenue Controls #19/20-2 August 2019 Page 10 Rec # Recommendations Completed Underway Planned Estimated Date of Completion Updated Follow-up comments Initial Comments 16 It is recommended for the County to rescind the checking account authority by resolution. X Checking account is closed and all checks are destroyed per Finance Department The Business Manager will work with the Finance Department to rescind authority for the closed checking account. 17 It is recommended for the petty cash custodians periodically be educated on the usage and documentation required for petty cash. X The Department conducts random audits of petty cash (last conducted department- wide in June 2019). During that time, the process, purpose, and documentation is reviewed with petty cash custodians. This will continue on an annual basis. Petty cash custodians will be required to receive annual training on the usage and documentation required for petty cash. 18 It is recommended Administrative Services Division staff re-establish the control for assuring monies received are deposited in accordance with County policy. X Mail logs are reviewed daily by an on-call staff hired after the audit to ensure Health Services monies received are deposited within 24 hours. Tracking of where each receipt is deposited occurs weekly. The Business Manager will review current process and make necessary changes to ensure monies received by mail are deposited in accordance with County policy. Follow-up Health Services – Fiscal Revenue Controls #19/20-2 August 2019 Page 11 Rec # Recommendations Completed Underway Planned Estimated Date of Completion Updated Follow-up comments Initial Comments 19 It is recommended for the Environmental health program and Vital Records Program to consider how they might consolidate receipting. This might allow them to eliminate the duplicate receipting efforts through importing those transactions to Munis. X Dec-19 Health Services worked with the IT Department to consolidate receipting from Environmental Health program's receipting system to Munis. The Vital Records program plans to move to invoicing directly from Tyler Munis. Staff are trained and this recommendation is still in progress. The Administrative Services Division will work with leadership in the Public Health Division to examine the feasibility of receipt consolidation including the use of Munis. 20 It is recommended for Administrative Services Division to consider including in workflow a daily or periodic reconciliation of revenues in the two systems to the amounts deposited. X Revenues are reconciled daily with OCHIN, and electronic checks received and posted. Environmental Health checks received by mail are compared to the ones that have been deposited to the bank. The Administrative Services Division will implement revenue reconciliation processes for all programs where multiple systems of tracking are utilized. 21 It is recommended for the department to update their fiscal policies and procedures. X Jun-20 No yet initiated. Anticipated to begin in 2020. Fiscal policies and procedures will be update and/or created to reflect current practices. Follow-up Health Services – Fiscal Revenue Controls #19/20-2 August 2019 Page 12 Rec # Recommendations Completed Underway Planned Estimated Date of Completion Updated Follow-up comments Initial Comments 22 It is recommended the department update their billing to follow the County fee schedule and/or develop and propose in the budget process a new fee schedule for these items. X Jun-20 Medical Records forms are revised to be in line with the approved FY20 fees. The Oregon Revised Statutes allow for different fees, and FY21 fees will be in line with ORS. A comparison of current billing practices to county fee schedules will be conducted with any disparities corrected in the FY 2020 fee schedule. This process will be repeated annually to ensure ongoing compliance. 23 It is recommended for the department to periodically review their billings for compliance to the County fee schedule. X Jun-20 A comparison of current billing practices to County fee schedules was conducted in February 2019, which resulted in one new fee and revisions, as appropriate. The Department plans a kick-off meeting with all program managers for the FY21 fee process to review County fee policies and ensure all fees are accurately captured. A comparison of current billing practices to county fee schedules will be conducted with any disparities corrected in the FY 2020 fee schedule. This process will be repeated annually to ensure ongoing compliance. {End of Report}