Sliding Fee Discount Program Triennial Evaluation

Use it for the person or team responsible for compliance review, such as a clinic manager, compliance lead, finance lead, or operations director. It is especially useful when a sliding fee discount program needs a documented periodic review rather than an informal check-in. The evaluator should have access to policy history, application data, and patient feedback. An approver should review the final findings before the evaluation is closed.

This template is designed for a triennial review, so it should be completed at least once every three years. Many organizations also use it after major policy changes, access complaints, or shifts in patient mix. If your program changes materially before the three-year mark, update the evaluation rather than waiting for the next cycle. Keeping the review date and evaluation period visible helps avoid missed deadlines.

It captures the review period, who performed the evaluation, whether the pay class structure was reviewed, and any policy changes since the last cycle. It also records application counts, approvals, denials, the most common pay class, and whether the discount structure is working as intended. The patient input section documents how feedback was collected and what access barriers were identified. The final section records findings, recommended actions, priority, and approval status.

Patient input is not always collected the same way, but this template gives you a place to document whether it was collected and by what method. You can use surveys, interviews, comment cards, or feedback from front-desk and care teams if that is your approved process. Keep the method consistent with your policy and only collect PII that you actually need. If feedback is anonymous, note that clearly in the form.

A common mistake is reviewing the program without comparing current pay class data to the prior cycle, which makes trend analysis weak. Another is listing policy changes without explaining whether they affected access, eligibility, or discount levels. Teams also sometimes skip patient feedback or summarize it too broadly, which leaves out real barriers. Finally, the form can lose value if recommended actions are not assigned a priority or approval status.

Yes. You can adjust the number of pay classes, rename fields to match your internal policy language, and add conditional logic for programs with special eligibility rules. If your organization uses a separate audit trail or approval workflow, connect those steps to the final approval section. Keep the core structure intact so the evaluation still covers structure, data, patient input, barriers, and actions.

An ad hoc review often leaves gaps because it depends on whoever happens to gather the information. This template creates a repeatable structure, so each triennial evaluation includes the same core evidence and decision points. That makes it easier to compare cycles, show why changes were made, and track whether actions were implemented. It also reduces the chance that a key section, such as access barriers or approval comments, gets skipped.

Use the sources that already support your program, such as application logs, pay class tables, policy documents, patient feedback records, and prior evaluation reports. If your organization tracks approvals or action items in another system, reference those records in the findings section. The template is meant to summarize evidence, not replace source documentation. Keep the inputs aligned with your retention and audit trail practices.