1. Hire a Revenue Cycle Liaison o Designate a dedicated Revenue Liaison who will serve as the primary trainer and subject matter expert for the Sliding Fee Discount Program under the Revenue Cycle Director. o Responsibilities include developing training materials, conducting onboarding sessions, and serving as the point of contact for SFDP-related questions. o Estimated Time of Completion: • 1–2 weeks for interviews and selection • 2–3 weeks for onboarding, access setup, and curriculum review • Liaison fully functional by mid-January 2026 2. Immediate Staff Retraining o Retrain all staff involved in SFDP on program requirements, eligibility criteria, and correct implementation of sliding fee determination and billing. o Training will include real-world scenarios, documentation standards, and compliance checkpoints to ensure accuracy. o Quarterly training will be conducted for all Clinic Managers, Front Office staff and Call Center staff. o The topics at these courses covered: i. The overall philosophy and purpose of collecting accurate data. ii. Definition of income; how to accurately calculate income. iii. Definition of family size / household. iv. The call center role in scheduling the patient appointments and how to set the document expectations. v. The importance of collecting all necessary forms and documents from patients in order to insert their financial status into MCC sliding fee scale. vi. How to enter accurate information into all the applicable forms in the EHR. vii. Operational workflow. o Estimated Time of Completion • Retraining will start after the Liaison is fully operational. • Retraining Start: Early to Mid-February 2026 • Retraining Completion: Late February 2026 3. Periodic Compliance Audits o Compliance department will perform independent audits of SFDP transactions on a quarterly basis. o Findings will be reported to senior leadership and incorporated into compliance risk assessments. o Findings will be used for ongoing training and process improvement across all clinics. o Estimated Time of Completion • First audit period: January–March 2026 • Report delivered: April 2026 4. Ongoing Staff Retraining Based on Audit Outcomes o Use audit results to identify gaps and retrain staff accordingly. o Maintain a continuous improvement cycle to ensure adherence to SFDP policies and minimize errors. o Estimated Time of Completion • First audit period: January–March 2026 • Report delivered: April 2026 5. Monthly Peer review o Each supervisor will review a random sample of applications from a different clinic (not their own). o Any discrepancies will be corrected promptly and communicated to the originating clinic. o Results will be tracked monthly to identify trends and target training needs. o Estimated start date will be in March 2026 o The result will be assessed to determine the duration of this review. Responsible- Multiple team members share responsibility for accurately documenting and preserving these records in the correct patient charts. This includes the Clinic Manager, Front Office Supervisors, and the Director of Revenue Cycle. Ultimately, MCC views this as a measure that the Chief Financial Officer and Director of Revenue Cycle all hold responsibility to ensure this policy is adhered to closely. Contact person for Corrective Action Plan listed above: Bharatha Naotunne, CFO Email: bnaotunne@marinclinic.org