Best Practices for Sliding Fee Discount Evaluation

Evaluating the Sliding Fee Discount Program is an area that creates challenges for many Federally Qualified Health Centers (FQHCs).  According to Chapter 9 Sliding Fee Discount of the Health Resources and Services Administration (HRSA) Health Center Compliance Manual (Compliance Manual Chapter 9), the health center is required to “evaluate, at least once every three years, its sliding fee discount program.”  Here we will discuss some best practices in preparing  successful evaluations.

While health centers have some latitude in how the evaluation is done, there are several requirements that must be met. The health center must collect utilization data to be able to assess the rate at which patients within each pay class are accessing the health center; they must then use this data to evaluate the effectiveness of the sliding fee and identify and implement any changes that need to be made.

The following sections are some best practices when performing this analysis and implementing changes.

Collecting utilization data 

  • The health center must be able to assess the rate at which patients within each of its discount pay classes, as well as those at or below 100% of the FPG, are accessing health center services. There are several ways to gather this information including:
    • Practice Management Systems
      • Systems should have the capability of reporting not only by payor group, but by slide level. 
        • Verify during the initial set up of your practice management system that the system is capable of reporting, not only by payor type but by slide level.
        • In the event the practice management systems are unable to do this, you will need to develop a methodology to determine the utilization rate at each sliding fee level. 
    • Focus Groups
      • When utilizing focus groups, documentation of the meetings must be clear and presented in a format that is usable.
    • Patient Satisfaction surveys
        • Patient satisfaction surveys are acceptable methods of gathering information, however, the information concerning the sliding fee scale should be presented to the board of directors to allow a discussion and documentation in the minutes, and not simply reported as information.
    • Patient board members
      • While it is important to get feedback from your patient board members, this alone would not meet the requirement of evaluating the sliding fee discount programs effectiveness.


Utilizing data to evaluate the effectiveness of the sliding fee discount program

  • Information must be tabulated and reported to the board of directors in a meaningful manner.
  • This data should encourage discussions about the impact of the sliding fee program and whether or not there is a barrier to care at all levels.
  • The board meeting minutes should clearly indicate the discussion as to “whether or not the sliding fee discount program created a barrier to care for patients” and if any action is required.


Identifying and implementing changes as needed

  • Changes identified may include:
      • Lowering the current nominal fees
      • Raising the current nominal fees
      • Adding additional slide fee scales based on services
      • Reducing the percentage of charge for patients between 100% – 200% FPG
      • Changing from levels based on percentage to a flat fee or from a flat fee to a percentage method for patients between 100% – 200% FPG
  • When a change is approved by the board of directors, leadership needs to make sure:
    • The change is implemented in a timely manner, and
    • Upon implementation, report back to the board of directors that the change has been completed successfully


The sliding fee discount program is what makes health care accessible to all patients based on the ability to pay in our FQHCs. The purpose of the nominal fees is not to support the FQHC, but to allow patients to have ownership in their care. We certainly do not want to create a barrier to care for our patients, consequently, it is imperative that we effectively evaluate the sliding fee discount program utilizing best practices.

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